Nokea
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.
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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.
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.
Which type of debridement is a hydrocolloid dressing used for?
- A. Autolytic debridement
- B. Sharp debridement
- C. Enzymatic debridement
- D. Chemical debridement
Correct Answer: A
Rationale: Hydrocolloid dressings promote autolytic debridement by maintaining a moist environment for the body's enzymes to break down necrotic tissue.
Because the patient with an abdominal dressing requires frequent dressing changes, and the abdomen is beginning to show skin irritation from repeated tape removal, the nurse would change the dressing procedure in order to use:
- A. Elastic adhesive tape.
- B. Karaya paste.
- C. Montgomery straps.
- D. Paper tape.
Correct Answer: C
Rationale: Montgomery straps allow frequent dressing changes without removing tape from the skin, reducing irritation.
A nurse is assessing a surgical patient for internal hemorrhage. Which of the following would indicate internal hemorrhage?
- A. Headache.
- B. Rising pulse and falling blood pressure.
- C. Lethargy, falling pulse, and rising blood pressure.
- D. Restlessness, rising pulse, and falling blood pressure.
Correct Answer: D
Rationale: Restlessness, rising pulse, and falling blood pressure indicate hypovolemic shock from internal hemorrhage due to blood loss affecting circulation.