The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound?

Correct Answer: B

Rationale: Stage 1 injuries are intact. Transparent dressing , per Braden Scale care, protects non-open skin (red, no breakdown) while allowing monitoring. Hydrogel adds moisture for open wounds. Antimicrobial targets infection, unneeded here. Alginate suits heavy drainage. Transparency preserves integrity and prevents progression, making it the expected choice.

Correct Answer: D

Rationale: as the nurse should monitor for both hypersensitivity or allergic reaction and leukopenia or decreased white blood cell count when using silver sulfadiazine (Silvadene) on a burn wound. This topical antimicrobial can cause allergic reactions like rash, itching, or swelling, which may escalate to severe symptoms like difficulty breathing, requiring immediate attention. It can also lead to leukopenia, a drop in white blood cells, increasing infection risk, necessitating regular blood count monitoring. Hyperglycemia isn't a typical adverse reaction to Silvadene; it may occur in burn patients due to stress or infection, not the cream itself. Since both A and B are valid concerns supported by the need for baseline and periodic complete blood counts choice D encompasses the full scope of critical monitoring, ensuring comprehensive care for potential complications.

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: 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: 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.