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.
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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.
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.
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.
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 stage is a wound if the epidermis is closed and has unblanchable redness?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: A
Rationale: Stage 1 pressure injuries show unblanchable redness with intact skin.
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