Nokea
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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While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
- A. Empty the reservoir.
- B. Notify the surgeon about the drainage.
- C. Remove the drain
- D. Leave it until the end of the shift
Correct Answer: A
Rationale: Emptying the reservoir maintains drainage function and allows monitoring of output; significant changes would then prompt notifying the surgeon.
The nurse warns the patient that one of the patient's habits has caused the reduction of functional hemoglobin, which limits the hemoglobin's oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit:
- A. Using marijuana.
- B. Eating excessive fats.
- C. Smoking cigarettes.
- D. Drinking
Correct Answer: C
Rationale: Smoking introduces carbon monoxide, reducing hemoglobin's oxygen-carrying capacity.
Which type of debridement is a hydrocolloid dressing used for?
- A. Autolytic debridement
- B. Sharp debridement
- C. Enzymatic debridement
- D. Chemical debridement
Correct Answer: A
Rationale: Hydrocolloid dressings promote autolytic debridement by maintaining a moist environment for the body's enzymes to break down necrotic tissue.
The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:
- A. Drawing the wound edges together using negative pressure.
- B. Strengthening the wall of the wound.
- C. Interrupting the proliferation of bacteria in the wound.
- D. Making and air occlusive cover for the wound
Correct Answer: A
Rationale: Vacuum-assisted closure uses negative pressure to draw wound edges together, promoting granulation and healing.
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.