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Which type of debridement is a hydrocolloid dressing used for?
- A. Autolytic debridement
- B. Sharp debridement
- C. Enzymatic debridement
- D. Chemical debridement
Correct Answer: A
Rationale: Hydrocolloid dressings promote autolytic debridement by maintaining a moist environment for the body's enzymes to break down necrotic tissue.
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The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:
- A. Second intention.
- B. Fourth intention.
- C. Third intention.
- D. First intention.
Correct Answer: D
Rationale: First intention healing occurs with clean, sutured incisions, minimizing scarring.
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.
What is the physiological effect of moist heat on the treated area?
- A. Numbing the area treated.
- B. Drawing fluid to the site of application.
- C. dilating the blood vessels
- D. Constricting the blood vessels.
Correct Answer: C
Rationale: Moist heat dilates blood vessels, increasing blood flow and promoting healing.
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 removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?
- A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle.
- B. Double bag the dressing, label it "biohazard," and send it for decontamination.
- C. Discard the dressing in the bedside trash receptacle.
- D. Place the dressing in a biohazardous waste container.
Correct Answer: D
Rationale: Blood and purulent drainage require disposal in a biohazard container per infection control standards.