A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
Shearing is more likely from wet sheets.
The patient has to be repositioned for the bed to be changed.
The Correct Answer is A
Choice A rationale
Moisture from incontinence can compromise skin integrity and create a favorable environment for bacterial growth, increasing the risk of infection and skin breakdown.
Choice B rationale
While a wet bed may be uncomfortable, it does not exert greater pressure that would lead to skin breakdown or infection.
Choice C rationale
Shearing can occur from moving a patient on any surface; however, wet sheets do not inherently increase the likelihood of shearing.
Choice D rationale
Repositioning the patient is necessary for comfort and to prevent pressure ulcers, but it is not a direct cause of skin breakdown or infection due to incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Prolonged immobility can indeed cause swelling due to fluid accumulation; however, it typically does not lead to sudden worsening or significant swelling at a specific wound site. It is more associated with generalized edema, particularly in dependent areas of the body.
Choice B rationale
While infections can cause swelling, they are also accompanied by other signs such as redness, warmth, pain, and possibly fever. Swelling alone, without these other symptoms, is less indicative of an infection.
Choice C rationale
A deeper injury might cause swelling, but this would have been identified during the initial assessment. Swelling that occurs later in the healing process is less likely to be from a deeper, previously unnoticed injury.
Choice D rationale
Swelling at a wound site is often due to inflammation, where blood vessels dilate and become more permeable, allowing plasma to leak into the tissue. This is a normal part of the healing process as the body brings in necessary cells and substances to promote recovery.
Correct Answer is D
Explanation
Choice A rationale
An abrasion occurs when the skin is scraped off, usually due to a surface rubbing or scraping against the skin. It does not involve pooling of blood under the skin but rather an injury to the top layer of the skin.
Choice B rationale
An avulsion is a severe type of wound that occurs when a portion of the skin and sometimes the tissue beneath is partially or completely torn away. It is not characterized by pooling of blood under unbroken skin.
Choice C rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because lacerations imply that the skin is broken and torn, it does not describe the condition where blood pools under unbroken skin.
Choice D rationale
A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This is the correct term for a pooling of blood under unbroken skin, as described in the scenario following the patient’s fall. Hematomas can be caused by injury, such as a fall, that causes blood vessels to break and bleed into the surrounding tissues.
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