The patient is undergoing Negative Pressure Wound Therapy (NPWT) treatment for wound healing. Which would be your first priority in caring for this patient?
Assess the patient for any complaints or problems in the wound area.
Check the settings on the NPWT unit.
Document your findings.
Observe the dressing area.
The Correct Answer is A
Choice A rationale
The nurse’s first priority should always be to assess the patient’s condition. In the context of NPWT, this means checking for any complaints or problems in the wound area. This assessment helps to ensure that the NPWT is not causing additional issues and that the wound is healing as expected.
Choice B rationale
While it is important to check the settings on the NPWT unit to ensure it is functioning correctly, this is not the first priority. The patient’s well-being and response to treatment take precedence over equipment checks.
Choice C rationale
Documentation is a critical part of patient care, but it comes after patient assessment and any necessary interventions. It serves to record the patient’s status and the care provided but is not the immediate priority.
Choice D rationale
Observing the dressing area is part of the overall assessment of the patient and the effectiveness of the NPWT. However, it is not the first action to take. The nurse must first assess the patient for any discomfort or complications before focusing on the dressing itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Elastic adhesive tape is not the best option for a patient experiencing skin irritation from tape removal because it may cause further irritation when removed.
Choice B rationale
Karaya paste is primarily used as a skin barrier and adhesive for ostomy appliances, not for securing dressings, especially in cases of skin irritation.
Choice C rationale
Montgomery straps are designed for situations where frequent dressing changes are needed. They allow the dressing to be changed without removing the adhesive straps each time, minimizing skin irritation.
Choice D rationale
Paper tape is less irritating to the skin than elastic adhesive tape, but it still requires removal with each dressing change, which can irritate sensitive skin.
Correct Answer is A
Explanation
Choice A rationale
A Stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The presence of pain and redness that does not blanch when pressure is applied are indicative of this early stage of pressure injury.
Choice B rationale
Stage 2 pressure injuries involve partial-thickness loss of dermis and present as a shallow open ulcer with a red-pink wound bed, without slough. This does not match the description of the patient’s condition, which indicates intact skin.
Choice C rationale
Stage 3 pressure injuries are defined by full-thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s symptoms do not suggest such an advanced stage.
Choice D rationale
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Since the patient’s skin is intact and only red, this stage does not apply.
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