A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Apply a debriding agent.

Apply steri-strips.

Obtain a wound culture.

Remove every other suture.

Answer and Explanation

The Correct Answer is C

A.   Debriding agents are used to remove necrotic or non-viable tissue from a wound. While debridement can be necessary if there is evidence of necrotic tissue or eschar, the presence of thick tan exudate alone does not necessarily indicate that debridement is needed.
B.   Steri-strips are used to support wound closure and can be applied to wounds with approximated edges. However, in the case of a wound healing by secondary intention (where the edges are not brought together but heal from the inside out), steri-strips are not typically used. This action is not relevant if the wound is healing by secondary intention and if there is a thick exudate present.
C.   Obtaining a wound culture is important if there is a suspicion of infection, especially if there is a change in the character of the exudate, increased redness, swelling, or other signs of infection. A thick tan exudate might be indicative of an infection or could be a normal part of the healing process
D.   Removing sutures in a wound that is healing by secondary intention is not appropriate as it could disrupt the healing process and potentially lead to complications. Sutures are typically removed when the wound is healing by primary intention and the edges are approximated.

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Correct Answer is ["C","D","E"]

Explanation

A. Placing the client on her left side is not a standard practice for delivering enteral feedings. Generally, the client should be in a semi-Fowler’s position (head of bed elevated at 30-45 degrees) to minimize the risk of aspiration and aid in digestion.
B. While asking for a preferred flavor may be appropriate for improving patient comfort and adherence to the feeding regimen, it is not always feasible or necessary, particularly if the client has limited ability to communicate or make choices.
C. Elevating the head of the bed to 30 degrees for 1 hour after administering a bolus feeding helps to reduce the risk of aspiration and aids in digestion by allowing gravity to assist in moving the feeding into the stomach. This is a standard practice for patients receiving enteral feedings and is important for preventing complications like aspiration pneumonia.
D. Flushing the tubing with warm water before and after administering the bolus is essential to ensure that the entire amount of feeding is delivered and to prevent clogging of the tube. This practice helps in maintaining tube patency and ensuring that the client receives the full intended dose of nutrition.
E. It is important to record the amount of enteral feeding as part of the client’s total fluid intake. Accurate documentation helps in monitoring the client’s fluid balance and nutritional intake, which is critical for managing the client’s overall health and adjusting their care plan as needed.

A. To administer a medication that is very irritating to the tissues. B. To administer a medication that requires use of an extra long needle. C. To follow the healthcare provider's prescription for Z track administration. D. To administer a large volume of medication.

Correct Answer is A

Explanation

A. The Z-track technique helps to prevent medication from leaking into the subcutaneous tissue and minimizes irritation by sealing the medication in the muscle. This is especially important for medications that are known to cause irritation or staining, such as iron supplements or some antipsychotics
B. The length of the needle is not directly related to the use of the Z-track technique. The Z-track method is used to minimize irritation and ensure that the medication is deposited in the muscle rather than leaking into the subcutaneous tissue.
C. The reason for using the Z-track technique is related to preventing irritation and ensuring proper medication delivery, rather than simply following a prescription.
D. The volume of medication is not the primary reason for using the Z-track technique. While the Z-track method can be used for administering larger volumes of medication, the technique's primary purpose is to prevent leakage and reduce tissue irritation.

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A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

Correct Answer is A

Explanation

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