Nokea
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.
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The nurse clarifies that the second stage of wound healing is:
- A. Proliferation
- B. Maturation
- C. Inflammation
- D. Remodeling
Correct Answer: A
Rationale: Proliferation is the second stage, involving granulation and epithelialization, following inflammation.
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.
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.
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.
The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
- A. Excessive gas
- B. Complaint of constipation
- C. Increased drainage from the wound
- D. Increased pallor of the surgical site
Correct Answer: C
Rationale: Increased drainage suggests wound separation (dehiscence) as fluid escapes the incision.