The nurse notes intact eschar without site drainage on a client's top and outer aspect of the left great toe. The client has diabetes mellitus. What does the nurse anticipate will be the goal of treatment?
Wound debridement
Maintenance and protection of the intact eschar
Use of a topical antimicrobial agent to prevent infection
Removal of eschar to create a moist environment for healing
The Correct Answer is B
A. Wound debridement: Debriding dry, stable eschar on a distal extremity with poor vascularity can expose underlying tissue to infection without sufficient blood flow to heal. In patients with diabetes and peripheral arterial disease, aggressive debridement of stable eschar is often contraindicated.
B. Maintenance and protection of the intact eschar: For stable, dry, and intact eschar on ischemic limbs or digits, the clinical goal is to keep the area dry and protected. This "natural cover" prevents the entry of pathogens into deeper tissues while avoiding the risks of surgical or chemical intervention.
C. Use of a topical antimicrobial agent to prevent infection: Topical agents often introduce moisture, which can soften the eschar and promote bacterial proliferation. If the eschar is dry and intact without signs of infection, the priority is maintaining that dryness rather than applying creams or ointments.
D. Removal of eschar to create a moist environment for healing: Creating a moist environment is beneficial for many wounds but dangerous for ischemic, stable eschar. Softening this tissue can lead to "wet gangrene," which spreads rapidly and significantly increases the risk of limb amputation in diabetic patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Prescription: cefixime 200 mg PO
Available: 100 mg per teaspoon
First convert teaspoons to mL.
1 teaspoon = 5 mL
So:
100 mg = 5 mL
200mg /100mg× 5ml=10ml
Correct Answer is ["3"]
Explanation
Dose prescribed /Dose available=Number of capsules
900mg300mg=3
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