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?
Leave nonbleeding wounds open to air.
Administer a corticosteroid medication.
Initiate mechanical debridement.
Apply oxygen at 2L/min via nasal cannula.
None
None
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Leaving nonbleeding wounds open to air increases the risk of infection and delayed healing. Wounds need a moist environment to promote cell migration and collagen synthesis, essential for the initial inflammatory phase of healing.
Choice B rationale: Corticosteroids suppress the immune response and inflammation, which can delay wound healing. They inhibit leukocyte migration and fibroblast proliferation, which are crucial during the initial stage of the healing process.
Choice C rationale: Mechanical debridement is typically used for chronic wounds with necrotic tissue. In the initial stage of wound healing, it is not necessary and could damage newly formed tissue, delaying the healing process.
Choice D rationale: Oxygen therapy at 2L/min via nasal cannula enhances tissue oxygenation, promoting cellular activities such as collagen synthesis, angiogenesis, and leukocyte function, which are critical during the initial inflammatory phase of wound healing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice B rationale:
Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.
Choice C rationale:
Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice D rationale:
Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Correct Answer is A
Explanation
Choice A rationale:
Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.
Choice B rationale:
Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.
Choice C rationale:
Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.
Choice D rationale:
Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.
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