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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Application of antibiotic ointment involves assessment and clinical judgment, which should be performed by a licensed nurse rather than an AP.
B. The removal of a nasogastric tube is a nursing task that requires training and knowledge of potential complications, and it should not be assigned to an AP.
C. Monitoring vital signs of a client who had an appendectomy 12 hours ago can be safely delegated to an AP, as it is a basic task that does not require clinical judgment beyond standard procedures.
D. Obtaining medical history information from a stable client is a task that requires assessment skills and critical thinking, making it inappropriate to assign to an AP.
Correct Answer is B
Explanation
A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.
B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.
C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.
D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.
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