Nokea
A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a/an:
- A. Abrasion.
- B. Avulsion.
- C. Laceration.
- D. Hematoma.
Correct Answer: D
Rationale: A hematoma is a collection of blood under intact skin, caused by trauma like a fall.
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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 is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:
- A. The moisture creates an environment suitable for the growth of microorganisms in a wound.
- B. Greater pressure is exerted by a wet bed.
- C. Shearing is more likely from wet sheets.
- D. The patient has to be repositioned for the bed to be changed.
Correct Answer: A
Rationale: Moisture from incontinence fosters microbial growth, increasing infection risk.
What stage is a wound if the epidermis is closed and has unblanchable redness?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: A
Rationale: Stage 1 pressure injuries show unblanchable redness with intact skin.
The nurse assesses the large raised scar on the African American patient. How should the nurse document the lesion?
- A. Contusion
- B. Keloid
- C. Laceration
- D. Hematoma
Correct Answer: B
Rationale: A keloid is a raised scar that grows beyond the original wound, common in African Americans due to increased collagen production. A contusion is a bruise, a laceration is a tear, and a hematoma is a blood collection under the skin.
While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?
- A. Leave it in place and cover it with new, wet dressings.
- B. Moisten it with povidone-iodine.
- C. Add normal saline to loosen it.
- D. Pull it off using slow, steady pressure.
Correct Answer: C
Rationale: Adding saline loosens the dressing without damaging new tissue, unlike pulling it off dry.