Nokea
The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: B
Rationale: Stage 2 involves partial-thickness loss with a pink, viable wound bed, unlike Stage 1 (intact skin) or Stage 3 (full-thickness).
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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.
When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?
- A. Sanguineous
- B. Serous
- C. Serosanguineous
- D. Purulent
Correct Answer: C
Rationale: Yellow-red drainage indicates serosanguineous (serum and blood mix), not purulent (pus) or sanguineous (blood only).
What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?
- A. Tegaderm or Opsite
- B. Abdominal pads held in place with paper tape
- C. Retention
- D. Montgomery straps
Correct Answer: D
Rationale: Montgomery straps secure dressings with ties, allowing changes without removing tape from the skin.
What safety factors should be considered when using an Aquathermia pad unit for a patient? (Select all that apply)
- A. Inspecting the plug and cord for cracks or fraying
- B. Securing the pad to the patient
- C. Instructing the patient not to sleep on the pad
- D. Assisting the patient to lie on top of the pad
- E. Using a thermometer to check the temperature of the pad
Correct Answer: A,C
Rationale: A: Ensures electrical safety. C: Prevents burns from prolonged pressure. Lying on the pad (D) increases burn risk.
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.