A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?

Correct Answer: D

Rationale: Consulting with the provider about surgical debridement is the correct action for a diabetic foot ulcer with black, dry, hard eschar. Eschar indicates significant necrotic tissue, which delays healing and heightens infection risk in diabetic patients, who are prone to complications due to poor vascularity and immune response. Surgical debridement swiftly removes this barrier, exposing viable tissue for healing, and is the most efficient method for extensive necrosis. Wet-to-dry dressings are outdated and inappropriate for dry eschar, as they're better for moist slough and can harm healthy tissue. Transparent film traps moisture but doesn't address necrosis, risking infection beneath the eschar. Leaving it open to air invites contamination and drying, slowing recovery. Given the wound's severity and diabetes context, consulting for surgical intervention ensures timely, effective management, reducing risks like osteomyelitis or amputation.

Correct Answer: C

Rationale: Alginate is the correct dressing for a stage 3 pressure ulcer with moderate serosanguineous drainage, depth, and mixed tissue. Derived from seaweed, alginate absorbs moderate to heavy exudate (up to 20 times its weight), forming a gel that maintains moisture, supports autolytic debridement of the 20% slough, and fills the 2 cm depth, promoting healing. Hydrocolloid suits minimal drainage, risking maceration in deeper, exudative wounds. Hydrogel hydrates dry wounds but can't handle moderate drainage, potentially leaking. Transparent film is non-absorbent, unfit for exudate or depth, and better for superficial wounds. Alginate's absorbency and adaptability make it ideal for this wound's characteristics, balancing moisture and clearing debris effectively.

Correct Answer: C

Rationale: Primary intention wound is the correct documentation for a wound with approximated edges, minimal drainage, and visible granulation tissue. This healing type occurs when edges are closed (e.g., by sutures), minimizing tissue loss and scarring, with granulation supporting epithelialization. Partial-thickness involves only epidermis and part of dermis, healing by regeneration, not matching the deeper granulation here. Full-thickness extends to subcutaneous layers, healing with significant scarring, not minimal drainage. Secondary intention involves open wounds with extensive loss, healing slowly via granulation and contraction, not approximated edges. Primary intention fits the orderly, efficient healing observed, reflecting a controlled closure process typical of surgical or well-managed wounds.

Correct Answer: D

Rationale: A and C,' as unintentional wounds are characterized by being accidental and often having clean edges, depending on the cause. 'Accidental' fits because unintentional wounds result from unplanned events like falls or cuts, not deliberate actions like surgery. 'Clean edges' applies to wounds from sharp objects (e.g., a knife slice), common in accidents, though not universal jagged edges can occur too. 'High risk for infection' isn't exclusive to unintentional wounds; it depends on contamination, not intent, and intentional wounds (e.g., surgical) can also get infected if mishandled. Combining A and C captures key traits without overgeneralizing infection risk. In nursing, recognizing these features aids assessment accidental wounds may need tetanus prophylaxis, and clean edges suggest primary closure potential. 'All of the above' (E) overstates infection specificity, making D the precise choice per wound classification principles.

Correct Answer: D

Rationale: Obtain clean towels,' as it's a mistake in managing dehiscence a surgical wound reopening. Proper protocol requires sterile materials (e.g., saline-moistened sterile dressings) to cover the wound, preventing contamination, not just clean towels, which may harbor bacteria. 'Notify the physician' is correct urgent reporting is essential. 'All of the above have mistakes' is wrong, as A is valid. 'None of the above have mistakes' overlooks D's error. In nursing, sterility is critical in dehiscence to avoid infection or evisceration; clean towels fail this standard. The document lists 'Moisten towels with sterile 0.9% sodium chloride' separately, implying D's non-sterile intent is the flaw, making it the mistaken step.