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:

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

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

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

an infection is in progress at the wound site.

Answer and Explanation

The Correct Answer is C

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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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. BMI of 20. B. Peripheral neuropathy. C. Immobility. D. Hypoperfusion. E. Prealbumin level of 16 mg/dL. .

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

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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:

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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

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

Correct Answer is ["B","C","D"]

Explanation

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