Deck 66: Debriding Agents

Question 1

A client has a pressure ulcer that has not healed after 4 weeks of treatment.The nurse questions the physician about an order for which of the following therapies?

A) Frequent wound irrigations
B) Topical antibiotic therapy
C) Wound debriding agent
D) Systemic antibiotic therapy

Answer 1

Topical antibiotic therapy

Question 2

Which of the following interventions would the nurse use to prevent the development of pressure ulcers?

A) Turn the client minimally to reduce pressure
B) Refrain from bed changing
C) Place the client on a low-protein diet
D) Provide meticulous skin hygiene

Answer 2

Provide meticulous skin hygiene

Question 3

Before using fibrinolysin and desoxyribonuclease (Elase)on a client's pressure ulcer,the nurse assesses the client for allergy to which of the following?

A) Egg protein
B) Thimerosal
C) Yeast
D) Copper

Answer 3

Thimerosal

Question 4

The nurse is using a proteolytic enzyme combination product containing chlorophyll.The nurse explains to the client that this ingredient will help do which of the following?

A) Hasten debridement
B) Generate oxygen
C) Control wound odor
D) Absorb exudate

Question 5

Which of the following nursing diagnoses is not appropriate for a client with a pressure ulcer?

A) Altered cardiac output
B) Impaired skin integrity
C) High risk for infection
D) Impaired comfort

Question 6

The nurse assesses the client on collagenase therapy for the occurrence of which of the following?

A) Hemorrhage
B) Constipation
C) Bacteremia
D) Dyskinesia

Question 7

The nurse determines that wound care therapy with a proteolytic enzyme should be discontinued after noting which of the following characteristics of the wound bed?

A) Drainage is white instead of yellow
B) Only small amounts of necrotic tissue are present
C) Granulation tissue is forming
D) The tissue is spongy and yellow

Question 8

The client with a pressure ulcer is beginning topical therapy with Granulex.The nurse writes on the care plan that the dressing needs to be changed how many times per day?

A) One
B) Three
C) Four
D) Six

Question 9

A new orientee questions the nurse about the use of proteolytic enzymes in a client with a pressure ulcer.The nurse explains that these enzymes are used for chemical debridement because they

A) enhance protein synthesis.
B) facilitate the proliferation of fibrin.
C) produce eschar.
D) digest or liquefy necrotic tissue.

Question 10

Collagenase (Santyl)is ordered by the physician for the treatment of a client with a stage III to IV sacral pressure ulcer.The nurse would do which of the following to use this agent appropriately?

A) Refrigerate the solution after use to maintain stability
B) Cleanse the wound area of debris by gentle irrigation with sterile normal saline before application of the solution
C) Use a mild soap to cleanse the wound before applying the agent
D) Use the agent with Burrow's solution or another acidic-type solution for maximal effects

Question 11

The nurse should assess a pressure ulcer for which common adverse effect from fibrinolysin and desoxyribonuclease (Elase)ointment being used in wound care?

A) Bleeding at wound margins
B) Yellow discoloration of wound bed
C) Local erythema and irritation
D) Increased wound drainage

Question 12

The nurse who started using a proteolytic enzyme on a pressure ulcer on Sunday makes a note in the care plan to reevaluate the wound carefully for full effect on which of the following days of the same week?

A) Monday
B) Wednesday
C) Friday
D) Saturday

Question 13

Which of the following is a contributing factor in the development of pressure ulcers?

A) Full-thickness skin
B) Adipose tissue
C) Raising the head of the bed more than 30 degrees
D) Surgical procedures

Question 14

The wound care nurse who is consulting about a client with a pressure ulcer indicates that the wound should be treated with collagenase (Santyl).The wound care nurse explains to the nursing staff that it will probably take how long for granulation tissue to appear after starting this treatment?

A) 7 days
B) 11 days
C) 21 days
D) 28 days

Question 15

A client with a pressure ulcer has an order for wound care with flexible hydroactive dressings and granules (DuoDERM).The staff nurse asks the wound care nurse why the granules are needed.Which of the following is an appropriate response?

A) "They absorb exudates from the wound."
B) "They contain slow-release proteolytic enzymes."
C) "They provide friction to aid in debridement."
D) "They keep the ointment in suspension."

Question 16

The wound care nurse would select a flexible hydroactive dressing (DuoDERM)as a product to treat which of the following skin problems?

A) Infected wound
B) Active vasculitis
C) Deep fungal infection
D) Venous stasis ulcer

Question 17

Which of the following would the nurse select first as a cleaning agent for a client's pressure ulcer?

A) Saline solution
B) Dakin's solution
C) Hydrogen peroxide
D) Acetic acid

Question 18

Before beginning an application of collagenase (Santyl),the nurse plans to apply which of the following substances to the skin to protect it from this topical debriding agent?

A) Zinc oxide paste
B) Nitrofurazone
C) Mineral oil
D) Petrolatum jelly

Question 19

A wound culture shows that an infection is present in a sacral pressure ulcer.The nurse should plan to use which of the following medications,if ordered,to treat the wound before collagenase is applied?

A) Iodine
B) Mercury compound
C) Silver nitrate
D) Polymyxin B

Question 20

The nurse needs to irrigate a wound and apply both a debriding agent and an antibacterial agent.In which order should the nurse complete these steps?

A) Irrigate the wound,then apply the debriding agent,followed by the antibacterial
B) Apply the debriding agent,then irrigate the area,then apply the antibacterial
C) Irrigate the wound,then apply the antibacterial,followed by the debriding agent
D) Mix the debriding agent and antibacterial together and apply them after the irrigation