The same nurse is now preparing to clean the abrasion on the client’s right elbow. The provider has prescribed mechanical debridement for the wound.
Which of the following is a form of mechanical debridement that the nurse should expect to use?
Wet-to-dry dressings
Surgical debridement
Enzymatic debridement
Autolytic debridement
The Correct Answer is A
Choice A rationale: Wet-to-dry dressings are a form of mechanical debridement. This method involves applying a wet dressing to the wound and allowing it to dry. When the dressing is removed, it also removes some of the dead or damaged tissue from the wound, helping to clean the wound and promote healing. This method can be painful and is not selective, meaning it can also remove healthy tissue. However, it is often used for wounds with a large amount of debris or necrotic tissue.
Choice B rationale: Surgical debridement is another method of wound debridement, but it is not a form of mechanical debridement. This method involves using surgical instruments to remove dead or damaged tissue. It is the fastest method of debridement and is often used for wounds that are infected or have a large amount of necrotic tissue. However, it requires a skilled practitioner and can be painful.
Choice C rationale: Enzymatic debridement involves applying a topical ointment that contains enzymes to the wound. These enzymes help to break down dead or damaged tissue. This method is selective and only removes necrotic tissue, leaving healthy tissue intact. However, it is not a form of mechanical debridement.
Choice D rationale: Autolytic debridement is a method that uses the body’s own enzymes and moisture to break down dead or damaged tissue. This is the slowest method of debridement but is also the least painful and is selective for necrotic tissue. Like enzymatic debridement, autolytic debridement is not a form of mechanical debridement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Detecting the scent of a rose is primarily associated with the olfactory system, not the tactile system.
Choice B rationale
Observing the color of a flower is primarily associated with the visual system, not the tactile system.
Choice C rationale
Feeling the texture of a fabric is primarily associated with the tactile system. The tactile system, part of the somatosensory system, allows us to perceive touch, pressure, temperature, pain, and vibration.
Choice D rationale
Hearing the sound of a bell is primarily associated with the auditory system, not the tactile system.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.
The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.
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