Ch. 26 Wound Care

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. Notify the charge nurse about the change in status and the potential for infection. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). Notify the wound care nurse about the change in status and the potential for infection.

Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? Raise the head of the bed 15 to 20 degrees Place the client supine with knees bent. Assess the client for manifestations of shock. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of Primary intention. Partial-thickness wound repair. Full-thickness wound repair. Tertiary intention.

Full-thickness wound repair.

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing. Which of the following can be appropriately delegated to the nurse assistant? Performing a sterile dressing change Observing for any drainage on the dressing Performing wound assessment during the dressing change Notifying the physician of drainage present on the dressing

Observing for any drainage on the dressing

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serous Purulent Sanguineous Serosanguineous

Serosanguineous

The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? The incision site has started to itch. The incision site is approximated. The patient has pain at the incision site. The incision has a mass, bluish in color.

The incision has a mass, bluish in color.

The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer? The patient who is bedridden, but who turns himself randomly The patient whose Braden Scale score is 8 The patient who can ambulate to the bathroom independently The patient whose Braden Scale score is 18

The patient whose Braden Scale score is 8

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate? Droplet Contact Airborne Protective

Contact

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes Monitoring of the wound. Irrigation of the wound. Débridement of the wound. Management of drainage.

Débridement of the wound.

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is a. Pressure. b. Resistance. c. Stress. d. Weight.

Pressure

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by Tertiary intention. Secondary intention. Partial-thickness repair. Primary intention.

Secondary intention.

A patient has developed a decubitus ulcer. What laboratory data would be important to gather? Serum albumin Creatine kinase Vitamin E Potassium

Serum albumin

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? Stage I pressure ulcer Healing stage II pressure ulcer Healing stage III pressure ulcer Stage III pressure ulcer

Healing stage III pressure ulcer

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? Apply a tourniquet just above the wound. Apply pressure directly to the wound. Start two large-bore IV catheters. Place the client in a modified Trendelenburg position.

Apply pressure directly to the wound.

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage I. II. III. IV.

II.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? Check the client's vital signs. Assess the client's pain level. Cover the wound with a moist, sterile gauze dressing. Obtain a culture and sensitivity of the wound drainage.

Cover the wound with a moist, sterile gauze dressing.

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? Discard the dressing in the bedside trash receptacle. Dispose of the dressing in a biohazardous waste container. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. Double-bag the dressing in clear bags and label it "biohazard".

Dispose of the dressing in a biohazardous waste container.

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? Gloves Gown Face Shield Mask

Gloves

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? Eschar Slough Granulation Purulent drainage

Granulation

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? Cotton-tipped applicator Disposable measuring tape Sterile gloves Halogen ligh

Halogen light

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? Use a low-air-loss therapy unit. Consult a dietitian. Irrigate with hydrogen peroxide. Utilize hydrogel dressing.

Irrigate with hydrogen peroxide.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? Abrasion Contusion Laceration Puncture

Laceration

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by Tertiary intention. Secondary intention. Partial-thickness repair. Primary intention.

Primary intention.

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? Don sterile gloves. Provide analgesic medications as ordered. Avoid accidentally removing the drain. Gather supplies.

Provide analgesic medications as ordered.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? Serum albumin 3.2 g/dL Hemoglobin 16 g/dL WBC count 8,000/mm3 PTT 1.8

Serum albumin 3.2 g/dL