The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.
Palpate the client's skin for moisture, temperature, and texture.
Ask the client whether the wound bed or surrounding skin itches.
Measure and assess the client's wound bed, size, edges, and margins.
Evaluate the client's level of pain, using a numeric value pain scale.
Review the client's prothrombin time test and international normalized ratio.
Correct Answer : A,C,D
Choice A rationale
Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.
Choice B rationale
While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.
Choice C rationale
Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.
Choice D rationale
Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.
Choice E rationale
Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A pustule is an elevated, round lesion filled with pus, not serum. Pustules are commonly seen in acne or infections.
Choice B rationale
A macule is a flat, discolored area of the skin that is not elevated. Macules do not contain fluid and are often seen in conditions like freckles or flat moles.
Choice C rationale
A vesicle is an elevated, round lesion filled with clear serum. Vesicles can result from conditions such as chickenpox, herpes simplex, or dermatitis.
Choice D rationale
A cyst is an elevated, round lesion filled with semi-solid material or fluid. Cysts are typically deeper in the skin compared to vesicles.
Correct Answer is D
Explanation
Choice A rationale
Onychocryptosis, also known as an ingrown toenail, is a condition where the edge of the toenail grows into the surrounding skin. This can cause pain, swelling, and sometimes infection. It is not related to a dermatophyte infection, which is a fungal infection affecting the toenail.
Choice B rationale
Pediculosis refers to an infestation of lice, which are small parasitic insects that feed on human blood. It typically affects areas like the scalp, body, and pubic region but not the toenails. Pediculosis is not related to fungal infections.
Choice C rationale
Tinea pedis, commonly known as athlete's foot, is a fungal infection that primarily affects the skin on the feet, particularly between the toes. While it is a dermatophyte infection, it does not specifically affect the toenails.
Choice D rationale
Onychomycosis is a fungal infection of the toenails or fingernails. It is caused by dermatophytes, yeasts, or nondermatophyte molds. The infection leads to thickened, brittle, and discolored nails, which accurately describes a dermatophyte infection of the toenail.
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