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 ["31"]
Explanation
Step 1: Calculate the total volume to be infused. Total volume = 250 mL.
Step 2: Calculate the total time for the infusion in minutes. Total time = 2 hours × 60 minutes/hour = 120 minutes.
Step 3: Calculate the flow rate in mL/min. Flow rate = Total volume ÷ Total time = 250 mL ÷ 120 min = 2.08 mL/min.
Step 4: Calculate the flow rate in drops/min. Flow rate = 2.08 mL/min × 15 drops/mL = 31.25 drops/min. So, the nurse should adjust the flow rate to deliver approximately 31 drops per minute.
Correct Answer is B
Explanation
Choice A rationale
While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.
Choice B rationale
Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.
Choice C rationale
Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.
Choice D rationale
Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.
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