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A 28-year-old male is a patient at your clinic.
He states that he had a minor accident with his motorcycle 5 days ago.
He sustained several scrapes and wounds.
The wound on his calf has a pinkish-red center area that looks bumpy.
This indicates that the wound is:

Is purulent.

Becoming infected.

Needs to be débrided.

Beginning to heal.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Purulent indicates pus, which is not described here.

Choice B rationale:

Infection usually presents with redness, swelling, and possibly pus, which is not described here.

Choice C rationale:

Debridement is the removal of dead tissue, not indicated by a pinkish-red bumpy area.

Choice D rationale:

A pinkish-red center area that looks bumpy indicates granulation tissue, which is a sign of healing.

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Correct Answer is C

Explanation

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

A. Leave it until the end of the shift. B. Remove the drain. C. Empty the reservoir. D. Notify the surgeon about the blood loss.

Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

Correct Answer is C

Explanation

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

When preparing to change a sterile dressing over an incision, it is most important to remember to:

A nurse is caring for a client who is at risk for a pressure injury.Which of the following actions should the nurse take?

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Which type of debridement is a hydrocolloid dressing used for?

When giving a hot soak treatment, it is most important to:

A 28-year-old male is a patient at your clinic.
He states that he had a minor accident with his motorcycle 5 days ago.
He sustained several scrapes and wounds.
The wound on his calf has a pinkish-red center area that looks bumpy.
This indicates that the wound is: