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 A
Explanation
Choice A rationale
Keeping a superficial wound moist can promote faster healing. A moist environment helps to protect the new tissue, prevent the wound from drying out and forming a scab, which can slow down the healing process. It also allows cells to move across the wound more easily, which can speed up healing.
Choice B rationale
While it was once common practice to keep wounds dry, research has shown that a dry environment can actually slow down the healing process by causing cells to dehydrate and scabs to form, which can impede the growth of new tissue.
Choice C rationale
A wet-to-dry dressing is typically used for mechanical debridement and not for the purpose of speeding up healing. This type of dressing can be useful for removing dead tissue but is not necessarily conducive to the fastest healing of superficial wounds.
Choice D rationale
Debridement is the removal of dead or infected tissue from a wound to help healing. While it is an important part of wound care, the act of debridement itself does not speed up healing; rather, it sets the stage for it by cleaning the wound.
Correct Answer is B
Explanation
Choice A rationale
A contusion, commonly known as a bruise, is characterized by bleeding under the skin, causing discoloration and swelling. It does not involve a break in the skin and therefore does not match the description of the wound with torn skin tissue.
Choice B rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse discovered torn skin tissue, this type of wound is consistent with the client’s injury described in the scenario.
Choice C rationale
An abrasion is a wound caused by superficial damage to the skin, usually no deeper than the epidermis. It is typically caused by a scrape against a rough surface and is not associated with torn skin tissue.
Choice D rationale
A puncture is a small hole caused by a long, pointed object, such as a nail or needle. This type of wound usually does not result in torn skin tissue but rather a deeper, more narrow penetration.
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