Nokea
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.
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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.
When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:
- A. He has lain in one position for such a long time that swelling has occurred.
- B. An infection is in progress at the wound site.
- C. There is probably a deeper injury than what appears on the surface.
- D. Vessels have dilated and allowed plasma to leak into the wound site.
Correct Answer: D
Rationale: Swelling from dilated vessels leaking plasma is part of the inflammatory response, not necessarily infection.
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.
After closing the curtain around the client's bed and lifting his gown to expose the horizontal abdominal wound, which of the following positions should you assist the client into for comfortable wound irrigation?
- A. High-Fowler's
- B. Side-lying
- C. Supine
- D. Dorsal Recumbent
Correct Answer: D
Rationale: Dorsal recumbent position allows access to the abdominal wound while keeping the client comfortable and stable.
A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?
- A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle.
- B. Double bag the dressing, label it "biohazard," and send it for decontamination.
- C. Discard the dressing in the bedside trash receptacle.
- D. Place the dressing in a biohazardous waste container.
Correct Answer: D
Rationale: Blood and purulent drainage require disposal in a biohazard container per infection control standards.