A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg has and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
Abrasion
Contusion
Laceration
Puncture
The Correct Answer is C
A. Abrasion:
This type of wound occurs when the skin rubs or scrapes against a rough surface. It's often referred to as a "scrape" and typically involves superficial damage to the skin without penetration or tearing.
B. Contusion:
Commonly known as a bruise, a contusion results from blunt trauma to the body, causing blood vessels to break and leak blood into the surrounding tissues. The skin remains intact, but there's discoloration due to the blood.
C. Laceration:
This type of wound involves a tear or irregular cut in the skin, often with jagged or rough edges. Lacerations typically result from sharp or blunt trauma that causes the skin to tear.
D. Puncture:
Puncture wounds occur when a sharp object pierces the skin and underlying tissues, creating a small, deep hole. These wounds might not bleed much externally but can cause damage to internal structures and carry a risk of infection due to the depth and possible trapping of debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.
B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.
C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.
D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.
Correct Answer is A
Explanation
A.Crackles in the lung fields indicate the presence of fluid in the lungs, which can be a sign of pulmonary edema. This is a serious adverse effect of hypertonic saline infusion (3% saline), as it can lead to fluid overload and respiratory compromise.
B.A slightly elevated heart rate (tachycardia) could occur in response to fluid shifts or the underlying condition, but it is not a specific indicator of an adverse outcome related to hypertonic saline infusion.
C.Sediment or blood in the urine is not a typical adverse outcome associated with hypertonic saline infusion. These findings may indicate a separate issue, such as a urinary tract infection or renal impairment, but they are unrelated to the administration of 3% saline for hyponatremia.
D.A rise in blood pressure may be expected as a result of volume expansion due to fluid administration, and it may even be beneficial if the patient was hypotensive.
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