A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Motor impairment

Pain

The client's culture

Hearing loss

Answer and Explanation

The Correct Answer is B

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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Correct Answer is C

Explanation

A. Wearing sterile gloves when moving sterile items is appropriate practice and should not be intervened with.

B. Positioning the wrapped package so the outer flap is away from the nurse is correct to prevent contamination when opening.

C. The nurse should avoid holding sterile items too far above the sterile field to prevent contamination from falling or being exposed to non-sterile areas. Items should be held as close as possible to the sterile field, typically no more than 2 inches (5 cm).

D. Holding the bottle of solution with the label away from the palm of the hand is proper to maintain sterility.

A. Abrasion B. Laceration C. Puncture D. Contusion

Correct Answer is B

Explanation

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Correct Answer is C

Explanation

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Correct Answer is B

Explanation

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