A nurse is caring for a client who has a non-healing pressure injury on the right ankle.
Which action would the nurse take first?
Draw blood for albumin, prealbumin, and total protein.
Prepare for and assist with obtaining a wound culture.
Instruct the client to elevate the foot.
Assess the right leg for pulses, skin color, and temperature.
The Correct Answer is D
While nutritional status is crucial for wound healing, and labs such as albumin (normal range 3.5-5.0 g/dL) and prealbumin (normal range 15-36 mg/dL) are important indicators, assessing the underlying cause of non-healing is a priority. Drawing labs is a subsequent step after a thorough assessment has been completed to rule out circulatory issues as the primary cause.
Choice B rationale
A wound culture is performed to identify pathogens that may be causing a non-healing wound. However, it should only be done after assessing for other potential causes, such as poor circulation, which can compromise the delivery of immune cells and antibiotics to the wound site, making it impossible for the wound to heal regardless of the presence of bacteria.
Choice C rationale
Elevating the foot may be beneficial for reducing edema if present, which can impede circulation. However, this intervention should be based on a comprehensive circulatory assessment. Without first assessing the vascular status of the leg, this action is premature and may not be the most critical first step to take in addressing the underlying problem.
Choice D rationale
Assessing the right leg for pulses, skin color, and temperature is the most critical first step. A non-healing wound on an extremity, particularly an ankle, may indicate underlying peripheral arterial disease. Inadequate blood flow compromises oxygen and nutrient delivery to the wound bed, preventing cellular repair and growth. Ruling out or identifying circulatory compromise is the initial priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.5"]
Explanation
Step 1 is to convert the child's weight from pounds to kilograms: 55 lb ÷ 2.2 lb/kg = 25 kg.
Step 2 is to calculate the total daily dosage in milligrams: 7 mg/kg × 25 kg = 175 mg/24h.
Step 3 is to calculate the dosage per dose: 175 mg ÷ 2 doses = 87.5 mg per dose.
Step 4 is to calculate the volume per dose in mL: 87.5 mg ÷ (125 mg/5 mL) = 87.5 mg ÷ 25 mg/mL = 3.5 mL per dose. The final calculated dosage for this child is 3.5 mL per dose.
Correct Answer is D
Explanation
Choice A rationale
Wet-to-damp saline moistened gauze is a method of debridement and is not the most effective choice for a wound with copious exudate. This dressing type is less absorbent and would quickly become saturated, requiring frequent changes. Frequent changes and wetness can lead to periwound skin maceration and irritation, hindering the healing process.
Choice B rationale
Leaving a stage 3 pressure injury open to the air is contraindicated. A stage 3 pressure injury involves full-thickness skin loss and is susceptible to infection. Leaving the wound open would not manage the copious exudate, would expose the wound bed to pathogens, and would lead to dehydration of the wound bed, which impairs cellular migration and proliferation necessary for healing.
Choice C rationale
A transparent film is a moisture-retaining dressing that is inappropriate for a wound with copious exudate. This dressing is designed for superficial wounds with minimal exudate. Applying a transparent film to a heavily draining wound would lead to the accumulation of exudate underneath the dressing, causing maceration of the surrounding skin and potential for infection.
Choice D rationale
A multi-fiber superabsorbent dressing is the most appropriate choice for a stage 3 pressure injury with copious exudate. These dressings are designed to absorb large volumes of fluid, wicking it away from the wound bed and periwound skin. This action helps to manage moisture, protect the surrounding skin from maceration, and maintain a moist environment ideal for wound healing.
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