Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

Unable to state the phase

Inflammatory

Proliferative

Maturation

Answer and Explanation

The Correct Answer is B

A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.

B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.

C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.

D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

A. "You can expect fecal output within 24 hours" B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week" D. "You may experience a small amount of bleeding around the stoma"

Correct Answer is D

Explanation

A. After a bowel preparation, it typically takes a few days for fecal output to occur from the new colostomy due to the emptying of the bowel before surgery.

B. Increasing raw vegetables immediately after surgery is not recommended, as they can cause gas and irritation to the bowel. Clients are usually advised to start with low-fiber foods and gradually introduce more fiber.

C. A healthy stoma should be pink to red in color. A purplish color may indicate compromised blood flow and should be reported to the healthcare provider.

D. A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the appliance, as the tissue is delicate and highly vascular.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a new colostomy, and had a bowel preparation before surgery. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?

A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?

. A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?