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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 A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

A. sharp debridement. B. chemical debridement. C. enzymatic debridement. D. autolytic debridement.

Correct Answer is D

Explanation

Choice A rationale:

Sharp debridement involves the use of a sharp instrument or heat to remove dead tissue, which is not achieved with a hydrocolloid dressing.

Choice B rationale:

Chemical debridement involves the use of chemicals to remove dead tissue, which is not the function of a hydrocolloid dressing.

Choice C rationale:

Enzymatic debridement involves the use of enzymes to soften and remove dead tissue, which is not the function of a hydrocolloid dressing.

Choice D rationale:

Autolytic debridement uses the body’s own enzymes and moisture to soften and remove dead tissue. A hydrocolloid dressing helps maintain a moist wound environment, promoting autolytic debridement.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

Which type of debridement is a hydrocolloid dressing used for?

Correct Answer is D

Explanation

The nurse places Dakin solution in a wound to accomplish chemical:

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

When applying an ice pack, it is necessary to:

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

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