The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?
Adequate nutrition delays wound healing and increases risk of infection.
Chronic wounds heal better in a dry, open environment so leave them open to air.
Fat tissue heals more rapidly because there is less vascularization.
Long term steroid use diminishes the inflammatory response and delays wound healing.
The Correct Answer is D
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.
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View Related questions
Correct Answer is A
Explanation
Rationale:
A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.
B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.
C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.
D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.
Correct Answer is ["A","B","E"]
Explanation
Rationale:
A. The opening of the pouch should be cut about 1/8 of an inch larger than the stoma to ensure a proper fit without restricting blood flow or irritating the stoma.
B. Placing a gauze over the stoma during a pouch change helps to absorb any discharge and keep the area clean while preparing the new appliance.
C. Povidone-iodine should not be used to clean around the stoma, as it can irritate the skin. The skin should be cleaned with mild soap and water or a recommended stoma cleanser.
D. A stoma that turns purple-blue is a sign of impaired blood flow and requires immediate medical attention. A healthy stoma should appear pink or red and moist.
E. The ostomy pouch should be emptied when it is about one-third full to prevent leakage, odor, and unnecessary pressure on the stoma.