When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:
He has lain in one position for such a long time that swelling has occurred.
An infection is in progress at the wound site.
There is probably a deeper injury than what appears on the surface.
Vessels have dilated and allowed plasma to leak into the wound site.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is D
Explanation
Choice A rationale
Pointing the device away while opening it is a safe practice to prevent contamination and accidental exposure to bodily fluids.
Choice B rationale
Not touching the drainage spout with the hand is correct as it prevents contamination of the spout, which could lead to infection.
Choice C rationale
Compressing the device before closing it is part of the proper procedure to re-establish the vacuum within the drain, which is necessary for it to function correctly.
Choice D rationale
Using one alcohol wipe to clean both the spout and the plug is incorrect because each should be cleaned with a separate sterile wipe to prevent cross-contamination and maintain sterility.
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