Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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.

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

Choice A rationale:

While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.

Choice B rationale:

Placing a discard bag close to the wound can increase the risk of infection.

Choice C rationale:

Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.

Choice D rationale:

Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.

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.

Choice A rationale:

Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice B rationale:

Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.

Choice C rationale:

Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice D rationale:

Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice A rationale:

Numbing the area treated is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.

Choice B rationale:

Dilating the blood vessels is the correct answer. Moist heat therapy works by increasing the temperature of the skin/soft tissue, which leads to vasodilation and increased blood flow to the treated area.

Choice C rationale:

Drawing fluid to the site of application is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.

Choice D rationale:

Constricting the blood vessels is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area through vasodilation.

Choice A rationale:

Leaving nonbleeding wounds open to air is not recommended during the initial stage of wound healing as it can lead to infection and delay the healing process.

Choice B rationale:

Corticosteroids can help reduce inflammation and promote healing during the initial stage of wound healing.

Choice C rationale:

Mechanical debridement is usually not necessary during the initial stage of wound healing unless there is necrotic tissue present.

Choice D rationale:

Applying oxygen at 2L/min via nasal cannula is not directly related to wound healing.

Choice A rationale:

Decreased serum calcium does not directly contribute to pressure injury development.

Choice B rationale:

Decreased circulation can lead to tissue ischemia and necrosis, increasing the risk of pressure injury.

Choice C rationale:

Increased collagen is beneficial for wound healing and does not increase the risk of pressure injury.

Choice D rationale:

Increased muscle mass can actually provide more padding over bony prominences, reducing the risk of pressure injury.

Choice A rationale:

An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.

Choice B rationale:

A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.

Choice D rationale:

A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.

Choice A rationale:

Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.

Choice B rationale:

Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.

Choice C rationale:

Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.

Choice D rationale:

Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.

E.

Choice A rationale:

Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.

Choice B rationale:

Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.

Choice C rationale:

Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.

Choice D rationale:

Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.

Choice E rationale:

Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.

Choice A rationale:

Karaya paste is used for ostomy care, not for dressing changes.

Choice B rationale:

Paper tape might not provide the necessary adhesion for frequent dressing changes.

Choice C rationale:

Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.

Choice D rationale:

Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.

E.

Choice A rationale:

Increased immunity is not a characteristic of aging. In fact, immunity decreases with age, which can slow healing.

Choice B rationale:

Atherosclerosis, or hardening of the arteries, can reduce blood flow to tissues and slow healing.

Choice C rationale:

Metabolism slows with age, which can delay the body’s ability to repair and regenerate tissues.

Choice D rationale:

Excessive production of blood factors is not a characteristic of aging. Blood factors are typically produced in response to injury or illness.

Choice E rationale:

Diminished lung function can reduce oxygen supply to tissues, slowing healing.

E.

Choice A rationale:

Wet-to-dry dressings are not typically used for chronic wounds as they can cause tissue damage.

Choice B rationale:

Negative pressure treatment can promote healing by removing excess fluid and promoting blood flow to the wound.

Choice C rationale:

NPWT therapy, or Negative Pressure Wound Therapy, can help heal chronic wounds by removing excess fluid and promoting blood flow.

Choice D rationale:

Hydrocolloid dressings maintain a moist wound environment, which can promote healing.

Choice E rationale:

Protein is essential for wound healing as it is needed for the growth and repair of tissues.

Choice A rationale:

An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.

Choice B rationale:

A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.

Choice D rationale:

A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.

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.

Choice A rationale:

Documentation is important but not the first priority.

Choice B rationale:

Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.

Choice C rationale:

Checking the setting on the NPWT unit is important but comes after assessing the patient.

Choice D rationale:

Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.

Choice A rationale:

Purulent indicates pus, which is not described here.

Choice B rationale:

Infection usually presents with redness, swelling, and possibly pus, which is not described here.

Choice C rationale:

Debridement is the removal of dead tissue, not indicated by a pinkish-red bumpy area.

Choice D rationale:

A pinkish-red center area that looks bumpy indicates granulation tissue, which is a sign of healing.

Choice A rationale:

Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.

Choice B rationale:

Repositioning should be done every 2 hours or less for at-risk patients.

Choice C rationale:

Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.

Choice D rationale:

A high-calorie diet can promote skin integrity and wound healing.

Choice A rationale:

Abdominal pads are not designed to minimize pain during dressing changes.

Choice B rationale:

Hydrogel dressings are known to minimize pain during dressing changes.

Choice C rationale:

Wet-to-dry dressings can cause discomfort during dressing changes.

Choice D rationale:

Dry gauze can stick to the wound bed and cause pain during dressing changes.

Choice A rationale:

Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.

Choice B rationale:

First intention healing occurs when the wound edges are approximated, such as with sutures.

Choice C rationale:

Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.

Choice D rationale:

Fourth intention healing is not a recognized term in wound healing.

Choice A rationale:

Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.

Choice B rationale:

Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.

Choice C rationale:

Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.

Choice D rationale:

Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.