Nokea
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).
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Match the following types of wound healing with their examples: Second intention
- A. A traumatic wound first left open to drain and then sutured closed
- B. An appendectomy incision sutured closed
- C. A pressure ulcer being packed with moist gauze
Correct Answer: C
Rationale: Second intention healing involves granulation tissue filling an open wound, as in a pressure ulcer packed with gauze.
Which of these patients is most at risk for developing a pressure injury?
- A. A well-nourished 54-year-old patient who had a left total knee replacement and is up in the chair twice per day
- B. A 78-year-old with a feeding tube who is nonambulatory and is incontinent of bowels and bladder
- C. A 66-year-old who had a myocardial infarction (heart attack) yesterday and is not eating well because of nausea
- D. A 42-year-old with pneumonia who is receiving IV antibiotics and can only get up to go to the bathroom
Correct Answer: B
Rationale: The 78-year-old patient has multiple risk factors: immobility, incontinence, and likely poor skin integrity, increasing pressure injury risk.
A colonized wound is one in which
- A. There is potential for becoming infected.
- B. Infection is present as a result of gross contamination related to trauma.
- C. Infection is present as evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue.
- D. A high number of microorganisms are present without signs and symptoms of infection.
Correct Answer: D
Rationale: A colonized wound has many microorganisms but no clinical signs of infection, distinguishing it from an infected wound.
A patient is at risk for wound dehiscence as a result of nutritional issues and medical history. Which interventions should be included in the care plan?
- A. Assist the patient to splint the incision with a pillow when coughing.
- B. Enforce strict bedrest with bathroom privileges only.
- C. Administer stool softeners and antinausea medicine promptly.
- D. Obtain VS every 15 minutes.
Correct Answer: A,C
Rationale: Splinting the incision and preventing straining (via stool softeners/antinausea meds) reduce stress on the wound, preventing dehiscence.
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.