Foundations Exam 2- Supplement

A patient who has had a number of postoperative complications appears upset and agitated, yet withdrawn. Which is the most appropriate statement by the nurse?

"You've been having a pretty rough time of it since surgery."

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding?

+1 edema Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal will the nurse include in Alexander's plan of care?

. Client's skin will remain intact A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.

After Alexander receives the first dose of linezolid, a rash and itching develop on his thorax, but he has no respiratory symptoms. Which class of medication should the nurse expect to administer?

.An antihistamine, such as diphenhydramine. An antihistamine should control the itching and rash of this reaction. Rash and itching are identified side effects of linezolid. The nurse should, however, continue to monitor for a more severe

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal?

A 1 cm hypertrophy of the right upper arm Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm Fasciculations are fine muscle twitches that normally are not present. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal.

The patient with pneumonia requires which of the following?

A private room Droplet isolation

Which identifies accurate nursing documentation notation(s)? Select all that apply.

Abdominal wound dressing is dry and intact without drainage The client slept through the night The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

The nurse is preparing to admit a patient with a confirmed measles diagnosis. The nurse will prepare the room for which type of isolation?

Airborne Isolation

Considering Alexander's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group?

Alexander's girlfriend and his two best male friends from the college. As a young adult, Alexander's primary developmental task, according to the theorist Erikson, is to develop intimacy. The nurse should emphasize interaction with a small group of intimate friends to support this developmental task.

A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in the patient?

Altered nutrient metabolism

Pharmacology: Antibiotics Prior to administering the first dose of the antibiotic, the nurse asks Alexander about any drug allergies. The nurse explains to Alexander that this precaution reduces the risk for what potential problem?

Anaphylactic reaction. An anaphylactic reaction is a severe allergic response that can be life threatening.

A tether is:

Anything attached to a patient or possibly impeding a patient's movement

11. Which intervention is important to reduce the effect of the diarrhea on Alexander's skin?

Apply a moisture-repellent ointment to intact skin areas. . After the skin is cleaned and dried, a moisture-repellent ointment should be applied to protect and moisturize the skin. Fecal toxins are damaging to tissue, and excessive moisture causes skin

After assessing for sinus tracts, the nurse irrigates the wound as prescribed with normal saline, Which irrigation technique is best?

Apply steady pressure using a 35 ml syringe and 19 gauge needle. Correct PSL. Using a 35 mL syringe and 19 gauge needle provides 8 pounds per square inch (PSI), which applies adequate pressure to ensure effective irrigation, Safe, effective pressure is between 4 and 15 PSI. More than 15 PSI will drive bacteria into the wound and destroy healthy tissue

The nurse is caring for a client who has had surgery and has been confined to bed for the past 3 days. The nurse is preparing to get the client out of bed for the first time. What precautionary measure will the nurse take when getting this client up?

Assist the client to sit and dangle her feet over the bed before standing up The client should be placed in a sitting position and should dangle her feet at the bedside for a few minutes before the nurse helps her stand up. Orthostatic hypotension commonly occurs when immobilized clients are out of bed for the first time. If the client tolerates sitting, then stand the client at the bedside and assess her tolerance for standing before allowing her to begin walking away from the bedside. A semi-Fowler's position does not eliminate the effects of immobility. Thigh-high antiembolism stockings should already be on the client, and they should be in place before getting the client out of bed.

The nurse is conducting a class on preventing complications of immobility for nursing assistants who are working in a long-term care facility. What is important information for the nurse to include?

Assist the clients to get out of bed and walk short distances Getting the client out of bed and bearing weight on the legs are critical in preventing venous stasis in the lower extremities and in maintaining muscle tone. Long-term care clients should be mobilized as much as possible, and weight bearing should be included if possible. Passive ROM is not as effective as active ROM. The client's fluid intake should be increased for healthy hydration. The client's legs should not be rubbed because rubbing precipitates an increased risk of dislodging an embolus from the venous stasi

A patient has been on bed rest with cervical traction for 2 weeks. The traction is discontinued, and the patient has an order to ambulate. Prior to getting the patient out of bed, it is important for the nurse to take which of the following initial actions?

Assist the patient in sitting on the side of the bed for several minutes before standing Raise the head of the bed slowly Take the patient's blood pressure while the patient is sitting upright prior to standing

A nurse plans to meet the hygiene needs of a patient is experiencing left sided weakness due to a recent brain attack (stroke). Which is appropriate nursing intervention?

Assisting with the bath as needed

Which laboratory values should be monitored during the course of antibiotic treatment with linezolid?

CBC. This medication may cause bone marrow suppression, anemia, leukopenia, or pancytopenia.

Surgical patients are routinely cleansed in the following way prior to transfer to the OR.

CHG bath

A wound culture indicates that Alexander's wound is infected with methicillin-resistant Staphylococcus aureus (MRSA). After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client?

Contact precautions. as well as contact with infected surfaces. The client should be cared for using contact precautions when there is potential for wound drainage and debris to splatter during care. The mode of transmission of MRSA includes direct contact,

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

A nurse plans to foster therapeutic communication with a patient. Which is important for the nurse to do?

Demonstrate respect when discussing emotionally charged subjects

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR?

Document the correct information and end with the nurse's signature and title Obtain a cosignature from the RN who witnessed the waste of the remaining 1mg Modify the entry to reflect the correct information Document in a nurse's note in the client's record detailing the corrected information Electronic health records (EHR) will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the MAR, the nurse can click on the entry (usually right-click) and modify it to reflect the corrected information. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication, to validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary in this situation

Client Teaching: Wound Healing The home care nurse teaches Alexander about dietary measures to promote wound healing and emphasizes the need for extra protein. The nurse encourages him to select which breakfast items to provide a good source of protein?

Eggs and orange juice. Eggs are a good source of protein, iron, and zinc, which are all important for wound healing. Citrus juices, such as orange juice, are a good source of vitamin C. which is also important for wound healing.

A nurse is supervising a nursing team consisting of two nurses and two nursing assistants. Which tasks can the nurse delegate to the nursing assistants?

Emptying a urine drainage bag Weighing a patient using a bed scale Performing passive range of motion exercises

What is the best nursing action to prevent pulmonary emboli in clients who are immobilized?

Encourage dorsiflexion and rotation of the feet To prevent pulmonary emboli, it is important to prevent venous stasis. Dorsiflexion of the feet and rotation of the feet at the ankles causes contraction of the muscles in the leg and increases venous tone, thereby decreasing venous stasis. The other three options are important nursing actions for the immobilized client; however, these actions do not prevent venous stasis and possible thrombophlebitis.

When providing oral hygiene to a patient, the nurses first priority is to assess:

Ensure the patient has a gag reflex

Phases of nursing clinical judgment that are most frequently documented are:

Evaluate outcomes Take action Analyzing cues

Which essential role does the nurse play in the health care team between multiple primary health care providers and specialists?

Facilitates communication between the team Nurses play a key role in facilitating communication between primary health care providers and specialists. The nurse is the center of collaboration for the client. It is necessary to communicate and share the client's information where and to who it is needed most. The nurse does not diagnose. Options 3 and 4 may be actions that the nurse takes, but these are not associated with the essential role the nurse plays in the health care team between multiple primary health care providers and specialists.

To prevent complications of immobility, what would be the most effective activity to implement for a client on the first postoperative day after a colon resection?

Get the client out of bed and ambulate to a bedside chair Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing. Passive ROM maintains joint mobility but is not as effective as weight bearing to prevent venous stasis and the complications of immobility. Turning and coughing every 30 minutes around the clock is too often—it would disrupt effective rest and sleep; every 2 hours is the standard. Prevention of complications of immobility begins when the client becomes immobilized

The nurse identifies that Alexander has developed a Stage 1 pressure ulcer and is concerned that Alexander may have other pressure ulcers, 3. Which areas are most important for the nurse to observe for additional pressure ulcers?

Heels and ankles.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client?

Help the client identify the causes of the anxiety Ask the client to identify how he or she feels If a client experiences anxiety, immediate actions are to provide a calm environment, decrease environmental stimuli, and stay with the client. Excess stimulation would escalate the anxiety. Next, asking the client to identify what and how he or she feels and helping the client to identify the causes of the feelings increase the client's awareness of the connection between behaviors and feelings. This awareness helps to decrease the anxiety. While listening to the client, the nurse observes for expressions of helplessness and hopelessness that could indicate self-harm intentions. The nurse provides follow-up care as needed, based on observations and assessments. Finally, the nurse documents the event, significant information, actions taken and follow-up actions, and the client's response. Turning the TV on ignores the client's feelings and increases stimuli. Leaning casually against the wall with the arms crossed presents a defensive stance.

A nurse is admitting a new patient. Which of the following labs would be of greatest concern to the nurse?

Hematocrit (HCT) of 25

The nurse identifies a priority problem for Alexander's plan of care as "impaired skin integrity." Which etiology identified by the nurse is accurate?

Impared physical mobility Since Alexander is paraplegic, he has impaired physical mobility, a major factor that contributes to pressure ulcer development

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Nigeria. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0° C (100.4° F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the primary health care provider and other state and local authorities of the client's signs and symptoms.

A patient who has been in isolation for Clostridium difficile (C. diff) asks the nurse to explain what he needs to know about this organism. Which of the following statements indicates the need for further education?

It is not necessary for family members to wear gloves while in the room with the patient

A nurse caring for patients in the critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care?

It promotes the patient's sense of well-being It decreases the incidence of pneumonia in patients with artificial airways. It may improve the patient's appetite and the taste of food

The nurse is caring for a client who is on bed rest. What nursing measures will the nurse implement to assist in preventing pulmonary complications?

Maintain good hydration status Encourage turning, coughing, and deep breathing Perform ROM exercises with the feet and legs Place the client in a semi-Fowler's position Semi-Fowler's position, coughing, and deep breathing, along with good hydration, will assist in maintaining good pulmonary hygiene and thus avoiding pulmonary complications. Dorsiflexion and rotation of the feet will facilitate muscle contraction and increase venous tone to assist in prevention of venous stasis and pulmonary emboli. Prevention, not treatment, of a problem is the priority. Clients should not be suctioned on a routine basis. Body alignment will help prevent musculoskeletal and skin problems, not pulmonary problems.

Alexander states, "I'm sorry I yelled at you, but I'm so discouraged about this bed sore and the infection." How should the respond respond to Alexander's statement?

O "You are trying to cope with a lot of concerns right now." This response acknowledges the client's experience and encourages further insight and verbalization by the client.

The home care nurse observes that Alexander's ulcer is red, with obvious granulation tissue filling in the ulcer crater. What teaching should the nurse provide?

O Hydrocolloid dressings should be continued over the ulcer. The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid dressing.

During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. 4. What action should the nurse implement?

O Identify these areas as sites where pressure damage has occurred. Palpable changes in the consistency of the tissue underlying a bony prominence, often described as spongy an indication that pressure damage has occurred. Additional manifestations may include a change in skin temp and Induration

The nurse observes that the reddish at es is round and is directly over the clients sacrim. The wkkin is intact. In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform?

O Measure the diameter of the redness. O Apply light pressure to the area with the fingertips. (To assess for blanching,

The nurse correctly uses which technique when pouring the suspension?

O Place the medication cup on a flat surface at eye level. To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.

The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document?

O Reactive hyperemia- occurs when tíssue is relieved of pressure. It is considered normal when the redness lasts longer than 1 hour and surrounding tissues do not blanch

Psychosocial Support No evidence of drug toxicity is found. Alexander's next BP is within normal limits for him, and he has no further episodes of diarhea. The wound eschar has been removed, and there is no further drainage. A hydrocolloid dressing is placed over the wound, and Alexander is discharged. Alexander will complete the 2-week antibiotic treatment at home. Alexander, as well as when to call the HCP. Alexander yells at the The home care nurse visits Alexander a week after nurse and says, "I don't need a nurse to tell me that I will spend the rest of my life in and out of hospitals!" What initial action should the nurse take?

Offer Alexander the opportunity to discuss his feelings of anger and hopelessness. Using therapeutic communication techniques, the nurse can provide the opportunity for Alexander to deal with his concerms.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

The acronyms SWIPE In and BRowN COW represent which of the following?

Part of DCN's Universal Safety Protocol

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

Particulate respirator, gown, and gloves The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

Which of the following would require a variance report?

Patient's wife slipped and fell in the bathroom Patient fell in the bathroom Nurse had a needle stick injury Nurse almost administered the wrong medication but caught the error right as she was handing the medication to the patient

Alexander has been receiving antibiotic therapy for several days. He has a mild elevation in blood pressure and a 2 x 2 had two diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatoxicity related to antibiotic use. cm bruise in the antecubital space, where blood was obtained earlier that day, and he has Which diagnostic test should the nurse request a prescription for to determine if Alexander is developing drug toxicity?

Peak and trough. Serum drug levels are obtained at the highest (peak) and lowest (trough) levels, which provides useful information regarding the amount of drug the individual client has in the bloodstream, If the trough is greater than the acceptable limit for the drug, the next dose should be withheld and the blood level rechecked 6 hours later.

Medication Administration: Administering a Liquid Suspension by Mouth Before pouring the suspension, the nurse determines that the medication and dose on the bottle's label are correct as prescribed, but the client name listed on the bottle is incorrect. Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?

Pharmacist Incorrectly labeled medications are the responsibility of the pharmacist

Which nursing intervention most requires he nurse to consider the concept of personal space?

Providing a bed bath

A month later, Alexander arrives in the emergency department at the local hospital. He reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that the sacral ulcer is open, has a crater-like present. Alexander is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. He is admitted to the hispital with a fever, fluid volume defecit, and possible sepsis Which documentation best describes the drainage from Alexander's wound?

Purulent. Purulent refers to something that contains or produces pus, Pus is an indication that an infection is likely.

It is most important to include this group in which aspect of Alexander's overall care?

Reviewing class notes and studying for exams. The young adult is developmentally involved in establishing intimacy and working toward future goals. In addition, studying with his peers will help maintain a sense of normalcy for Alexander. Other tasks can easily be performed by other groups, such as family members. This task can best be performed by his peers.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?

The client was found lying on the floor The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

A client has been involved in an accident, does not speak English, is hemorrhaging, and requires immediate surgery. No one is with him. What is the best way for the nurse to handle this situation?

The nursing staff and the surgical team should prepare to continue with the impending surgery If the client's life is at risk and consent cannot be obtained from the client, the surgery required to save the life is performed without client consent. Because this is an emergency situation, it would not be necessary to contact the hospital ethics review board, as valuable time would be lost. An interpreter is on call; again, valuable time would be lost trying to get the interpreter to the hospital. The physician signing and witnessing the attempts is not necessary. (Zerwekh, Garneau, 8 ed., p. 475.)

The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching?

The use of an interpreter does not need to occur until the client requests one The use of an interpreter should occur regularly and frequently while interacting with the client. Family members and friends should not be asked by a health care professional to be an interpreter. Confidentiality, conflict of interest, and the risk of relaying inaccurate information are all barriers to not using a designated health care agency interpreter.

At the end of the appointment, the nurse provides client teaching about measures to promote healing and to prevent further tissue destruction. To provide pressure relief at night, the nurse teaches Alexander to sleep in which position?

Thirty-degree lateral inclined position. This position best reduces pressure on bony prominences where pressure ulcers frequently develop. Pillows and foam wedges may be used for support and protection in this position.

The nurse type teaches Alexander to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer?

Transparent film dressing. This type of dressing allows for visualization of the area and protects it from shear.

When the medication bottle is property relabeled, the nurse mixes the suspension prior to pouring it. Which technique should the nurse use to mix the linezolid?

Turn the bottle upside down 3 to 5 times. This method mixes the suspension according to manufacturer's specifications. Linezolid should never be shaken.

Medication Administration: Ongoing Monitoring The nurse monitors lab values and assesses for adverse effects during the course of Alexander's treatment with linezolid. What should the nurse assess Alexander for during the course of.antibiotic therapy?

Visual changes. Client's should be monitored for changes in visual function due to possibility of optic neuropathy.

Which side effects should the nurse include when teaching Alexander about linezolid therapy? (Select all that apply.)

Visual changes. Visual changes may be a side effect of the medication and should be reported to the HCP immediately. Itching. Itching may be associated with an allergic reaction to this medication and should be reported to the HCP immediately. Abdominal cramping. Diarrhea, abdominal cramping, and blood stools may be a side effect of this medication. These signs should be reported to the HCP immediately as they are signs of clostridium difficile associated Diarrhea Diarrhea, abdominal cramping, and blood stools may be a side effect of this medication. These signs should be reported to the HCP immediately as they are signs of clostridium difficile associated

Which of the following are biological barriers to effective communication?

Visual impairment Cognitive impairments Hearing impairment

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

d. Gloves, gown, goggles, and a mask or face shield Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

The nursing process (nursing care plan) is not part of the EMR.

false

Legal/Ethical Issue The nurse prepares a written positioning schedule and places it in Alexander's room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with Alexander's care. The charge nurse removes the schedule and states that it violates Alexander's privacy. What action should the nurse take?

• Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights. A written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client's room without compromising client confidentiality

Upon learning that Alexander has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take?

• Encourage him to continue to use this device in his wheelchair at all times. These cushions help redistribute weight so that it is not all on the ischium. The client should also be instructed to shift weight frequently.

Following wound irigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing?

• Mechanically debride the tissue. Moistened gauze is placed on the wound and allowed to dry. It then adheres to the wound tissue and debrides necrotic or infected tissue as it is removed.

The nurse suspects that Alexander's wound has developed a sinus tract, or tunneling Which equipment will the nurse use to assess the length of the tract?

• Sterile cotton-tipped applicator. A sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the location and length of the tunneling