The nurse observes a thick, tannish-brown covering over a large wound and needs to stage the wound. What action by the nurse is most appropriate?
a. Removing this covering with a sterile forceps and scissors
b. Filling the base of the patient's ulcer with a silicone lotion
c. Placing a hydrocolloid dressing directly over the tannish-brown covering
d. Deferring staging until the tannish-brown covering has been removed
D
The tannish-brown covering is eschar, which has formed as a result of the severe tissue injury. Until the base of the wound can be seen, the true depth and therefore the stage cannot be deter-mined. Eschar is not simply removed; often it is scored, and a solution is put on it to soften it so it can be removed. When the eschar is removed, sterile instruments are used because removing it exposes fresh tissue. If the nurse applies the dressing over eschar, the dressing effectively seals the necrotic tissue onto the wound bed. Silicone lotion is contraindicated for use in a large crater. A hydrocolloid dressing creates its own seal and cannot be used until the eschar has been re-moved.
You might also like to view...
An 82-year-old woman with fibromyalgia reports that she is not sleeping well at night. The nurse realizes that this patient is at particular risk for which complication of fibromyalgia?
1. Falling 2. Point tenderness 3. Becoming addicted to pain medications 4. Respiratory difficulties
A client with increased intracranial pressure (ICP) is being repositioned by the nurse with the help of the family members present. Of the following, which interventions are appropriate for the nurse to teach the family? (Select all that apply
) 1. Clients with ICP should remain in a stationary position. 2. The family should use slow, gentle movements when repositioning the client. 3. The client should be returned to supine position. 4. The client should be repositioned every hour. 5. The head of the bed should be elevated.
As diabetic retinopathy progresses, the presence of "cotton wool" spots can be detected. Cotton wool spots refer to:
a. Nerve fiber layer infarctions. c. Venous beading. b. Blood vessel proliferation. d. Retinal hemorrhage.
A nurse is required to care for multiple clients in the healthcare facility. Which step
should the nurse keep in mind to allow her to provide efficient care for the clients without any difficulty? A) The nurse has to focus on clients' potential problems. B) Clients with the same health problem share a single plan. C) Every client has an individualized nursing care plan. D) The nurse seeks the physician's assistance at each stage.