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The nurse assesses the large raised scar on the African American patient.
The nurse documents the lesion as a:

Laceration.

Contusion.

Keloid.

Hematoma.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A laceration is a cut or tear in the skin, not a raised scar.

Choice B rationale:

A contusion is a bruise caused by an impact to the skin, not a raised scar.

Choice C rationale:

A keloid is a thick, raised scar that can develop at the site of an injury or inflammation. It’s more common in people with darker skin tones.

Choice D rationale:

A hematoma is a collection of blood outside of the blood vessels, not a raised scar.

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Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

A. Leave it until the end of the shift. B. Remove the drain. C. Empty the reservoir. D. Notify the surgeon about the blood loss.

Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

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Correct Answer is B

Explanation

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The nurse assesses the large raised scar on the African American patient.
The nurse documents the lesion as a: