Question

SELECT THE RIGHT ANSWER :

QUES :

The patient underwent a surgical debridement during the day shift to remove a large amount of nonviable tissue from a complex abdominal wound. The nurse caring for the patient on the evening shift notices that the patient is tachycardic and febrile. Which action is the most appropriate nursing intervention?

Select one:

a. Notify the practitioner and express concern regarding infection.

b. Encourage the patient to take deep breaths to reduce anxiety.

c. Medicate the patient for pain and anxiety.

d. Document the finding as an expected outcome.

QUES :

The practitioner performed conservative sharp debridement at the bedside and removed a layer of eschar. There are orders for daily dressing changes using an enzymatic debriding agent. When assessing the periwound skin, the nurse notices tissue maceration. Which action should the nurse take?

Select one:

a. Wrap the area with a protective pad to maintain moisture in the dressing.

b. Increase the frequency of dressing changes.

c. Apply a barrier film to the periwound and request twice-daily dressing changes.

d. Reinforce the secondary dressing with more gauze.

QUES :

During an assessment, the nurse notices that the patient’s abdominal wound contains a small to moderate amount of loosely adherent yellow slough. If the practitioner decides to treat the wound using autolytic debridement, the nurse would expect an order for which step?

Select one:

a. Moisture-retentive dressing such as foam

b. Preparation for surgical intervention

c. Larval therapy every few days

d. Moist-to-dry dressing changes twice a day

Answer 1

Answer:

1) a. Notify the practitioner and express concern regarding infection.

'Patient is tachycardic and febrile', means the patient has infection. Anxiety or pain can make patient tachycardic but not febrile. so option b and c can be excluded.Infection is not an expected outcome in wound management and before documenting any unusual event, it has to be reported to the practitioner.

2) d.Reinforce the secondary dressing with more gauze

When the wound is exposed to moisture for a long time, it can make the periwound skin( skin around the wound) macerated,and it wound have drainage, so need for a protective dressing for maintaining moisture.  Barrier film can be used to prevent periwound maceration. Increased frequency of dressing change can introduce infection.The best method to treat the macerated periwound is absorbant dressing, it can be done with secondary dressing with more gauze to absorb the drainage.(When gauze is used as secondary, it won't irritate the skin.)

3) a. Moisture-retentive dressing such as foam.

Autolytic debridement is the most commonly used methode of debridement by using body's own enzyme and moisture to rehydrate and soften the debris and results in automatic debridement.This can be facilitated by applying moisture retentive dressing such as films, hydrocolloides and hydrogel.