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:

Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.

Choice B rationale:

It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.

Choice C rationale:

Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.

Choice D rationale:

Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.

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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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When applying an ice pack, it is necessary to:

Correct Answer is C

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 patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.You would document this wound as:

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

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:

When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?