A nurse is caring for a client who has a stage 3 pressure ulcer on the sacrum. Which type of dressing should the nurse use to promote moist wound healing?

Hydrocolloid

Transparent film

Calcium alginate

Gauze

Answer and Explanation

The Correct Answer is A

Correct answer: A) Hydrocolloid

Rationale: Hydrocolloid dressings are occlusive and adhesive, forming a gel-like substance over the wound bed that maintains a moist environment and facilitates autolytic debridement. They are suitable for stage 3 pressure ulcers, as they protect the wound from contamination and reduce pain and trauma during dressing changes.

Incorrect options:

B) Transparent film - This type of dressing is semi-permeable and allows oxygen exchange, but does not absorb exudate or provide cushioning. It is suitable for stage 1 pressure ulcers, as it protects the skin from friction and moisture.

C) Calcium alginate - This type of dressing is highly absorbent and forms a gel-like substance when in contact with wound exudate. It is suitable for stage 4 pressure ulcers with heavy drainage, as it fills the dead space and promotes hemostasis.

D) Gauze - This type of dressing is inexpensive and readily available, but it can adhere to the wound bed and cause pain and bleeding during removal. It is suitable for stage 4 pressure ulcers with minimal drainage, as it provides mechanical debridement.

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Correct Answer is A

Explanation

Correct answer: A) Autograft

Rationale: An autograft is a type of skin graft that uses the client's own skin as the donor site. This is the preferred type of graft, as it has the lowest risk of rejection and infection, and provides the best cosmetic and functional results.

Incorrect options:

B) Allograft - This is a type of skin graft that uses human skin from a cadaver or a living donor as the donor site. This type of graft is used as a temporary measure to cover large wounds until an autograft is available.

C) Xenograft - This is a type of skin graft that uses animal skin, usually from pigs, as the donor site. This type of graft is also used as a temporary measure to protect wounds from infection and fluid loss until an autograft is available.

D) Mesh graft - This is a type of skin graft that involves making small slits in the donor skin to create a mesh-like pattern. This allows the graft to cover a larger area and conform to irregular surfaces. This type of graft can be either an autograft or an allograft.

A. Serous drainage B. Reddened periwound skin C. Increased pain and tenderness D. Granulation tissue formation

Correct Answer is C

Explanation

Correct answer: C) Increased pain and tenderness

Rationale: Increased pain and tenderness of the wound site may indicate an infection, as the inflammatory response is triggered by the presence of microorganisms. The nurse should obtain a wound culture and notify the provider of the suspected infection.

Incorrect options:

A) Serous drainage - This is a normal finding for a healing wound, as serous fluid is clear and watery and contains plasma and white blood cells. It does not indicate an infection unless it is cloudy, foul-smelling, or purulent.

B) Reddened periwound skin - This is a normal finding for a healing wound, as the increased blood flow to the area promotes oxygen and nutrient delivery to the wound site. It does not indicate an infection unless the redness is spreading, warm, or accompanied by other signs of inflammation.

D) Granulation tissue formation - This is a normal finding for a healing wound, as granulation tissue is new connective tissue that fills the wound bed and supports epithelialization. It does not indicate an infection unless it is pale, friable, or necrotic.

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A nurse is caring for a client who has a stage 3 pressure ulcer on the sacrum. Which type of dressing should the nurse use to promote moist wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?

Correct Answer is A

Explanation

A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?

Correct Answer is C

Explanation

A nurse is caring for a client who has a stage 3 pressure ulcer on the sacrum. Which type of dressing should the nurse use to promote moist wound healing?

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