A client is receiving negative pressure wound therapy (NPWT) for a chronic wound on the lower leg. The nurse observes that the wound edges are approximated and granulation tissue is filling the wound bed. Which action should the nurse take?

Correct Answer: C

Rationale: Discontinuing NPWT and applying a moist dressing is the correct action when wound edges are approximated and granulation tissue fills the bed. This indicates successful healing progression, as NPWT has achieved its goals removing fluid, reducing edema, and stimulating tissue growth. Continuing beyond this point risks overgranulation or maceration, while a moist dressing supports epithelialization in the final stages. Increasing dressing changes disrupts healing and isn't warranted with good progress. Decreasing pressure reduces efficacy unnecessarily, as the therapy's work is largely done. Continuing until complete closure may over-treat, causing complications like tissue overgrowth. Transitioning to a moist dressing aligns with wound healing phases, shifting from granulation support to surface closure, reflecting evidence-based practice for chronic wound management.

Correct Answer: A

Rationale: Hydrocolloid is the correct dressing to promote moist wound healing in a stage 3 pressure ulcer. Its occlusive, adhesive nature forms a gel over the wound, retaining moisture, facilitating autolytic debridement, and protecting from contamination ideal for deeper wounds with moderate drainage. Transparent film allows oxygen exchange but doesn't absorb exudate or cushion, better for stage 1 ulcers. Calcium alginate is highly absorbent for heavy drainage, more suited to stage 4 ulcers, and less focused on moisture retention alone. Gauze can stick and dry out, disrupting healing and causing trauma. Hydrocolloid's moisture-maintaining properties support granulation and epithelialization in a stage 3 ulcer, reducing pain and enhancing recovery, making it the optimal choice.

Correct Answer: B

Rationale: Two,' because the skin comprises two primary layers the epidermis and dermis excluding the subcutaneous tissue layer, which is beneath the skin proper. The epidermis, the outermost layer, acts as a waterproof barrier and protects against pathogens, while the dermis, below it, houses blood vessels, nerves, and glands, providing strength and elasticity. The subcutaneous layer, or hypodermis, is a separate entity of fat and connective tissue, not counted as a skin layer but as underlying support. 'One' is incorrect, as it ignores the dermis. 'Three' might confuse the subcutaneous layer as a skin layer, which it isn't in standard terminology. 'Four' exceeds the anatomical structure entirely. This distinction is vital in nursing for assessing skin integrity and wounds, as each layer's condition affects healing and care strategies, making 'Two' the accurate choice based on established skin anatomy.

Correct Answer: A

Rationale: Primary intention,' as it describes intentional wounds (e.g., surgical incisions) with minimal tissue loss and closely approximated edges, typically closed with sutures or staples. This method promotes rapid healing, minimal scarring, and low infection risk due to immediate edge alignment. 'Delayed primary intention' involves intentional wounds left open briefly before closure, not immediate approximation. 'Secondary intention' applies to wounds with significant tissue loss, healing open from the base up, with unapproximated edges. 'Tertiary intention' combines initial open healing with later closure, also not immediate. In nursing, primary intention is standard for clean surgical wounds, ensuring efficient recovery. The question's emphasis on minimal loss and close edges rules out alternatives, making A the precise fit per wound healing classifications.

Correct Answer: C

Rationale: Joe Swanson, because he is a paraplegic,' as immobility is the primary risk factor for pressure ulcers. Paraplegia limits movement, causing prolonged pressure on skin over bony prominences (e.g., sacrum), reducing blood flow and leading to tissue breakdown. 'Obesity' increases pressure but allows repositioning unless bedridden. 'Minor brain impairment' may affect awareness, not mobility directly. 'Infant' risks skin fragility, but frequent care mitigates pressure. In nursing, assessing mobility is key Joe's paralysis heightens vulnerability, requiring interventions like turning schedules. C's direct link to sustained pressure distinguishes it as the highest risk per pressure ulcer etiology.