Nokea
A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite the administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
- A. Abdominal pads
- B. Hydrogel
- C. Wet-to-dry
- D. Dry gauze
Correct Answer: B
Rationale: Hydrogel dressings are soothing and reduce pain by maintaining moisture, unlike wet-to-dry, which can stick and hurt.
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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.
A patient who underwent a mastectomy must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, which action should the nurse correct?
- A. Points the device away from herself while opening it.
- B. Refrains from touching the drainage spout with her hand.
- C. Compresses the device in her hand before closing it.
- D. Uses one alcohol wipe to clean both the spout and the plug.
Correct Answer: D
Rationale: Using one wipe for both spout and plug risks contamination; separate wipes maintain sterility.
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.
What type of wound heals by delaying the suturing until the infection is resolved?
- A. Remodeling phase
- B. Primary intention
- C. Tertiary intention
- D. Secondary intention
Correct Answer: C
Rationale: Tertiary intention delays suturing until infection clears, allowing controlled closure.
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.