When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:

He has lain in one position for such a long time that swelling has occurred.

An infection is in progress at the wound site.

There is probably a deeper injury than what appears on the surface.

Vessels have dilated and allowed plasma to leak into the wound site.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Prolonged immobility can indeed cause swelling due to fluid accumulation; however, it typically does not lead to sudden worsening or significant swelling at a specific wound site. It is more associated with generalized edema, particularly in dependent areas of the body.

Choice B rationale
While infections can cause swelling, they are also accompanied by other signs such as redness, warmth, pain, and possibly fever. Swelling alone, without these other symptoms, is less indicative of an infection.

Choice C rationale
A deeper injury might cause swelling, but this would have been identified during the initial assessment. Swelling that occurs later in the healing process is less likely to be from a deeper, previously unnoticed injury.

Choice D rationale
Swelling at a wound site is often due to inflammation, where blood vessels dilate and become more permeable, allowing plasma to leak into the tissue. This is a normal part of the healing process as the body brings in necessary cells and substances to promote recovery.

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Correct Answer is D

Explanation

Choice A rationale
A headache is a nonspecific symptom and can be associated with many conditions. It is not typically indicative of internal hemorrhage, which is more likely to present with hemodynamic changes.

Choice B rationale
While a rising pulse is a sign of internal hemorrhage due to the body’s attempt to maintain cardiac output, the blood pressure would typically fall, not rise, as the blood volume decreases.

Choice C rationale
Lethargy and a falling pulse are signs of decreased cardiac output, but in the case of internal hemorrhage, the blood pressure would usually fall, not rise, due to the loss of blood volume.

Choice D rationale
Restlessness, a rising pulse, and falling blood pressure are classic signs of internal hemorrhage. The body responds to blood loss by increasing heart rate to maintain perfusion, but as volume continues to decrease, blood pressure falls.

A. Elastic adhesive tape. B. Karaya paste. C. Montgomery straps. D. Paper tape.

Correct Answer is C

Explanation

Choice A rationale
Elastic adhesive tape is not the best option for a patient experiencing skin irritation from tape removal because it may cause further irritation when removed.

Choice B rationale
Karaya paste is primarily used as a skin barrier and adhesive for ostomy appliances, not for securing dressings, especially in cases of skin irritation.

Choice C rationale
Montgomery straps are designed for situations where frequent dressing changes are needed. They allow the dressing to be changed without removing the adhesive straps each time, minimizing skin irritation.

Choice D rationale
Paper tape is less irritating to the skin than elastic adhesive tape, but it still requires removal with each dressing change, which can irritate sensitive skin.

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When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a surgical patient for internal hemorrhage. Which of the following would indicate internal hemorrhage?

Correct Answer is D

Explanation

Because the patient with an abdominal dressing requires frequent dressing changes, and the abdomen is beginning to show skin irritation from repeated tape removal, the nurse would change the dressing procedure in order to use:

Correct Answer is C

Explanation

When preparing to change a sterile dressing over an incision, it is most important to remember to:

The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?

The patient is undergoing Negative Pressure Wound Therapy (NPWT) treatment for wound healing. Which would be your first priority in caring for this patient?

The nurse is performing a dry sterile dressing change for an abdominal wound. In which direction should the nurse use a swab to clean?

The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:

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

A nurse is caring for a client who has a stage 4 sacral pressure injury. 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?

The nurse clarifies that the second stage of wound healing is: