NCLEX Questions - Wound Care. Questions and answers, rated A+

NCLEX Questions - Wound Care. Questions and answers, rated A+ A nurse is assessing a patient's skin and notes a 3 cm shallow crater on the patient's buttocks. The patient winces when the area is palpated. How should the nurse stage this wound? A. stage 1 pressure ulcer B. stage 2 pressure ulcer C. stage 3 pressure ulcer D. stage 4 pressure ulcer - -B. Stage 2 pressure ulcer Which of the following are functions of dressings? (select all that apply) A. promote hemostasis B. keep wound bed dry C. wound debridement D. prevent contamination E. increase circulation - -A. promote hemostasis C. wound debridement D. prevent contamination We don't want to keep the wound bed dry and dressings don't increase circulation Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical debridement)? (select all that apply) A. 24 year old with an open infected wound from a spider bite B. 7 year old with an abrasion on bilateral knees C. 50 year old with a post operative knee replacement incision D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound - -A. 24 year old with an open, infected wound from a spider bite. D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound. Which of the following devices should be used to ensure the appropriate amount of irrigation pressure during a wound irrigation? A. 10 mL syringe with a 19 gauge needle B. 35 mL syringe with a 19 gauge needle C. steady flow of fluid from a height of 12 inches above the wound D. steady but gentle squirt of irrigant through a catheter irrigating system - -B. 35 mL syringe with a 19 gauge needle The nurse is caring for a patient who had knee replacement surgery 5 days go. The patient's knee appears red and warm to the touch and patient is requesting increased pain medication. What complication should the nurse be concerned about? A. nothing, this is expected post operatively B. patient is becoming dependent on pain medication C. post operative wound dehiscence D. post operative wound infection - -D. post operative wound infection Which of the following may indicate internal hemorrhage? (select all that apply) A. distention or swelling of the affected body part. B. elevated WBC C. decrease in blood pressure and increase in pulse D. change in the type and amount of drainage. - -A. Distention or swelling of effected body part C. decrease in blood pressure and increase in pulse Which of the following are common sites for development of pressure ulcers? (select all that apply) A. sternum B. heels