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An elderly patient who lives alone and has a vascular stasis ulcer on his right leg is most at risk for infection because he
- A. May not see well enough to notice changes in the wound that indicate infection.
- B. Is unable to stay off of his leg, which will compromise circulation to the area.
- C. Does not eat healthy meals, causing a lack of granulation tissue.
- D. Lacks the ability to understand the way that antibiotics work.
Correct Answer: A
Rationale: Poor vision in the elderly can prevent early detection of infection signs, increasing infection risk in chronic wounds like stasis ulcers.
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You are a nurse, and you are running behind schedule on a very busy workday. The UAP offers to change a patient's abdominal dressing for you. She is a first-semester nursing student. Which is the most appropriate response?
- A. That would be great. Don't forget to measure the open area in the middle of her incision for me.'
- B. I know you have been taught to do this in school, so you are not the same as the other UAPs. Go ahead and change the dressing.'
- C. Thanks, but could you help Mr. Wu walk in the hall instead? That way I can get that dressing changed.'
- D. You know you can't do that as a UAP. I would be in big trouble if I let you change that dressing!'
Correct Answer: C
Rationale: UAPs, including nursing students, are not permitted to perform complex tasks like dressing changes, which require nursing judgment. Delegating a simpler task is appropriate.
You are calling a health-care provider to report a possible wound infection. What information will you include in your report?
- A. Most recent vital signs
- B. Amount and type of wound drainage
- C. Observed signs of infection
- D. Type and frequency of bowel movements
- E. Patient's rating of his or her pain
- F. Amount of activity the patient has had in the past 24 hours
- G. Laboratory results
Correct Answer: A,B,C,E,G
Rationale: Vital signs, drainage, infection signs, pain, and lab results are critical for assessing and managing a potential wound infection.
Which of the following orders would you expect the health-care provider to write after receiving laboratory results for the patient in Question 20?
- A. Bedrest with bathroom privileges
- B. Discharge tomorrow morning
- C. Wound culture and sensitivity
- D. Low-protein diet
Correct Answer: C
Rationale: A wound culture and sensitivity test is appropriate to identify the specific bacteria and effective antibiotics for an infected wound.
When you assess a patient's skin, you will pay special attention to the color, noting which of the following?
- A. Excoriation
- B. Erythema
- C. Smoothness
- D. Pallor
- E. Bruising
- F. Jaundice
Correct Answer: B,D,E,F
Rationale: Skin color changes like erythema, pallor, bruising, and jaundice indicate inflammation, poor perfusion, trauma, or liver issues, respectively.
In what order do wounds heal?
- A. Reconstruction phase, maturation phase, inflammatory phase
- B. Inflammatory phase, reconstruction phase, maturation phase
- C. Prodromal phase, symptoms phase, inflammatory phase, reconstruction phase
- D. Symptoms phase, maturation phase, inflammatory phase, reconstruction phase
Correct Answer: B
Rationale: Wounds heal in three phases: inflammatory (immediate response), reconstruction (tissue repair), and maturation (scar formation).