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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Leaving the old dressing in place and simply covering it with new wet dressings would not address the issue of the dressing being adhered to the wound bed, which could lead to further tissue damage when it is eventually removed.

Choice B rationale
Povidone-iodine is an antiseptic and not typically used to moisten dressings that are stuck to a wound bed, as it may irritate the wound and delay healing.

Choice C rationale
Adding normal saline is the gentlest method to loosen a dressing that is stuck to a wound bed. It helps to rehydrate the dressing and the wound, making it easier to remove without causing additional trauma to the healing tissue.

Choice D rationale
Pulling off the dressing using slow, steady pressure could cause damage to the new tissue forming in the wound bed and should be avoided unless all other methods have failed.

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Correct Answer is B

Explanation

Choice A rationale
Stage 1 wounds are characterized by non-blanchable redness of intact skin. The presence of partial-thickness skin loss indicates that the wound has progressed beyond stage 1, making this choice incorrect.

Choice B rationale
Stage 2 wounds involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This description matches the nurse’s assessment of the patient’s wound, confirming that it is indeed a stage 2 wound.

Choice C rationale
Stage 3 wounds exhibit full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s wound, with partial-thickness skin loss and no mention of exposed subcutaneous structures, does not fit the criteria for stage 3.

Choice D rationale
Stage 4 wounds involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The patient’s wound does not have these characteristics, ruling out stage 4.

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When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?

Correct Answer is C

Explanation

The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?

Correct Answer is B

Explanation

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