Nokea
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.
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While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
- A. Empty the reservoir.
- B. Notify the surgeon about the drainage.
- C. Remove the drain
- D. Leave it until the end of the shift
Correct Answer: A
Rationale: Emptying the reservoir maintains drainage function and allows monitoring of output; significant changes would then prompt notifying the surgeon.
When giving a hot soak treatment, what is most important to ensure?
- A. Soak only the affected area.
- B. Position the patient comfortably.
- C. Monitor the temperature of the water.
- D. Check the patient's skin integrity.
Correct Answer: C
Rationale: Monitoring water temperature prevents burns, the primary safety concern with hot soaks.
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.
The patient is undergoing Negative Pressure Wound Therapy (NPWT) treatment for wound healing. Which would be your first priority in caring for this patient?
- A. Assess the patient for any complaints or problems in the wound area.
- B. Check the settings on the NPWT unit.
- C. Document your findings.
- D. Observe the dressing area.
Correct Answer: A
Rationale: Assessing the patient's condition first ensures any immediate issues (e.g., pain, leakage) are addressed.
When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?
- A. Sanguineous
- B. Serous
- C. Serosanguineous
- D. Purulent
Correct Answer: C
Rationale: Yellow-red drainage indicates serosanguineous (serum and blood mix), not purulent (pus) or sanguineous (blood only).