A 28-year-old male patient at your clinic reports a minor motorcycle accident that occurred 5 days ago, resulting in several scrapes and wounds. The wound on his calf has a pinkish-red center area that appears bumpy. What does this indicate about the wound?
Beginning to heal
Suppurating
Becoming infected
Needs to be debrided
The Correct Answer is A
Choice A rationale
A pinkish-red center and a bumpy appearance in a wound are signs of granulation tissue formation, which is indicative of the healing process beginning.
Choice B rationale
Suppuration refers to the production of pus. Without additional information indicating pus or infection, the description provided does not suggest suppuration.
Choice C rationale
Becoming infected would typically involve signs such as increased pain, redness, swelling, warmth, and possibly pus, which are not described in the scenario.
Choice D rationale
Debridement is the removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. The description given does not indicate the presence of such tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Stage 1 wounds are characterized by non-blanchable redness of intact skin. The presence of partial-thickness skin loss indicates that the wound has progressed beyond stage 1, making this choice incorrect.
Choice B rationale
Stage 2 wounds involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This description matches the nurse’s assessment of the patient’s wound, confirming that it is indeed a stage 2 wound.
Choice C rationale
Stage 3 wounds exhibit full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s wound, with partial-thickness skin loss and no mention of exposed subcutaneous structures, does not fit the criteria for stage 3.
Choice D rationale
Stage 4 wounds involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The patient’s wound does not have these characteristics, ruling out stage 4.
Correct Answer is A
Explanation
Choice A rationale
Hydrocolloid dressings are used for autolytic debridement, which is a gentle method that allows the body’s enzymes to naturally break down necrotic tissue. This type of dressing maintains a moist wound environment that facilitates the breakdown of dead tissue without damaging healthy tissue.
Choice B rationale
Sharp debridement involves the physical removal of dead tissue using sterile instruments and is not typically performed with a hydrocolloid dressing.
Choice C rationale
Enzymatic debridement uses chemical enzymes to break down necrotic tissue. While enzymatic debridement is a chemical process, it is not synonymous with the use of hydrocolloid dressings.
Choice D rationale
Chemical debridement refers to the use of chemical agents to dissolve necrotic tissue. Hydrocolloid dressings do not contain these agents and are not used for chemical debridement.
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