A nurse is planning care for a patient with a chronic wound. What is a key component to include in the plan?
Pain control prior to dressing changes.
Daily use of strong antiseptics.
Immediate surgical intervention.
Frequent changes of antibiotics.
The Correct Answer is A
A. Pain control prior to dressing changes: Dressing changes and wound cleansing can be extremely painful, especially in chronic wounds where nerve endings are often exposed or hypersensitive. Ensuring adequate pain control (e.g., administering analgesics 30-60 minutes before the procedure) minimizes patient distress, reduces anxiety, and prevents the patient from guarding or resisting necessary wound care, thereby supporting the overall healing plan.
B. Daily use of strong antiseptics: Strong, non-selective antiseptics (like povidone-iodine or hydrogen peroxide) are cytotoxic and can damage the delicate, newly formed cells (fibroblasts and epithelial cells) in the wound bed, which ultimately delays healing in a chronic wound. Gentle cleansing with saline or a specialized wound cleanser is preferred.
C. Immediate surgical intervention: While some chronic wounds eventually require surgical intervention (e.g., grafting or flap rotation), this is not an immediate, standard component for all chronic wounds. Initial care focuses on correcting underlying causes, proper debridement, and moisture balance.
D. Frequent changes of antibiotics: Antibiotics are only used if a clinical infection is confirmed, usually based on culture results, and should be used judiciously to avoid antibiotic resistance. Frequent, random changes are poor practice and do not address the core issues of chronicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply talcum powder to areas at risk for breakdown:Talcum powder can cake or clump when mixed with moisture, which can act as an abrasive, causing friction and irritation that leads to skin breakdown.
B. Encourage the client to drink more fluids:This is an important intervention to maintain tissue hydration and perfusion, but it is not the most crucial direct measure to prevent mechanical injury on bony prominences.
C. Use pillows and cushions to support and position the client:Utilizing pillows, wedges, and specialty cushions is critical for proper alignment, redistribution of pressure, and ensuring that bony prominences (like the heels, sacrum, and trochanters) are floating or supported to eliminate skin-to-skin contact and relieve external pressure.
D. Perform a complete bed bath daily:This is a routine personal hygiene measure. While cleanliness is important, it is less crucial than pressure redistribution in the prevention of pressure injuries on bony prominences.
Correct Answer is B
Explanation
A. Sanguineous drainage: Sanguineous drainage is fresh, bright red blood.
B. Serosanguineous drainage: Serosanguineous drainage is a mixture of serous fluid (pale, watery) and sanguineous fluid (blood), resulting in a thin, watery, pale pink or light red color. This is a common, normal finding in the inflammatory and proliferative phases of healing.
C. Purulent drainage: Purulent drainage is thick, opaque, and colored (yellow, green, or brown) with a foul odor, indicative of infection.
D. Serous drainage: Serous drainage is clear, thin, and watery, like plasma. The presence of a pink tint indicates blood, classifying it as serosanguineous.
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