A patient with diabetes presents with a non-healing foot ulcer. Which factor is most likely contributing to wound ischemia in this patient?
High dietary protein intake
Regular exercise
Excessive vitamin C
Peripheral artery disease
The Correct Answer is D
A. High dietary protein intake: Adequate protein intake is essential for wound healing. High protein intake would generally be beneficial, not detrimental, to wound repair.
B. Regular exercise: Regular, appropriate exercise generally improves circulation and is beneficial for overall health and wound healing.
C. Excessive vitamin C: Vitamin C (ascorbic acid) is necessary for collagen synthesis and is generally beneficial for wound healing. Excessive intake is rarely a direct cause of wound ischemia.
D. Peripheral artery disease: Peripheral artery disease (PAD) is a common macrovascular complication of diabetes where blood vessels narrow, leading to severely reduced blood flow (ischemia) to the lower extremities. Without adequate perfusion, the wound cannot receive the oxygen, nutrients, and immune cells required for healing, making ischemia the most likely contributing factor to a non-healing diabetic foot ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Purulent drainage:Purulent drainage (often called pus) is a thick, opaque, yellow, green, or brown fluid that frequently has a foul odor. It is composed of dead white blood cells (leukocytes), bacteria, and tissue debris, and is the hallmark sign of an acute bacterial infection.
B. Serosanguineous drainage:Serosanguineous drainage is a thin, watery, pink-to-light red fluid, which is a mix of serous fluid and blood. It is a normal finding in the early stages of healing, indicating capillary damage but not necessarily infection.
C. Serous drainage:Serous drainage is a clear, thin, watery fluid. It is considered a normal, healthy product of the inflammatory phase of wound healing.
D. Sanguineous drainage:Sanguineous drainage is fresh, bright red blood. It is expected immediately after an injury or surgery, or if a wound has been traumatized, but its presence alone does not indicate a bacterial infection.
Correct Answer is C
Explanation
A. Apply a dry sterile dressing to the wound: While a dressing is needed, a dry dressing can adhere to the exposed tissues. The wound should be covered with a moist, sterile dressing to protect the open tissue.
B. Apply an antibiotic ointment directly to the open wound: Dehiscence is a mechanical failure, not an infection (at this stage). Topical antibiotics are not the initial priority and may irritate the wound.
C. Notify the healthcare provider immediately: This is the most appropriate initial nursing action. Wound dehiscence is a serious surgical complication that requires prompt evaluation by the surgeon. The nurse must immediately stabilize the patient and the wound and communicate the critical finding to the provider for repair or management planning.
D. Encourage the patient to ambulate to improve circulation: Ambulation, physical exertion, or straining (e.g., coughing, bending) could further separate the wound edges, potentially leading to a much more severe evisceration. The patient should be kept calm and placed in a position to minimize tension on the wound.
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