Nokea
The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:
- A. Second intention.
- B. Fourth intention.
- C. Third intention.
- D. First intention.
Correct Answer: D
Rationale: First intention healing occurs with clean, sutured incisions, minimizing scarring.
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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 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.
What type of wound heals by edges approximating with a suture?
- A. Secondary intention.
- B. Remodeling phase.
- C. Primary intention.
- D. Tertiary intention.
Correct Answer: C
Rationale: Primary intention healing occurs when wound edges are brought together with sutures, minimizing scarring. Secondary intention heals open wounds, tertiary delays closure, and remodeling is a phase, not a type.
A nurse performing a right eye irrigation will position the patient in which of the following ways?
- A. Upright with the head tilted toward the left eye.
- B. Supine with the head hyperextended.
- C. Upright with the head hyperextended.
- D. supine with the head tilted toward the right eye.
Correct Answer: A
Rationale: Tilting the head toward the unaffected (left) eye allows fluid to flow from the right eye outward, avoiding contamination.
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.