Nokea
While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?
- A. Leave it in place and cover it with new, wet dressings.
- B. Moisten it with povidone-iodine.
- C. Add normal saline to loosen it.
- D. Pull it off using slow, steady pressure.
Correct Answer: C
Rationale: Adding saline loosens the dressing without damaging new tissue, unlike pulling it off dry.
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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 warns the patient that one of the patient's habits has caused the reduction of functional hemoglobin, which limits the hemoglobin's oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit:
- A. Using marijuana.
- B. Eating excessive fats.
- C. Smoking cigarettes.
- D. Drinking
Correct Answer: C
Rationale: Smoking introduces carbon monoxide, reducing hemoglobin's oxygen-carrying capacity.
The nurse reminds the 85-year-old patient that his healing will be slower due to age-related changes such as: (Select all that apply)
- A. Atherosclerosis
- B. Diminished lung function
- C. Excessive production of blood factors
- D. Increased immunity
- E. slow metabolism
Correct Answer: A,B,E
Rationale: A: Reduces blood flow. B: Limits oxygen delivery. E: Slows cellular repair. Immunity decreases with age (not D), and blood factors don't increase (C).
Superficial wounds heal faster when kept:
- A. Moist
- B. Dry
- C. Covered with a wet-to-dry dressing
- D. Debrided
Correct Answer: A
Rationale: Moist environments promote epithelialization and faster healing of superficial wounds.
The nurse places Dakin's solution in a wound for which purpose?
- A. Chemical debridement
- B. Healing
- C. Phagocytosis
- D. Primary intention
Correct Answer: A
Rationale: Dakin's solution chemically debrides by breaking down necrotic tissue.