Nokea
A 28-year-old male patient at your clinic reports a minor motorcycle accident that occurred 5 days ago, resulting in several scrapes and wounds. The wound on his calf has a pinkish-red center area that appears bumpy. What does this indicate about the wound?
- A. Beginning to heal
- B. Suppurating
- C. Becoming infected
- D. Needs to be debrided
Correct Answer: A
Rationale: Pinkish-red, bumpy tissue indicates granulation, a sign of healing in the proliferative phase.
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A nurse performing a right eye irrigation will position the patient in which of the following ways?
- A. Upright with the head tilted toward the left eye.
- B. Supine with the head hyperextended.
- C. Upright with the head hyperextended.
- D. supine with the head tilted toward the right eye.
Correct Answer: A
Rationale: Tilting the head toward the unaffected (left) eye allows fluid to flow from the right eye outward, avoiding contamination.
The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:
- A. Drawing the wound edges together using negative pressure.
- B. Strengthening the wall of the wound.
- C. Interrupting the proliferation of bacteria in the wound.
- D. Making and air occlusive cover for the wound
Correct Answer: A
Rationale: Vacuum-assisted closure uses negative pressure to draw wound edges together, promoting granulation and healing.
A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
- A. Keep the wound dry.
- B. Leave the dressing in place for 7 days.
- C. Help destroy microorganisms in an infected wound.
- D. Promote a moist healing environment.
Correct Answer: D
Rationale: Hydrocolloid dressings maintain a moist environment to promote autolytic debridement and healing, not to dry the wound or kill microbes directly.
A nurse is concerned about an HIV immunocompromised patient's ability to heal due to a lack of certain factors. Which of the following are necessary for proper wound healing? (Select all that apply.)
- A. Adequate fibroblast function
- B. Intrinsic factor
- C. Synthesis of collagen
- D. Hemoglobin
- E. Adequate phagocytosis
Correct Answer: A,C,D,E
Rationale: A: Fibroblasts produce collagen. C: Collagen strengthens the wound. D: Hemoglobin delivers oxygen. E: Phagocytosis removes debris. Intrinsic factor (B) is unrelated to wounds.
The nurse places Dakin's solution in a wound for which purpose?
- A. Chemical debridement
- B. Healing
- C. Phagocytosis
- D. Primary intention
Correct Answer: A
Rationale: Dakin's solution chemically debrides by breaking down necrotic tissue.