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What safety factors should be considered when using an Aquathermia pad unit for a patient? (Select all that apply)
- A. Inspecting the plug and cord for cracks or fraying
- B. Securing the pad to the patient
- C. Instructing the patient not to sleep on the pad
- D. Assisting the patient to lie on top of the pad
- E. Using a thermometer to check the temperature of the pad
Correct Answer: A,C
Rationale: A: Ensures electrical safety. C: Prevents burns from prolonged pressure. Lying on the pad (D) increases burn risk.
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A nurse is concerned about an HIV immunocompromised patient's ability to heal due to a lack of certain factors. Which of the following are necessary for proper wound healing? (Select all that apply.)
- A. Adequate fibroblast function
- B. Intrinsic factor
- C. Synthesis of collagen
- D. Hemoglobin
- E. Adequate phagocytosis
Correct Answer: A,C,D,E
Rationale: A: Fibroblasts produce collagen. C: Collagen strengthens the wound. D: Hemoglobin delivers oxygen. E: Phagocytosis removes debris. Intrinsic factor (B) is unrelated to wounds.
The nurse clarifies that the second stage of wound healing is:
- A. Proliferation
- B. Maturation
- C. Inflammation
- D. Remodeling
Correct Answer: A
Rationale: Proliferation is the second stage, involving granulation and epithelialization, following inflammation.
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.
While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?
- A. Leave it in place and cover it with new, wet dressings.
- B. Moisten it with povidone-iodine.
- C. Add normal saline to loosen it.
- D. Pull it off using slow, steady pressure.
Correct Answer: C
Rationale: Adding saline loosens the dressing without damaging new tissue, unlike pulling it off dry.
When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?
- A. Sanguineous
- B. Serous
- C. Serosanguineous
- D. Purulent
Correct Answer: C
Rationale: Yellow-red drainage indicates serosanguineous (serum and blood mix), not purulent (pus) or sanguineous (blood only).