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. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.
B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.
C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.
D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.
Correct Answer is A
Explanation
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.
B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.
C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.
D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.
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