Nokea
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.
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A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
- A. Keep the wound dry.
- B. Leave the dressing in place for 7 days.
- C. Help destroy microorganisms in an infected wound.
- D. Promote a moist healing environment.
Correct Answer: D
Rationale: Hydrocolloid dressings maintain a moist environment to promote autolytic debridement and healing, not to dry the wound or kill microbes directly.
What type of wound heals by delaying the suturing until the infection is resolved?
- A. Remodeling phase
- B. Primary intention
- C. Tertiary intention
- D. Secondary intention
Correct Answer: C
Rationale: Tertiary intention delays suturing until infection clears, allowing controlled closure.
When giving a hot soak treatment, what is most important to ensure?
- A. Soak only the affected area.
- B. Position the patient comfortably.
- C. Monitor the temperature of the water.
- D. Check the patient's skin integrity.
Correct Answer: C
Rationale: Monitoring water temperature prevents burns, the primary safety concern with hot soaks.
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?
- A. Apply oxygen at 2 L/min via nasal cannula.
- B. Initiate mechanical debridement.
- C. Leave non-bleeding wounds open to air.
- D. Administer a corticosteroid medication.
Correct Answer: A
Rationale: Oxygen supports the initial inflammatory stage by aiding cellular function, unlike corticosteroids, which delay healing.
A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a/an:
- A. Abrasion.
- B. Avulsion.
- C. Laceration.
- D. Hematoma.
Correct Answer: D
Rationale: A hematoma is a collection of blood under intact skin, caused by trauma like a fall.