Upon changing the client's dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is:
1. Sterile saline
2. Hydrogen peroxide
3. Povidone-iodine (Betadine)
4. Sodium hypochlorite (Dakin's solution)
ANS: 1
Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite (Dakin's solution) are cytotoxic and therefore should not be used to clean a wound that is granulating.
You might also like to view...
A child was sent to the school nurse because of a rash. The nurse noted the rash was present on the trunk, extremities, and face. The child's cheeks were bright red. With what is the nurse aware this type of rash is consistent?
a. Measles b. Roseola c. Varicella d. Fifth disease
Which question would the nurse ask to best assess an older female client's report that she is experiencing decreased sexual pleasure?
a. "When did you first notice the problem?" b. "Which medications are you currently taking?" c. "What do you mean by decreased sexual pleasure?" d. "Is your partner also experiencing a problem?"
Catherine has head lice and her mother is asking about what products are available that are not neurotoxic. The only non-neurotoxin head lice treatment is:
1. Permethrin 1% (Nix) 2. Lindane shampoo 3. Malathion (Ovide) 4. Benzoyl alcohol (Ulesfia)
The nurse is teaching a pregnant 14-year-old patient who is at 10 weeks' gestation about the expected body changes that will occur during pregnancy. Which patient statement indicates that additional information is needed?
1. "My breasts are going to get even bigger than they've gotten over the past couple of years." 2. "My belly will gradually get more round, especially from the middle of pregnancy on." 3. "My hair will feel thicker until I deliver, and then I'll lose more hair than usual for a few weeks." 4. "My skin won't change, and I'll look just as good in a bikini next year as I did last summer."