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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.
Choice B rationale:
First intention healing occurs when the wound edges are approximated, such as with sutures.
Choice C rationale:
Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.
Choice D rationale:
Fourth intention healing is not a recognized term in wound healing.
Correct Answer is C
Explanation
Choice A rationale:
Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.
Choice B rationale:
It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.
Choice C rationale:
Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.
Choice D rationale:
Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.
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