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 D
Explanation
Choice A rationale
While an abdominal binder may be helpful postoperatively, it is not the immediate intervention for a patient who feels that ‘something just let go’ after surgery.
Choice B rationale
Seating the patient in a nearby chair is not the best initial action as it may increase abdominal pressure and potentially worsen any underlying issue.
Choice C rationale
Instructing the patient to pant is not an appropriate response to a potential complication from surgery, such as dehiscence or evisceration.
Choice D rationale
The best initial action is to assist the patient into a supine position to minimize tension on the abdominal incision, reduce the risk of further injury, and assess the situation.
Correct Answer is B
Explanation
Choice A rationale
Abdominal pads are generally used for absorption and are not specifically designed to minimize pain during dressing changes.
Choice B rationale
Hydrogel dressings provide moisture to the wound, which can facilitate autolytic debridement and reduce pain during dressing changes. They are cooling and soothing, which can be comfortable for the patient.
Choice C rationale
Wet-to-dry dressings are used for mechanical debridement and can be painful when removed, as they may adhere to the wound bed and pull on new tissue.
Choice D rationale
Dry gauze can adhere to the wound and cause pain upon removal, similar to wet-to-dry dressings, and is not the best choice for minimizing pain.
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