The nurse is caring for a client following debridement. The nurse is most concerned with which complication?

Correct Answer: D

Rationale: The correct answer is D: Infection. Following debridement, there is an increased risk of infection due to the open wound and potential exposure of underlying tissues. Infection can lead to serious complications such as delayed healing, sepsis, and tissue damage. The nurse must closely monitor for signs of infection like redness, swelling, warmth, and purulent drainage. Incorrect choices: A: Bleeding - While bleeding can occur post-debridement, it is a common and expected complication that can usually be managed with pressure and hemostatic agents. B: Pain control - Pain is also a common post-debridement complication, but can be managed with analgesics and other pain management strategies. C: Loss of fluids - Although fluid loss can occur during debridement, it is not typically a major concern post-procedure as long as the client is adequately hydrated.

Correct Answer: C

Rationale: The correct answer is C because calamine lotion contains insoluble powders that form a protective barrier on the skin, helping to soothe and protect irritated skin in contact dermatitis. This barrier prevents further irritation and allows the skin to heal. Choice A is incorrect because calamine lotion is not a suspension of oil and water. Choice B is incorrect as calamine lotion is not an emulsion of oil and water. Choice D is incorrect because calamine lotion does not contain a mixture that causes drying when moisture is absorbed.

Correct Answer: A

Rationale: Rationale for Correct Answer (A: Skin flap): 1. A skin flap involves transferring skin and subcutaneous tissue to repair extensive tissue loss. 2. Skin flaps have a direct blood supply, ensuring better survival in large areas of deep tissue destruction. 3. The term "skin graft" usually refers to a procedure where skin is transplanted without its own blood supply. 4. Therefore, a skin flap, with its vascular supply intact, is the appropriate choice. Summary of Incorrect Choices: B: Free graft - Incorrect because free grafts lack a direct blood supply and are more suitable for smaller areas. C: Soft tissue extension - Incorrect as it does not specifically describe the technique of transferring skin and subcutaneous tissue. D: Free graft with vascular anastomoses - Incorrect as this refers to a different technique involving connecting blood vessels, not commonly used for large areas of deep tissue destruction.

Correct Answer: C

Rationale: The correct answer is C: To leave the wound open. In the case of an infected wound, leaving it open allows for drainage of pus and promotes healing by secondary intention. Closing the wound with sutures (A) can trap bacteria and worsen the infection. Steri strips (B) may not be sufficient to hold the edges together in an infected wound. Covering with a loose dressing (D) can also trap bacteria and hinder healing. Overall, leaving the wound open is the most appropriate approach to manage an infected wound effectively.

Correct Answer: B

Rationale: The correct answer is B because a circular, brown-black lesion with elevated, palpable margins is characteristic of malignant melanoma. Melanomas often have irregular borders and colors, and they may be raised. Choice A is more indicative of a vascular lesion. Choice C describes a common mole. Choice D is more typical of a dermatofibroma. In summary, B is the correct choice due to its specific characteristics associated with malignant melanoma, while the other choices describe different types of skin lesions.