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.
A parish nurse checks the blood pressure of a church member
Debridement, or wound cleansing.
Responsibilities of the nurse manager
Sample client goals from the Wellness Massage Pyramid.
Measuring the client’s blood pressure