Nokea
A nurse is assisting with the care of a client who arrives at the emergency department following an industrial explosion. Upon inspecting the wound on the client's leg, the nurse finds torn skin tissue underneath. Which of the following types of wounds should the nurse report?
- A. Contusion
- B. Laceration
- C. Abrasion
- D. Puncture
Correct Answer: B
Rationale: A laceration is a tear in the skin, fitting the description of torn tissue from an explosion.
You may also like to solve these questions
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 caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?
- A. Applying hydrocolloids to the wound bed.
- B. Pulsating lavage.
- C. Using a topical enzyme solution in the wound bed.
- D. Placing a transparent dressing over the pressure injury.
Correct Answer: B
Rationale: Pulsating lavage is a mechanical debridement method using a pressurized stream of fluid to remove necrotic tissue. Hydrocolloids promote autolytic debridement, enzymes are chemical, and transparent dressings do not debride.
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.
Because the patient with an abdominal dressing requires frequent dressing changes, and the abdomen is beginning to show skin irritation from repeated tape removal, the nurse would change the dressing procedure in order to use:
- A. Elastic adhesive tape.
- B. Karaya paste.
- C. Montgomery straps.
- D. Paper tape.
Correct Answer: C
Rationale: Montgomery straps allow frequent dressing changes without removing tape from the skin, reducing irritation.
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.