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
The remodeling phase is the final stage of the healing process, where the wound strength and function are gradually restored over time. This phase does not involve initial suturing; rather, it is the period after the wound has closed. Therefore, this choice does not pertain to the initial management of a wound with an active infection.
Choice B rationale
Healing by primary intention involves closing a wound with sutures, staples, or adhesive to facilitate healing. However, when there is an infection, suturing is delayed until the infection is resolved to prevent trapping bacteria inside, which could worsen the infection or lead to abscess formation. Once the infection is under control, the wound can be closed, promoting faster and more cosmetically appealing healing. This method reduces scarring and speeds recovery compared to secondary intention, where the wound is left open to heal from the bottom up.
Choice C rationale
Tertiary intention, also known as delayed primary closure, is used when there is a need to delay closing the wound, often due to infection. The wound is left open to allow for adequate drainage and resolution of the infection before it is sutured closed. This method helps to prevent the entrapment of bacteria within the wound, which could exacerbate the infection1.
Choice D rationale
Secondary intention healing occurs when a wound is left open and allowed to close on its own without surgical closure. This method is typically used for wounds with significant tissue loss or those that cannot be closed directly. It is not specifically related to the delay of suturing due to infection
Correct Answer is C
Explanation
Choice A:
While marijuana use can have various health effects, it is not typically associated with a reduction in functional hemoglobin.
Choice B:
A diet high in fats can lead to various health problems, such as heart disease and obesity, but it is not directly linked to a reduction in functional hemoglobin.
Choice C:
Smoking cigarettes can indeed lead to a reduction in functional hemoglobin. Smokers have higher blood hemoglobin concentrations than non-smokers. This is because smoking causes the body to increase red blood cell production to compensate for lower oxygen supply.
Choice D:
While excessive alcohol consumption can have numerous negative health effects, it is not typically associated with a reduction in functional hemoglobin.
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