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A patient is incontinent the first day after his surgery.
This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

The patient has to be repositioned for the bed to be changed.

Shearing is more likely from wet sheets.

The moisture creates an environment suitable for the growth of microorganisms in a wound.

Greater pressure is exerted by a wet bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.

Choice B rationale:

While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.

Choice C rationale:

Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.

Choice D rationale:

A wet bed does not exert greater pressure on the patient’s skin.

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Correct Answer is C

Explanation

Choice A rationale:

Moistening the dressing with povidone iodine could cause irritation and is not the best method for removing a dressing stuck to the wound bed.

Choice B rationale:

Pulling off the dressing using slow, steady pressure could cause trauma to the wound bed and increase pain.

Choice C rationale:

Adding normal saline to loosen the dressing minimizes trauma to the wound bed and reduces pain during dressing removal.

Choice D rationale:

Leaving the old dressing in place and covering it with new, wet dressings could lead to infection and is not the best method for managing a dressing stuck to the wound bed.

A. there is probably a deeper injury than what appears on the surface. B. he has lain in one position for such a long time that swelling has occurred. C. vessels have dilated and allowed plasma to leak into the wound site. D. an infection is in progress at the wound site.

Correct Answer is C

Explanation

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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A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

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Naxlex Comprehensive Predictor Exams

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.The nurse's most beneficial intervention would be to:

Correct Answer is C

Explanation

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:

Correct Answer is C

Explanation

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A patient is incontinent the first day after his surgery.
This is a risk factor for the development of skin breakdown and infection because of the added moisture and because: