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 A
Explanation
Choice A rationale
The stoma for a sigmoid colostomy is typically located in the lower left abdomen. This is because the sigmoid colon is a part of the large intestine that is located in the lower left quadrant of the abdomen.
Choice B rationale
A stoma should appear pink or red and moist. A purple stoma could indicate a lack of blood supply, which is a medical emergency.
Choice C rationale
A sigmoid colostomy will produce formed stool because the sigmoid colon is the last part of the colon, where water is absorbed and stool is formed.
Choice D rationale
The end of the stoma (the part that sticks out from the abdomen) should not be painful after the procedure. If a patient experiences pain, it could indicate a complication such as a blockage or infection.
Correct Answer is C
Explanation
Rationale:
When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.
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