Nokea
A nurse is ambulating a patient in the hall a few days after abdominal surgery when the patient says, "I think something just let go." What should be the nurse's initial intervention?
- A. Ask someone to quickly get an abdominal binder.
- B. Seat the patient in a nearby chair.
- C. Instruct the patient to pant to reduce abdominal tension.
- D. Assist the patient into a supine position.
Correct Answer: D
Rationale: Assisting to a supine position reduces strain on the abdominal wound, preventing further dehiscence.
You may also like to solve these questions
Which type of wound debridement is Dakin's solution used for?
- A. Autolytic debridement
- B. Sharp debridement
- C. Enzymatic debridement
- D. Chemical debridement
Correct Answer: D
Rationale: Dakin's solution is a chemical debridement agent that breaks down necrotic tissue.
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.
What type of wound heals by edges approximating with a suture?
- A. Secondary intention.
- B. Remodeling phase.
- C. Primary intention.
- D. Tertiary intention.
Correct Answer: C
Rationale: Primary intention healing occurs when wound edges are brought together with sutures, minimizing scarring. Secondary intention heals open wounds, tertiary delays closure, and remodeling is a phase, not a type.
The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip. He states that it is painful. This is indicative of which stage of pressure injury?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: A
Rationale: Stage 1 pressure injuries present as non-blanchable redness with intact skin and may be painful.
The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: B
Rationale: Stage 2 involves partial-thickness loss with a pink, viable wound bed, unlike Stage 1 (intact skin) or Stage 3 (full-thickness).