A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

restlessness, rising pulse, and falling blood pressure.

lethargy, falling pulse, and rising blood pressure.

headache, rising pulse, and falling blood pressure.

restlessness, falling pulse, and rising blood pressure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.

Choice B rationale:

Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

Choice C rationale:

Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.

Choice D rationale:

Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

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Correct Answer is D

Explanation

Choice A rationale:

Purulent indicates pus, which is not described here.

Choice B rationale:

Infection usually presents with redness, swelling, and possibly pus, which is not described here.

Choice C rationale:

Debridement is the removal of dead tissue, not indicated by a pinkish-red bumpy area.

Choice D rationale:

A pinkish-red center area that looks bumpy indicates granulation tissue, which is a sign of healing.

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

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.

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A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

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Naxlex Comprehensive Predictor Exams

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

Correct Answer is D

Explanation

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 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:

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:

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

A nurse performing a right eye irrigation will position the patient:

The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a: