When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

there is probably a deeper injury than what appears on the surface.

he has lain in one position for such a long time that swelling has occurred.

vessels have dilated and allowed plasma to leak into the wound site.

an infection is in progress at the wound site.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

There is probably a deeper injury than what appears on the surface is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice B rationale:

He has lain in one position for such a long time that swelling has occurred is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice C rationale:

Vessels have dilated and allowed plasma to leak into the wound site is the correct answer because this is a normal part of the inflammatory stage of wound healing.

Choice D rationale:

An infection is in progress at the wound site is incorrect because while swelling can be a sign of infection, it is also a normal part of the inflammatory stage of wound healing.

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Correct Answer is C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A. Hydrogel dressing. B. Polymeric membrane dressing. C. Hydrofiber dressing. D. Hydrocolloid dressing.

Correct Answer is C

Explanation

Choice A rationale:

Hydrogel dressings are used for wounds with little to no exudate. They are not suitable for wounds with significant exudate.

Choice B rationale:

Polymeric membrane dressings are used for dry wounds with or without depth. They are not suitable for wounds with significant exudate.

Choice C rationale:

Hydrofiber dressings are used for wounds with moderate to high amounts of exudate. They are suitable for wounds with significant exudate.

Choice D rationale:

Hydrocolloid dressings are used for wounds that have minimal to moderate exudate. They are not suitable for wounds with significant exudate.

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When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

Correct Answer is C

Explanation

When applying an ice pack, it is necessary to:

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

The nurse places Dakin solution in a wound to accomplish chemical:

What type of wound heals by delaying the suturing until the infection is resolved?

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)