A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?
Apply oxygen at 2 L/min via nasal cannula.
Initiate mechanical debridement.
Leave non-bleeding wounds open to air.
Administer a corticosteroid medication.
The Correct Answer is C
Choice A rationale
Applying oxygen at 2 L/min via nasal cannula is not typically indicated in the initial stage of wound healing. Oxygen therapy is used for clients with respiratory distress or hypoxia, not as a standard wound care procedure.
Choice B rationale
Mechanical debridement is a method used to remove dead tissue from wounds, but it is not usually part of the initial wound care plan. Debridement is considered when there is necrotic tissue present that may impede healing.
Choice C rationale
Leaving non-bleeding wounds open to air can be beneficial during the initial stage of wound healing. Exposure to air can help to dry out the wound and prevent maceration of the surrounding skin. It also allows for the observation of the wound and easy access for dressing changes if needed.
Choice D rationale
Administering a corticosteroid medication is not a standard part of initial wound care. Corticosteroids can actually delay wound healing and are generally avoided unless there is a specific indication, such as an inflammatory skin condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Healing by secondary intention occurs when a wound is left open and closes naturally through granulation tissue formation, contraction, and epithelialization. This process is typically for wounds that cannot be closed with sutures due to infection or other factors.
Choice B rationale
The remodeling phase is the final stage of the healing process where the wound strength increases and scar tissue forms. It is not a type of wound healing but rather a phase that can occur in both primary and secondary intention healing.
Choice C rationale
Primary intention healing is when the wound edges are brought together, typically with sutures, staples, or adhesive tape. This method minimizes scarring and speeds up the healing process, making it the preferred method for surgical incisions.
Choice D rationale
Tertiary intention, also known as delayed primary closure, involves initially leaving the wound open due to contamination or infection and then closing it surgically once it is clean. This is not the type of healing described in the question.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale
Inspecting the plug and cord for cracks or fraying is essential to prevent electrical hazards and ensure the safety of both the patient and healthcare staff.
Choice B rationale
Securing the pad to the patient helps to maintain the correct position and prevent burns or other injuries from improper pad placement.
Choice C rationale
Instructing the patient not to sleep on the pad is important because prolonged, direct contact with the heat source can cause burns, especially if the patient is immobile or has sensory deficits.
Choice D rationale
Assisting the patient to lie on top of the pad is not recommended as it can lead to burns due to increased temperature exposure in one area.
Choice E rationale
Using a thermometer to check the temperature of the pad ensures that it is within a safe range for application to the patient's skin, preventing burns.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today