A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.
Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

applying hydrocolloids to the wound bed.

placing a transparent dressing over the pressure injury.

pulsating lavage.

using a topical enzyme solution in the wound bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.

Choice B rationale:

Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.

Choice C rationale:

Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.

Choice D rationale:

Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.

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Correct Answer is C

Explanation

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

A. Debridement. B. Primary intention. C. Healing. D. Phagocytosis.

Correct Answer is A

Explanation

Choice A rationale:

Dakin solution is used for chemical debridement of a wound.

Choice B rationale:

Primary intention is a method of wound healing, not a result of Dakin solution.

Choice C rationale:

While Dakin solution can aid in wound healing, it does not directly cause healing.

Choice D rationale:

Phagocytosis is a process carried out by certain cells in the body, not a result of Dakin solution.

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A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Correct Answer is C

Explanation

The nurse places Dakin solution in a wound to accomplish chemical:

Correct Answer is A

Explanation

Superficial wounds heal faster when kept:

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A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.
Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?