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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.
Choice B rationale:
Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.
Choice C rationale:
Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.
Choice D rationale:
Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.
Correct Answer is B
Explanation
Choice A rationale:
An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.
Choice B rationale:
A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.
Choice D rationale:
A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.
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