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 A
Explanation
Choice A rationale:
Testing the temperature of the solution is crucial to prevent burns.
Choice B rationale:
While using sterile equipment and solution is important, it’s not the most important in a hot soak treatment.
Choice C rationale:
Comfort is important but not as critical as preventing burns.
Choice D rationale:
Soaking only the affected area is good practice but not as vital as preventing burns.
Correct Answer is A
Explanation
Choice A rationale:
The side-lying position allows gravity to assist in wound irrigation and prevent pooling of the solution.
Choice B rationale:
High-Fowler’s position is not ideal for abdominal wound irrigation as it can lead to pooling of the solution.
Choice C rationale:
In the supine position, the solution can pool around the wound and not effectively irrigate it.
Choice D rationale:
The dorsal recumbent position is not ideal as it can also lead to pooling of the solution.
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