A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?

Apply compression bandages to the affected leg

Obtain a wound culture and sensitivity

Administer prescribed analgesics and antipyretics

Elevate the affected leg above the level of the heart

Answer and Explanation

The Correct Answer is B

Correct answer: B) Obtain a wound culture and sensitivity

Rationale: The nurse should first obtain a wound culture and sensitivity to identify the causative organism and the appropriate antibiotic therapy for the client's wound infection. The nurse should use sterile technique and collect the specimen from the wound bed after cleansing the wound with normal saline.

Incorrect options:

A) Apply compression bandages to the affected leg - Compression therapy is indicated for clients with venous leg ulcers to improve venous return and reduce edema, but it is not the first priority in this case. The nurse should first address the infection before applying compression bandages.

C) Administer prescribed analgesics and antipyretics - Administering analgesics and antipyretics may help to relieve the client's pain and fever, but it does not treat the underlying cause of the infection. The nurse should first obtain a wound culture and sensitivity before administering medications.

D) Elevate the affected leg above the level of the heart - Elevating the affected leg may help to reduce edema and improve blood flow, but it does not address the infection. The nurse should first obtain a wound culture and sensitivity before elevating the leg.

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Correct Answer is B

Explanation

Correct answer: B) Instruct the client to splint the incision when coughing

Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.

Incorrect options:

A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.

C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.

D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.

A. Soaking the old dressing with sterile saline before removing it B. Applying antibiotic ointment to the new dressing before placing it on the wound C. Moistening the new dressing with sterile water before wringing it out and applying it to the wound D. Covering the new dressing with an occlusive secondary dressing to prevent evaporation

Correct Answer is C

Explanation

Correct answer: C) Moistening the new dressing with sterile water before wringing it out and applying it to the wound

Rationale: Wet-to-dry dressings are used for mechanical debridement of necrotic tissue from chronic wounds. The new dressing should be moistened with sterile water (not saline, as saline can cause sodium crystals to form on the wound bed and impair healing), wrung out to remove excess moisture (to prevent maceration of surrounding skin), and loosely packed into the wound (to allow contact with necrotic tissue). The old dressing should be removed dry (not soaked, as soaking can rehydrate necrotic tissue and reduce debridement).

Incorrect options:

A) Soaking the old dressing with sterile saline before removing it - This can rehydrate necrotic tissue and reduce debridement.

B) Applying antibiotic ointment to the new dressing before placing it on the wound - This can interfere with debridement and increase the risk of infection and resistance.

D) Covering the new dressing with an occlusive secondary dressing to prevent evaporation - This can create a moist environment that promotes bacterial growth and infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a surgical incision with staples. Which intervention should the nurse include in the plan to prevent wound dehiscence?

Correct Answer is B

Explanation

A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?

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?

A nurse is assessing a client who has a wound on the abdomen. The nurse observes that the wound edges are approximated, there is minimal drainage, and granulation tissue is visible. How should the nurse document this wound?

A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is 4 cm in length, 3 cm in width, and 2 cm in depth. The wound bed is 80% granulation tissue and 20% slough. Which type of dressing should the nurse use for this wound?

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

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?

A client is admitted to the hospital with a burn injury that covers 30% of the total body surface area (TBSA). The client's weight is 70 kg. Using the Parkland formula, how much fluid should the client receive in the first 24 hours after the injury?

A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?