Nokea
The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip. He states that it is painful. This is indicative of which stage of pressure injury?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: A
Rationale: Stage 1 pressure injuries present as non-blanchable redness with intact skin and may be painful.
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Which type of wound debridement is Dakin's solution used for?
- A. Autolytic debridement
- B. Sharp debridement
- C. Enzymatic debridement
- D. Chemical debridement
Correct Answer: D
Rationale: Dakin's solution is a chemical debridement agent that breaks down necrotic tissue.
When applying an ice pack, it is necessary to:
- A. Fill the pack and refreeze it.
- B. Cover the pack with plastic wrap.
- C. Use a light cover over the pack.
- D. use small ice cubes
Correct Answer: C
Rationale: A light cover prevents direct skin contact, reducing frostbite risk while allowing cold therapy.
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.
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.
A nurse is assisting with the care of a client who arrives at the emergency department following an industrial explosion. Upon inspecting the wound on the client's leg, the nurse finds torn skin tissue underneath. Which of the following types of wounds should the nurse report?
- A. Contusion
- B. Laceration
- C. Abrasion
- D. Puncture
Correct Answer: B
Rationale: A laceration is a tear in the skin, fitting the description of torn tissue from an explosion.