Nokea
When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:
- A. He has lain in one position for such a long time that swelling has occurred.
- B. An infection is in progress at the wound site.
- C. There is probably a deeper injury than what appears on the surface.
- D. Vessels have dilated and allowed plasma to leak into the wound site.
Correct Answer: D
Rationale: Swelling from dilated vessels leaking plasma is part of the inflammatory response, not necessarily infection.
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A nurse is assisting with the care of a client who arrives at the emergency department following an industrial explosion. Upon inspecting the wound on the client's leg, the nurse finds torn skin tissue underneath. Which of the following types of wounds should the nurse report?
- A. Contusion
- B. Laceration
- C. Abrasion
- D. Puncture
Correct Answer: B
Rationale: A laceration is a tear in the skin, fitting the description of torn tissue from an explosion.
A nurse performing a right eye irrigation will position the patient in which of the following ways?
- A. Upright with the head tilted toward the left eye.
- B. Supine with the head hyperextended.
- C. Upright with the head hyperextended.
- D. supine with the head tilted toward the right eye.
Correct Answer: A
Rationale: Tilting the head toward the unaffected (left) eye allows fluid to flow from the right eye outward, avoiding contamination.
The nurse is performing a dry sterile dressing change for an abdominal wound. In which direction should the nurse use a swab to clean?
- A. Directly over the wound
- B. In a circular motion around the wound, circling to the outside
- C. From the outer abdomen toward the wound
- D. From the left to the right across the wound
Correct Answer: C
Rationale: Cleaning from the outer abdomen toward the wound prevents contamination of the sterile field by moving from the least to the most contaminated area.
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 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.