Author Question: A client requires wound debridement. The nurse is aware that which of the following statements is ... (Read 52 times)

Chelseaamend · **on:** Jul 22, 2018

A client requires wound debridement. The nurse is aware that which of the following statements is correct regarding this procedure?

a. This procedure involves flushing debris from wounds.
b. This procedure involves the removal of nonviable necrotic tissue.
c. Mechanical methods involve direct surgical removal of the eschar layer of the wound.
d. Enzymatic debridement may be implemented independently by the nurse when-ever it is required.

Question 2

While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first do which of the following?

a. Support the client and walk quickly back to the room.
b. Lean the client against the wall until the episode passes.
c. Lower the client gently to the floor.
d. Go for help.

bob · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to allow visuali-zation of the wound bed, and to provide a clean base necessary for healthy tissue to regenerate.
Irrigation is a method of delivering cleansing solution to a wound.
Mechanical methods include wet-to-dry dressings, wound irrigation, and whirlpool treatments. Surgical debridement involves direct surgical removal of the eschar layer of the wound.
Enzymatic debridement requires a physician's order.

Answer to Question 2

C
If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the client's weight to prevent injury. To extend the front leg, the nurse should move his/her back foot further away, and let the client slide against the forward leg to ease the client to the floor.
The nurse should not attempt to walk the client quickly back to the room.
The nurse should not lean the client against a wall as he or she might fall.
The nurse should not leave the client alone and go for help.