Nokea
What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?
- A. Tegaderm or Opsite
- B. Abdominal pads held in place with paper tape
- C. Retention
- D. Montgomery straps
Correct Answer: D
Rationale: Montgomery straps secure dressings with ties, allowing changes without removing tape from the skin.
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A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a/an:
- A. Abrasion.
- B. Avulsion.
- C. Laceration.
- D. Hematoma.
Correct Answer: D
Rationale: A hematoma is a collection of blood under intact skin, caused by trauma like a fall.
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 is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
- A. Excessive gas
- B. Complaint of constipation
- C. Increased drainage from the wound
- D. Increased pallor of the surgical site
Correct Answer: C
Rationale: Increased drainage suggests wound separation (dehiscence) as fluid escapes the incision.
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.
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.