Many factors aid in healing. You can assist the patient in improving their healing ability by encouraging the following (Select all that apply):

Keeping skin and surrounding tissue clean and dry.

Proper nutrition with adequate protein and vitamins.

Resting as much as possible and keeping the incisional area still.

Increasing fluid intake to at least 4000 mL per day.

Exercise and deep breathing to increase oxygen.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale
Keeping the skin and surrounding tissue clean and dry helps prevent infection, which is crucial for proper wound healing. A clean environment is less likely to harbor bacteria that can cause complications.

Choice B rationale
Proper nutrition, particularly adequate protein and vitamins, provides the necessary building blocks for tissue repair and supports the immune system, which is essential for healing.

Choice C rationale
Resting and minimizing movement of the incisional area help prevent further injury and allow the body’s resources to focus on the healing process.

Choice D rationale
While fluid intake is important, 4000 mL per day may be excessive unless specifically recommended for the patient’s condition. Overhydration can be harmful.

Choice E rationale

Exercise and deep breathing increase blood flow and oxygenation to tissues, which are vital for healing. Oxygen is needed for cellular functions that repair tissue.

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Correct Answer is B

Explanation

Choice A rationale
Applying hydrocolloids to the wound bed is not a form of mechanical debridement. Hydrocolloids are dressings that provide a moist environment and promote autolytic debridement but do not mechanically remove necrotic tissue.

Choice B rationale
Pulsating lavage is a form of mechanical debridement. It involves the use of a pressurized, pulsed solution to cleanse and remove debris and necrotic tissue from the wound bed, which is essential for the healing process of a stage 4 pressure injury.

Choice C rationale
Using a topical enzyme solution in the wound bed is a chemical, not mechanical, method of debridement. Enzymatic debridement uses proteolytic enzymes to break down necrotic tissue without affecting viable tissue.

Choice D rationale
Placing a transparent dressing over the pressure injury is not a form of debridement. Transparent dressings allow for oxygen exchange and protect the wound from infection, but they do not debride the wound.

A. Abrasion. B. Avulsion. C. Laceration. D. Hematoma.

Correct Answer is D

Explanation

Choice A rationale
An abrasion occurs when the skin is scraped off, usually due to a surface rubbing or scraping against the skin. It does not involve pooling of blood under the skin but rather an injury to the top layer of the skin.

Choice B rationale
An avulsion is a severe type of wound that occurs when a portion of the skin and sometimes the tissue beneath is partially or completely torn away. It is not characterized by pooling of blood under unbroken skin.

Choice C rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because lacerations imply that the skin is broken and torn, it does not describe the condition where blood pools under unbroken skin.

Choice D rationale
A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This is the correct term for a pooling of blood under unbroken skin, as described in the scenario following the patient’s fall. Hematomas can be caused by injury, such as a fall, that causes blood vessels to break and bleed into the surrounding tissues.

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Many factors aid in healing. You can assist the patient in improving their healing ability by encouraging the following (Select all that apply):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Correct Answer is B

Explanation

A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a/an:

Correct Answer is D

Explanation

What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis?

When applying an ice pack, it is necessary to:

A nurse is assisting with the care of a client who arrives at the emergency department following an industrial explosion. Upon inspecting the wound on the client’s leg, the nurse finds torn skin tissue underneath. Which of the following types of wounds should the nurse report?

A nurse is ambulating a patient in the hall a few days after abdominal surgery when the patient says, “I think something just let go.” What should be the nurse’s initial intervention?

Which type of wound debridement is Dakin’s solution used for?

A nurse is concerned about an HIV immunocompromised patient’s ability to heal due to a lack of certain factors. Which of the following are necessary for proper wound healing? (Select all that apply.)

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?