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 C
Explanation
Choice A rationale
Dry gauze is absorbent, but it is not the best option for promoting hemostasis in a heavily draining wound. It may adhere to the wound bed, causing pain and potential damage when removed.
Choice B rationale
Transparent dressings allow for easy monitoring of the wound but do not provide the necessary absorption for heavy drainage. They are also not specifically designed to promote hemostasis.
Choice C rationale
Alginate dressings are made from seaweed derivatives and are highly absorbent, which makes them suitable for wounds with heavy drainage. They also help to promote hemostasis by assisting with blood clot formation, making them an appropriate choice for this scenario.
Choice D rationale
Hydrogel dressings provide moisture to the wound and promote autolytic debridement but are not the best choice for heavy drainage. They do not have the absorptive capacity needed for a wound that is actively bleeding.
Correct Answer is A
Explanation
Choice A rationale
The High-Fowler’s position, with the client sitting upright at a 90-degree angle, is ideal for abdominal wound irrigation as it reduces the risk of fluid accumulation in the wound area and promotes drainage.
Choice B rationale
The side-lying position is not typically used for abdominal wound irrigation because it can cause pooling of the irrigation solution and does not facilitate easy access to the wound site.
Choice C rationale
The supine position, with the client lying flat on their back, is not suitable for abdominal wound irrigation as it can lead to fluid retention in the wound and does not aid in drainage.
Choice D rationale
The dorsal recumbent position, with the client lying on their back with knees bent, is also not optimal for abdominal wound irrigation due to the potential for fluid to collect in the wound area.
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