Nokea
Which of these factors affect wound healing?
- A. Positive attitude
- B. Chronic illness
- C. Medications
- D. Atmospheric pressure
- E. Diabetes mellitus
- F. Age
Correct Answer: B,C,E,F
Rationale: Chronic illness, medications, diabetes, and age impair immune response, tissue repair, or blood flow, delaying wound healing.
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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.
Which of these patients is most at risk for developing a pressure injury?
- A. A well-nourished 54-year-old patient who had a left total knee replacement and is up in the chair twice per day
- B. A 78-year-old with a feeding tube who is nonambulatory and is incontinent of bowels and bladder
- C. A 66-year-old who had a myocardial infarction (heart attack) yesterday and is not eating well because of nausea
- D. A 42-year-old with pneumonia who is receiving IV antibiotics and can only get up to go to the bathroom
Correct Answer: B
Rationale: The 78-year-old patient has multiple risk factors: immobility, incontinence, and likely poor skin integrity, increasing pressure injury risk.
Before you go in the room to change the dressing for your assigned patient, who has a stage 3 pressure injury infected with MRSA, your first priorities will be to
- A. Determine supplies needed for the dressing change.
- B. Obtain appropriate PPE for caring for a patient with MRSA.
- C. Review sterile technique to prevent contaminating the wound.
- D. Review how to assess a stage 3 pressure injury.
- E. Ask the patient how the other nurses have done the dressing change.
Correct Answer: B,C
Rationale: For an MRSA-infected wound, obtaining PPE and reviewing sterile technique are priorities to prevent transmission and further contamination.
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.
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.