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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
D.
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.
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.
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