Nokea
What phase of wound healing is a wound in when blood and fluid flow into the vascular space and produce edema erythema heat and pain?
- A. Healing
- B. Inflammatory
- C. Reconstruction
- D. Maturation
Correct Answer: B
Rationale: During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space.
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The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
- A. Destruction of tissue
- B. Bleeding
- C. Mechanical débridement
- D. Prevention of infection
Correct Answer: C
Rationale: The primary purpose of a wet-to-dry dressing is to débride a wound mechanically.
The nurse assures a patient that the purple raised immature scar of a surgical wound is normal and caused by ___ formation.
Correct Answer: collagen
Rationale: Collagen forms as an immature scar over a new surgical wound.
The nurse assessing a patient's wound notes pale red watery drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: D
Rationale: Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding.
The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?
- A. Cellulitis
- B. Dehiscence
- C. Evisceration
- D. Extravasation
Correct Answer: B
Rationale: Dehiscence is separation of a surgical incision or rupture of a wound closure.
The nurse assessing a patient's wound notes a clear watery drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: A
Rationale: Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage.