A client with diabetes mellitus has a diabetic foot ulcer on the left heel. The nurse is preparing to apply a hydrocolloid dressing to the wound. What is an advantage of using this type of dressing?

Correct Answer: D

Rationale: as hydrocolloid dressings stimulate autolytic debridement of necrotic tissue, a key advantage for a diabetic foot ulcer. These dressings are occlusive, forming a gel-like layer over the wound that traps moisture and enzymes, naturally breaking down dead tissue without mechanical intervention. This process is gentle, reducing trauma to surrounding healthy tissue, which is crucial for diabetic patients prone to slow healing. While providing a moist environment is true, it's not unique to hydrocolloids other dressings like hydrogels also do this making it less specific. Absorbing large amounts of exudate is incorrect, as hydrocolloids handle only minimal to moderate drainage, unlike alginates, and can leak if overwhelmed. Allowing frequent inspection is false; hydrocolloids are opaque and typically left in place for days, not designed for regular viewing. Autolytic debridement stands out as the distinct benefit, supporting healing in chronic wounds like diabetic ulcers by clearing necrotic debris efficiently.

Correct Answer: D

Rationale: Gangrene or necrosis of the toes is the correct finding to alert the nurse to a potential complication in an arterial ulcer. Arterial insufficiency reduces blood supply, causing ischemia, and gangrene dead tissue from prolonged oxygen deprivation signals severe progression, risking amputation or infection if not addressed urgently. Absent or diminished pedal pulses are expected in arterial insufficiency, reflecting chronic poor perfusion, not an acute complication unless suddenly worsening. Cold, pale, or cyanotic skin is typical due to low oxygen delivery, a baseline sign rather than an immediate threat. Loss of hair growth results from chronic nutrient deficiency, not an emergent issue. Gangrene escalates the situation, indicating critical tissue loss beyond typical arterial ulcer symptoms, necessitating immediate provider notification for intervention.

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.