Nokea
The patient is undergoing Negative Pressure Wound Therapy (NPWT) treatment for wound healing. Which would be your first priority in caring for this patient?
- A. Assess the patient for any complaints or problems in the wound area.
- B. Check the settings on the NPWT unit.
- C. Document your findings.
- D. Observe the dressing area.
Correct Answer: A
Rationale: Assessing the patient's condition first ensures any immediate issues (e.g., pain, leakage) are addressed.
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A nurse is ambulating a patient in the hall a few days after abdominal surgery when the patient says, "I think something just let go." What should be the nurse's initial intervention?
- A. Ask someone to quickly get an abdominal binder.
- B. Seat the patient in a nearby chair.
- C. Instruct the patient to pant to reduce abdominal tension.
- D. Assist the patient into a supine position.
Correct Answer: D
Rationale: Assisting to a supine position reduces strain on the abdominal wound, preventing further dehiscence.
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 places Dakin's solution in a wound for which purpose?
- A. Chemical debridement
- B. Healing
- C. Phagocytosis
- D. Primary intention
Correct Answer: A
Rationale: Dakin's solution chemically debrides by breaking down necrotic tissue.
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.
A 28-year-old male patient at your clinic reports a minor motorcycle accident that occurred 5 days ago, resulting in several scrapes and wounds. The wound on his calf has a pinkish-red center area that appears bumpy. What does this indicate about the wound?
- A. Beginning to heal
- B. Suppurating
- C. Becoming infected
- D. Needs to be debrided
Correct Answer: A
Rationale: Pinkish-red, bumpy tissue indicates granulation, a sign of healing in the proliferative phase.