Nokea
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.
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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.
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.
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.
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.
Chronic wounds that are not healing well may benefit from (Select all that apply):
- A. Promoting protein in the diet.
- B. NPWT therapy.
- C. Wet-to-dry dressings.
- D. Hydrocolloid dressings.
- E. Tolerate pressure treatment.
Correct Answer: A,B,D
Rationale: A: Protein aids tissue repair. B: Negative Pressure Wound Therapy promotes healing. D: Hydrocolloids maintain moisture. Wet-to-dry dressings (C) can damage tissue.