Nokea
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.
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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.
A nurse is caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?
- A. Applying hydrocolloids to the wound bed.
- B. Pulsating lavage.
- C. Using a topical enzyme solution in the wound bed.
- D. Placing a transparent dressing over the pressure injury.
Correct Answer: B
Rationale: Pulsating lavage is a mechanical debridement method using a pressurized stream of fluid to remove necrotic tissue. Hydrocolloids promote autolytic debridement, enzymes are chemical, and transparent dressings do not debride.
While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?
- A. Leave it in place and cover it with new, wet dressings.
- B. Moisten it with povidone-iodine.
- C. Add normal saline to loosen it.
- D. Pull it off using slow, steady pressure.
Correct Answer: C
Rationale: Adding saline loosens the dressing without damaging new tissue, unlike pulling it off dry.
The nurse is performing a dry sterile dressing change for an abdominal wound. In which direction should the nurse use a swab to clean?
- A. Directly over the wound
- B. In a circular motion around the wound, circling to the outside
- C. From the outer abdomen toward the wound
- D. From the left to the right across the wound
Correct Answer: C
Rationale: Cleaning from the outer abdomen toward the wound prevents contamination of the sterile field by moving from the least to the most contaminated area.
What is the physiological effect of moist heat on the treated area?
- A. Numbing the area treated.
- B. Drawing fluid to the site of application.
- C. dilating the blood vessels
- D. Constricting the blood vessels.
Correct Answer: C
Rationale: Moist heat dilates blood vessels, increasing blood flow and promoting healing.