A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:

The moisture creates an environment suitable for the growth of microorganisms in a wound.

Greater pressure is exerted by a wet bed.

Shearing is more likely from wet sheets.

The patient has to be repositioned for the bed to be changed.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Moisture from incontinence can compromise skin integrity and create a favorable environment for bacterial growth, increasing the risk of infection and skin breakdown.

Choice B rationale
While a wet bed may be uncomfortable, it does not exert greater pressure that would lead to skin breakdown or infection.

Choice C rationale
Shearing can occur from moving a patient on any surface; however, wet sheets do not inherently increase the likelihood of shearing.

Choice D rationale
Repositioning the patient is necessary for comfort and to prevent pressure ulcers, but it is not a direct cause of skin breakdown or infection due to incontinence.

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Correct Answer is C

Explanation

Choice A rationale
When administering a hot soak treatment, it is crucial to soak only the affected area to provide targeted heat therapy. This localized approach helps to increase blood flow, reduce pain, and promote healing in the specific area that requires treatment. Soaking only the affected area also minimizes the risk of overheating and potential burns to other parts of the body.

Choice B rationale
While positioning the patient comfortably is important for any treatment, it is not the most critical aspect of a hot soak treatment. Comfort should always be considered, but the primary goal of the hot soak is to apply heat to the affected area to aid in healing. Therefore, ensuring that only the affected area is soaked takes precedence over general patient comfort in this context.

Choice C rationale
Monitoring the temperature of the water is the most important aspect of a hot soak treatment. The water must be warm enough to be therapeutic but not so hot as to cause burns or discomfort. This ensures the treatment is both safe and effective1.

Choice D rationale
Checking the patient’s skin integrity is important, especially if the patient has a condition that affects skin sensitivity, such as diabetes. However, the immediate concern during a hot soak treatment is to monitor the temperature to prevent injury.

A. Directly over the wound B. In a circular motion around the wound, circling to the outside C. From the outer abdomen toward the wound D. From the left to the right across the wound

Correct Answer is B

Explanation

Choice A rationale
Cleaning directly over the wound with a swab could be harmful as it may disrupt the healing tissue. This method does not follow the principles of medical asepsis, which aim to reduce the risk of infection and promote wound healing.

Choice B rationale
The correct technique for cleaning a wound is to use a swab in a circular motion starting at the center and moving outward. This method helps to prevent recontamination of the clean area and is consistent with aseptic principles, ensuring that any contamination is moved away from the wound, not towards it.

Choice C rationale
Cleaning from the outer abdomen toward the wound could potentially bring contaminants from the less clean abdomen into the sterile area of the wound. This would increase the risk of infection and is not the recommended practice.

Choice D rationale
Swabbing from one side to the other across the wound does not ensure that contaminants are moved away from the wound area. It could spread bacteria across the surface, which is not conducive to proper wound care.

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A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:

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Naxlex Comprehensive Predictor Exams

When giving a hot soak treatment, what is most important to ensure?

Correct Answer is C

Explanation

The nurse is performing a dry sterile dressing change for an abdominal wound. In which direction should the nurse use a swab to clean?

Correct Answer is B

Explanation

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?

Chronic wounds that are not healing well may benefit from (Select all that apply):

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The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:

When applying an ice pack, it is necessary to:

A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?