In a clinical setting, a patient with a chronic wound is scheduled for debridement. Which of the following is the primary purpose of wound debridement?

To increase blood flow to the wound site

To remove necrotic tissue to promote healing

To apply antibiotics directly to the wound

To prevent scar formation

Answer and Explanation

The Correct Answer is B

A. To increase blood flow to the wound site: While debridement may indirectly help improve blood flow by removing barriers to healing, its primary purpose is not to increase blood flow. Increased blood flow is a result of improved wound bed conditions rather than the main goal of the procedure.

B. To remove necrotic tissue to promote healing: The primary purpose of wound debridement is to remove necrotic (dead) or devitalized tissue from the wound bed. This process promotes healing by creating a clean wound environment, facilitating granulation tissue formation, and reducing the risk of infection, making this option the most accurate.

C. To apply antibiotics directly to the wound: While antibiotics may be part of the overall wound care plan, debridement itself is not intended for the direct application of antibiotics. The focus is on removing non-viable tissue rather than applying medications during the procedure.

D. To prevent scar formation: While proper wound care, including debridement, can help improve healing outcomes and potentially minimize scarring, the primary aim of debridement is not to prevent scars. Scarring is influenced by multiple factors, including the type of wound, depth, and individual healing responses.

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Correct Answer is D

Explanation

A. “The precautions will protect me and help my blood count recover faster.”: While protective precautions are meant to safeguard the client from infections, this statement does not specifically address the necessary actions or behaviors that need to be followed to maintain reverse isolation. Recovery of blood counts is a complex process that depends on multiple factors, including the underlying condition and treatment.

B. "Persons entering the room with colds should stay at least 3 feet from me.": This statement is not sufficient for reverse isolation. Individuals entering the room should be free of any respiratory illnesses, and maintaining a distance may not be adequate protection. Ideally, anyone entering the room should be healthy and ideally wearing appropriate protective gear, such as masks, to reduce the risk of transmitting infections.

C. "My family plans to bring flowers from my garden to help me feel better.": Bringing flowers from outside can introduce pathogens and compromise the sterile environment necessary for a client in reverse isolation. This statement demonstrates a lack of understanding of the precautions required to maintain a safe environment.

D. "Persons entering my room should perform hand hygiene before entering.": This statement accurately reflects an understanding of the precautions needed in reverse isolation. Hand hygiene is critical in preventing the introduction of pathogens into the sterile environment of a client with a severely depressed neutrophil count. It helps to minimize the risk of infections, which is the primary goal of reverse isolation.

A. Bathe a client who had an amputation 2 days ago. B. Review a low-sodium diet for a client who has hypertension. C. Feed a client who had a stroke 3 months ago. D. Explain oral hygiene to a client receiving chemotherapy. E. Assist a client to ambulate using a gait belt.

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

Explanation

A. Bathe a client who had an amputation 2 days ago: This task can be delegated to assistive personnel (AP). APs are trained to assist with activities of daily living, including bathing, under the supervision of nursing staff. The nurse should ensure that the AP is aware of any special considerations related to the client's recent amputation.

B. Review a low-sodium diet for a client who has hypertension: This task should not be delegated to APs, as it requires nursing knowledge and understanding to educate the client effectively. Discussing dietary modifications involves assessing the client's understanding and providing education, which falls under the nursing scope of practice.

C. Feed a client who had a stroke 3 months ago: This task can be delegated to APs, provided that the client is stable and the AP has been trained to assist clients with feeding. However, the nurse should assess the client's swallowing ability and any specific precautions related to the stroke before delegating this task.

D. Explain oral hygiene to a client receiving chemotherapy: This task should not be delegated to APs because it involves providing specific education and instructions regarding oral care, which requires nursing judgment and knowledge about the implications of chemotherapy on oral health.

E. Assist a client to ambulate using a gait belt: This task can be delegated to APs. Assisting with ambulation is within the scope of practice for APs, especially when proper techniques and safety measures, such as using a gait belt, are followed. The nurse should ensure that the AP has received appropriate training to assist with ambulation safely.

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In a clinical setting, a patient with a chronic wound is scheduled for debridement. Which of the following is the primary purpose of wound debridement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

Correct Answer is D

Explanation

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

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

Explanation

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? (Select All that Apply.)

When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

A nurse is preparing to clean a client's dentures. Which of the following actions should the nurse plan to take?

Clients with special needs require specific communication techniques. Which specific communication techniques should a nurse utilize when caring for a client who is cognitively impaired?

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?