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 A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

A. pressure injury. B. stage 2. C. stage 1. D. stage 3. E. stage 4. .

Correct Answer is C

Explanation

Choice A rationale:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

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

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

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

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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?