Nokea
When you assess a patient's skin, you will pay special attention to the color, noting which of the following?
- A. Excoriation
- B. Erythema
- C. Smoothness
- D. Pallor
- E. Bruising
- F. Jaundice
Correct Answer: B,D,E,F
Rationale: Skin color changes like erythema, pallor, bruising, and jaundice indicate inflammation, poor perfusion, trauma, or liver issues, respectively.
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Match the following types of wound healing with their examples: First intention
- A. A traumatic wound first left open to drain and then sutured closed
- B. An appendectomy incision sutured closed
- C. A pressure ulcer being packed with moist gauze
Correct Answer: B
Rationale: First intention healing occurs when wound edges are closely approximated, as in a sutured appendectomy incision.
A patient comes to the clinic where you are working as a nurse. He had surgery 2 months ago and is very concerned. He asks you to feel the scar on his side. You feel a hard ridge beneath the incision scar extending about 1 cm on either side of the scar. Which response is most appropriate?
- A. This is a normal part of scar healing and strengthening. It will eventually thin out and become less hard.'
- B. This might be a keloid forming, which is an overgrowth of scar tissue. It is not dangerous.'
- C. This is very unusual at this stage of healing. The doctor will need to look at your scar.'
- D. Don't worry. Different people heal at different rates. You must just be a slow healer.'
Correct Answer: A
Rationale: A hard ridge under a scar is normal during the maturation phase of healing and typically softens over time.
You are caring for a patient with several risk factors for a pressure injury. Which would you avoid when caring for this patient?
- A. Pulling the sheets from beneath the patient so she does not have to turn frequently.
- B. Turning the patient using a lift sheet to prevent her from sliding on the sheets.
- C. Padding the bony prominences to help prevent pressure that could impair circulation.
- D. Turning the patient at least every 2 hours to prevent prolonged pressure in one area.
Correct Answer: A
Rationale: Pulling sheets can cause shear and friction, increasing pressure injury risk. The other options are preventive measures.
A patient with an open leg wound has the following laboratory results on his chart: WBC 15,350 mm^3 with an elevated percentage of neutrophils. What does this tell you about the patient's wound?
- A. He most likely no longer has any wound infection.
- B. He most likely has an acute wound infection.
- C. He most likely has a chronic wound infection.
- D. He most likely has a widespread bacterial infection.
Correct Answer: B
Rationale: Elevated WBC and neutrophils indicate an active immune response, typically seen in acute infections, suggesting the wound is acutely infected.
A colonized wound is one in which
- A. There is potential for becoming infected.
- B. Infection is present as a result of gross contamination related to trauma.
- C. Infection is present as evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue.
- D. A high number of microorganisms are present without signs and symptoms of infection.
Correct Answer: D
Rationale: A colonized wound has many microorganisms but no clinical signs of infection, distinguishing it from an infected wound.