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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

A. there is probably a deeper injury than what appears on the surface. B. he has lain in one position for such a long time that swelling has occurred. C. vessels have dilated and allowed plasma to leak into the wound site. D. an infection is in progress at the wound site.

Correct Answer is C

Explanation

Choice A rationale:

There is probably a deeper injury than what appears on the surface is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice B rationale:

He has lain in one position for such a long time that swelling has occurred is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice C rationale:

Vessels have dilated and allowed plasma to leak into the wound site is the correct answer because this is a normal part of the inflammatory stage of wound healing.

Choice D rationale:

An infection is in progress at the wound site is incorrect because while swelling can be a sign of infection, it is also a normal part of the inflammatory stage of wound healing.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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?