Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

Unable to state the phase

Inflammatory

Proliferative

Maturation

Answer and Explanation

The Correct Answer is B

A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.

B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.

C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.

D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.

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Correct Answer is A

Explanation

A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.

B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.

C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.

D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.

A. Place the client supine with knees bent. B. Assess the client for manifestations of shock. C. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation. D. Raise the head of the client's bed 15° to 20°.

Correct Answer is C

Explanation

A. Placing the client supine with knees bent helps reduce abdominal pressure, but it is not the first action. Protecting the exposed organs from infection or drying out takes priority.

B. Assessing for manifestations of shock is important, but the immediate concern is to prevent further injury or infection to the exposed tissues.

C. The priority action when a wound eviscerates is to cover the area with a sterile dressing moistened with 0.9% sodium chloride solution to keep the organs moist and prevent infection until surgical repair can be done.

D. Raising the head of the bed slightly may help reduce pressure, but it is not the most immediate action compared to covering the exposed organs to prevent drying or infection.

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Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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