Nokea
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.
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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).
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.
Chronic wounds that are not healing well may benefit from (Select all that apply):
- A. Promoting protein in the diet.
- B. NPWT therapy.
- C. Wet-to-dry dressings.
- D. Hydrocolloid dressings.
- E. Tolerate pressure treatment.
Correct Answer: A,B,D
Rationale: A: Protein aids tissue repair. B: Negative Pressure Wound Therapy promotes healing. D: Hydrocolloids maintain moisture. Wet-to-dry dressings (C) can damage tissue.
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.
When preparing to change a sterile dressing over an incision, it is most important to remember to:
- A. Prepare a discard bag next to the wound.
- B. Remain very still during the procedure.
- C. Restrain from moving the patient.
- D. Change gloves after removing the old dressing.
Correct Answer: D
Rationale: Changing gloves after removing the old dressing maintains sterility, as the old dressing is contaminated.