The healthcare provider has ordered hydrocolloid dressings as part of a wound
treatment plan. In teaching the client how to perform the wound care, what purpose does the nurse identify for the use of the hydrocolloid dressings?
To maintain moist wound healing
To create enzymatic debridement
To absorb excessive wound drainage
To directly reduce bioburden (bacteria count)
The Correct Answer is A
A. To maintain moist wound healing: Hydrocolloid dressings contain gel-forming agents that react with wound exudate to create a protective, moist environment. This occlusive seal prevents tissue dehydration and promotes autolytic debridement by the body’s own enzymes. Maintaining moisture is critical for facilitating faster epithelialization and reducing pain at the site.
B. To create enzymatic debridement: Enzymatic debridement requires the application of external chemical agents, such as collagenase, to actively break down necrotic tissue. Hydrocolloids facilitate autolytic debridement by trapping endogenous moisture but do not contain extrinsic enzymes. They support the body’s natural processes rather than providing a chemical catalyst.
C. To absorb excessive wound drainage: Hydrocolloids have limited absorptive capacity and are unsuitable for heavily draining or "copious" wounds. Excessive exudate will cause the dressing to lose its seal or cause periwound maceration. They are best utilized for wounds with minimal to moderate drainage where moisture retention is desired.
D. To directly reduce bioburden (bacteria count): These dressings are not inherently antimicrobial and do not contain silver or iodine to kill pathogens. In fact, their occlusive nature can promote anaerobic bacterial growth if an active infection is present. They are primarily used for clean, granulating wounds rather than infected ones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 1100. This time represents the passage of 2.5 hours, which is exactly one half-life of the medication. At this interval, only 50% of the initial 5 mg dose has been eliminated from the plasma. To reach 75% elimination, the drug must undergo a second half-life cycle to clear half of the remaining amount.
B. 1200. This interval is only 3.5 hours post-administration, which does not align with the completion of the required metabolic cycles. The drug concentration would still be significantly above the 25% retention threshold at this point. Pharmacokinetic clearance follows specific exponential decay intervals based on the established 2.5-hour half-life of Oxycodone.
C. 1330. After two half-lives, totaling 5 hours (2.5 plus 2.5), 75% of the drug is cleared from the systemic circulation. The first cycle reduces the dose to 50%, and the second cycle reduces that remaining half by another 50%. Starting from 0830, the addition of 5 hours correctly reaches the time of 1330.
D. 1600. This represents 7.5 hours since administration, which corresponds to the passage of three full half-lives. At this stage, approximately 87.5% of the drug would be eliminated, leaving only 12.5% in the body. This exceeds the 75% clearance threshold specified in the question regarding the metabolic rate of the dose.
Correct Answer is C
Explanation
A. That much ibuprofen should relieve your pain: This response is dismissive of the client's subjective experience of pain and fails to address safety. Pain threshold and intensity vary among individuals regardless of standard dosing. It lacks the necessary education regarding the maximum daily limits of the medication.
B. You probably should ask your healthcare provider if it is acceptable: While referring to a provider is necessary, this response is too passive and misses an immediate teaching opportunity. The nurse must identify the specific safety risk associated with the current dosage. It does not provide the rationale for the referral.
C. That amount is greater than the recommended daily amount. Discussing your increased pain with your healthcare provider is important: Doubling 400 mg every 4 hours results in 4800 mg daily, exceeding the 3200 mg maximum safe limit. This creates a high risk for gastrointestinal erosion and renal toxicity. The nurse must prioritize patient safety through education and provider consultation.
D. Ibuprofen is eliminated by the kidneys. It would be important for your healthcare provider to order BUN and creatinine levels to determine if the increased dose is safe: This focuses on diagnostic monitoring rather than the immediate danger of exceeding the maximum daily dose. While renal function is relevant, the priority is preventing toxicity by correcting the dosage. Staging the response around lab tests delays the necessary intervention.
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