Nokea
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.
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A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite the administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
- A. Abdominal pads
- B. Hydrogel
- C. Wet-to-dry
- D. Dry gauze
Correct Answer: B
Rationale: Hydrogel dressings are soothing and reduce pain by maintaining moisture, unlike wet-to-dry, which can stick and hurt.
A patient who underwent a mastectomy must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, which action should the nurse correct?
- A. Points the device away from herself while opening it.
- B. Refrains from touching the drainage spout with her hand.
- C. Compresses the device in her hand before closing it.
- D. Uses one alcohol wipe to clean both the spout and the plug.
Correct Answer: D
Rationale: Using one wipe for both spout and plug risks contamination; separate wipes maintain sterility.
A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?
- A. Anticholinergics
- B. Corticosteroids
- C. Beta-blockers
- D. Tricyclic antidepressants
Correct Answer: B
Rationale: Corticosteroids suppress inflammation and collagen synthesis, delaying wound healing.
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.
When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:
- A. He has lain in one position for such a long time that swelling has occurred.
- B. An infection is in progress at the wound site.
- C. There is probably a deeper injury than what appears on the surface.
- D. Vessels have dilated and allowed plasma to leak into the wound site.
Correct Answer: D
Rationale: Swelling from dilated vessels leaking plasma is part of the inflammatory response, not necessarily infection.