Nokea
Which are accurate statements about a deep tissue pressure injury?
- A. It may be caused by a medical device, such as a splint.
- B. It is deep red, maroon or purple colored, and does not blanch.
- C. It may be intact or nonintact skin.
- D. It is at least 2 cm deep or deeper.
- E. It is the result of prolonged pressure and/or shear force.
Correct Answer: A,B,C,E
Rationale: Deep tissue pressure injuries involve non-blanching discoloration, can be intact or nonintact, and result from pressure/shear, often from devices.
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You are a nurse, and you are running behind schedule on a very busy workday. The UAP offers to change a patient's abdominal dressing for you. She is a first-semester nursing student. Which is the most appropriate response?
- A. That would be great. Don't forget to measure the open area in the middle of her incision for me.'
- B. I know you have been taught to do this in school, so you are not the same as the other UAPs. Go ahead and change the dressing.'
- C. Thanks, but could you help Mr. Wu walk in the hall instead? That way I can get that dressing changed.'
- D. You know you can't do that as a UAP. I would be in big trouble if I let you change that dressing!'
Correct Answer: C
Rationale: UAPs, including nursing students, are not permitted to perform complex tasks like dressing changes, which require nursing judgment. Delegating a simpler task is appropriate.
All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.
During the inflammatory process, which of the following physiological responses occur?
- A. Capillaries dilate, causing erythema and increased warmth at the site of injury.
- B. Leukocytes are shunted away from the site to fight infection.
- C. Leukocytes move into the interstitial space and attack microorganisms.
- D. Red blood cells deliver more oxygen and nutrients to promote healing.
- E. Fluid in the interstitial spaces prevents redness and pain.
- F. Edema causes pressure on nerve endings, resulting in discomfort and pain.
Correct Answer: A,C,D,F
Rationale: During inflammation, capillaries dilate (erythema and warmth), leukocytes migrate to fight infection, red blood cells supply oxygen/nutrients, and edema causes pain. Leukocytes are not shunted away, and fluid does not prevent redness/pain.
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.
Match the following types of wound healing with their examples: Third 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: A
Rationale: Third intention healing involves delayed closure after initial open drainage, as in a traumatic wound later sutured.