***Funds Chapter 31 Wound Care ****

The nurse uses the RYB wound classifcation system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Débride the wound. d. Change the dressing frequently.

Ans: b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. Pain b. Impaired Skin Integrity c. Disturbed Body Image d. Disturbed Thought Processes

Ans: c. Wounds cause emotional as well as physical stress.

Which of the following are functions of the skin? Select all that apply. A: Protection B: Temperature regulation C: Sensation D: Vitamin C production E: Immunological

Ans:A, B, C, E Feedback:The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination.

Which is an example of a closed wound? A: Abrasion B: Ecchymosis C: Incision D: Puncture wound

Ans:B Feedback:A closed wound results from a blow, force, or strain caused by trauma (such as a fall, an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas. An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? A: Stage I B: Stage II C: Stage III D: Stage IV

Ans:C Feedback:In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence. In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A: Serous B: Sanguineous C: Serosanguineous D: Purulent

Ans:C Feedback:The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A: Clear, watery blood B: Large numbers of red blood cells C: Mixture of serum and red blood cells D: White blood cells, debris, bacteria

Ans:D Feedback:Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A: Self-care Deficit B: Risk for Imbalanced Nutrition C: Anxiety D: Risk for Infection

Ans:D Feedback:Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections, because corticosteroids decrease the inflammatory process that may in turn delay healing.

You are applying a saline‐moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate? a) "Wounds heal better when a moist wound bed is maintained." b) "You may be correct. I will check with your primary health care provider." c) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." d) "Allowing a scab to form would prevent us from observing the wound for signs of infection."

Ans: a A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A: Provide total physical hygiene, including perineal care. B: Provide total physical hygiene, excluding hair care. C: Provide supplies and orient to the bathroom. D: Provide supplies and assist with hard-to-reach areas.

Ans:D Feedback:Morning care is often identified as either self-care, partial care, or complete care. Clients requiring partial morning care most often receive care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach.

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? A: A client 83 years of age who is mobile B: A client 92 years of age who uses a walker C: A client 75 years of age who uses a cane D: A client 86 years of age who is bedfast

Ans:D Feedback:Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.

While the nurse is preparing the client with a leg wound for heat therapy, the client asks the nurse how long the warm compress will need to stay on since he wants to get up and walk. What would be the nurse's best response? a) 20 to 30 minutes b) 1 hour c) Five minutes each hour d) Two hours each morning and evening

Ans: a) Heat produces maximum vasodilation in 20 to 30 minutes. If heat is continued beyond that time, tissue congestion and vasoconstriction can occur and this can be detrimental to healing.

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) Hydrocolloid dressings b) Transparent films c) Alginates d) Hydrogels

Ans: a) Hydrocolloids are occlusive or semi‐occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full‐thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial‐thickness wounds with minimal drainage.

A medical‐surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? a) Removing dead or infected tissue to promote wound healing b) Removing excess drainage and wet tissue to prevent maceration of surrounding skin c) Stimulating the wound bed to promote the growth of granulation tissue d) Removing purulent drainage from the wound bed in order to accurately assess it

Ans: a) Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A: Full-thickness skin loss B: Skin pallor C: Blister formation D: Eschar formation

Ans:A Feedback:A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss.

The nurse is caring for a client who has a deep wound and whose saline‐moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which of the following modifications is most appropriate? a) Reduce the time interval between dressing changes. b) Discontinue application of saline‐moistened packing and apply a hydrocolloid dressing instead. c) Assure that the packing material is completely saturated when placed in the wound. d) Use less packing material.

Ans: a) A hydrocolloid dressing in not indicated

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

Ans: a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least one inch beyond the end of the new dressing if one is being applied. f. Clean to at least three inches beyond the wound if a new dressing is not being applied

Ans: a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.

Ans: a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as ordered. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic order

Ans: a. The assessment fndings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

Ans: a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

A physician orders the application of a warm, sterile compress to reduce edema in a client's wound. Which of the following is a recommended step in this procedure? a) Place an aquathermia or heating device directly on the dressing. b) Keep the dressing in place for the prescribed amount of time or up to 30 minutes. c) Cover the site with a three layers of gauze and with a clean, dry bath towel. d) Apply pressure to the compress to mold it around the wound site

Ans: b) After the prescribed time for the treatment (up to 30 minutes), the external heating device should be removed. The compress should be applied by gently and carefully molding it around the wound site. The site should be covered with one layer of gauze and the heating device should be placed over a towel covering the dressing.

A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do? a) Keep the feet and torso uncovered. b) Assess for rapid pulse and facial pallor. c) Maintain the temperature of water at 100ºF. d) Encourage use of sitz bath for about an hour.

Ans: b) When giving a sitz bath, the nurse should assess the client for a rapid pulse, pale facial color, or complaints of nausea. Because heat is being applied to a large area, vasodilation can occur, causing the client to feel light‐headed and faint. The temperature of the water should be 105ºF to 110ºF. The client's feet and upper torso should remain covered to prevent chilling. Sitz baths usually last for about 20 minutes, not an hour.

What observation should the nurse note about a client's open wound if the wound is healing by the third‐intention? a) Wound edges are close to each other but require closure material b) Wound edges are widely separated and brought together with closure material c) Wound edges are directly next to each other d) Wound edges are widely separated leading to complex reparative process

Ans: b) With third‐intention healing, the wound edges are widely separated and are later brought together with some type of closure material. First‐ intention healing, also called healing by primary intention, is a reparative process in which the wound edges are directly next to each other. In second‐intention healing, the wound edges are widely separated, leading to a more time‐consuming and complex reparative process. However, edges that are near or close to each other do not require closure material.

Which of the following actions should the nurse perform when applying negative pressure wound therapy? a) Test the seal of the completed dressing by briefly attaching it to wall suction. b) Cut foam to the shape of the wound and place it in the wound. c) Increase the negative pressure setting until drainage is brisk. d) Irrigate the wound thoroughly using normal saline and clean technique.

Ans: b) When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? a) Hydrocolloid b) Transparent c) Bandage d) Gauze

Ans: b) Transparent The nurse should use a transparent dressing to cover the IV insertion site because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage. A hydrocolloid dressing helps keep the wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply. a. The patient takes time to think about her responses to questions. b. The patient's age of 86 years. c. Patient reports inability to control urine. d. A scheduled hip arthroplasty e. Lab fndings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL). f. Patient reports increased pain in right hip when repositioning in bed or chair.

Ans: b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer development. Apathy, confusion, and/or altered mental status are risk factors for pressure ulcer development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure ulcer development.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: a. Stage I b. Stage II c. Stage III d. Stage IV

Ans: b. A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-flled blister.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) An individual's skin changes little over the life span. b) A child's skin becomes less resistant to injury and infection as the child grows. c) An infant's skin and mucous membranes are easily injured and at risk for infection. d) In children younger than 2 years, the skin is thicker and stronger than in adults.

Ans: c) An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing? a) A client whose breast reconstruction surgery required numerous incisions b) A client who is NPO (nothing by mouth) following bowel surgery c) An obese woman with a history of type 1 diabetes d) A man with a sedentary lifestyle and a long history of cigarette smoking

Ans: c) Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than is smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short‐term lack of food intake is not as significant as longer‐term lack of nutrition.

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A: Perform hand hygiene. B: Insert a swab into the wound at 90 degrees. C: Measure the width of the wound with a disposable ruler. D: Assess the condition of the visible wound bed.

Ans:A Feedback:Hand hygiene should precede any wound assessment or wound treatment.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? a) A gauze dressing premedicated with antibiotics b) A gauze dressing precut halfway to fit around the IV line c) A transparent film d) A dressing with a nonadherent coating

Ans: c) Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing.

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition? a) There is an accumulation of fluid in the interstitial tissue. b) There is redness or inflammation of an area as a result of dilation. c) There is an accidental separation of the wound. d) The edges of the wound are lightly pulled together

Ans: c) With dehiscence, there is an accidental separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema

Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply a) Use a sterile applicator to apply any ointment that is ordered. b) Avoid touching the wound bed, whether with gloves or forceps. c) Clean the wound from top to bottom. d) Clean from the outside of the wound to the center. e) Use a new gauze for each wipe of the wound.

Ans: c, a, e, b Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. Notify the physician immediately of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile NSS. c. Place the patient in the low Fowler's position.

Ans: c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position, cover the exposed tissue with sterile towels moistened with sterile NSS, and notify the physician immediately of the situation.

The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a. Enhanced healing due to the presence of sugars and proteins b. Delayed healing due to dead tissue present in the wound c. Decreased effectiveness of antibiotics against the bacteria d. Impaired skin integrity due to overhydration of the cells of the wound e. Delayed healing due to cells dehydrating and dying f. Decreased effectiveness of the patient's normal immune process

Ans: c, f. Wound bioflms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Beitz, 2012). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

Ans: c. Negative-pressure wound therapy (or topical negative pressure [TNP]) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."

Ans: c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately? a) A small plastic ruler b) A sterile tongue blade lubricated with water soluble gel c) An otic curette d) A sterile, flexible applicator moistened with saline

Ans: d) A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Pick the crusts off the sutures with the forceps before removing them. b) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c) Do not attempt to remove the sutures because they need more time to heal. d) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

Ans: d) If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing sutures.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate? a) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." b) "As soon as the infection clears, your surgeon will staple the wound closed." c) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." d) "Your wound will heal slowly as granulation tissue forms and fills the wound."

Ans: d) There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention.

A home care nurse is visiting a client as a part of a regular visit. The client's daughter age 4 years falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect? a) Increased blood flow b) Resolution of inflammation c) Relief of muscle stiffness d) Help in controlling swelling

Ans: d) A cold compress helps to control swelling. It controls local bleeding because it causes vasoconstriction, which decreases blood flow to the area. Heat therapies are used to increase blood flow, relieve muscular pain and stiffness, resolve inflammation, and improve healing of soft tissues.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical‐ surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a) Maceration b) Necrosis c) Evisceration d) Desiccation

Ans: d) Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

Which of the following types of wound drainage should alert the nurse to the possibility of infection? a) Drainage that appears to be mostly fresh blood b) Copious wound drainage that is blood‐tinged c) Large amounts of drainage that is clear and watery d) Foul‐smelling drainage that is grayish in color

Ans: d) Purulent drainage is frequently foul‐smelling and may vary in color; such drainage is associated with infection. Clear, watery (serous), blood‐ tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection.

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? a) Clean the wound from the bottom to the top, and outside to center. b) Use clean technique to clean the wound. c) Once the wound is cleaned, dry the area with an absorbent cloth. d) Clean the wound from the top to the bottom, and center to outside.

Ans: d) Using sterile technique, clean the wound from the top to the bottom, and from the center to the outside. Dry the area with a gauze sponge in the same manner and apply ointment and dressing.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90‐degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? a) Direction b) Size c) Tunneling d) Depth

Ans: d) When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90‐degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? a) Hemovac drain b) Jackson‐Pratt drain c) Wound pouching d) Penrose drain

Ans: d) Penrose drain Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. Jackson‐Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery. Wound pouching is used on wounds that have excessive drainage.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using sterile dressing supplies b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene

Ans: d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long-term care facility. Which action would be a priority in preventing a patient from developing a pressure ulcer? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

Ans: d. To prevent pressure ulcers, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

The nurse would recognize which of these devices as an open drainage system? A: Penrose drain B: Jackson-Pratt drain C: Hemovac D: Negative pressure dressing

Ans:A Feedback:A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A: Covering the wound area with sterile towels moistened with sterile 0.9% saline B: Closing the wound area with Steri-Strips C: Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D: Holding the wound together until the physician arrives

Ans:A Feedback:If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound? A: Stage II pressure ulcer B: Stage I pressure ulcer C: Stage III pressure ulcer D: Stage IV pressure ulcer

Ans:A Feedback:Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A: Proliferation phase B: Hemostasis C: Inflammatory phase D: Maturation phase

Ans:A Feedback:The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply. A: Constricts peripheral blood vessels B: Reduces muscle spasms C: Increases blood flow to tissues D: Increases the local release of pain-producing substances E: Reduces the formation of edema and inflammation

Ans:A, B, E Feedback:The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues and decreases the local release of pain-producing substances such as histamine, serotonin, and bradykinin. This action in turn reduces the formation of edema and inflammation. Decreased metabolic needs and capillary permeability, combined with increased coagulation of blood at the wound site, facilitate the control of bleeding and reduce edema formation. Cold also reduces muscle spasms, alters tissue sensitivity (producing numbness), and promotes comfort by slowing the transmission of pain stimuli.

Which of the following clients would be considered at risk for skin alterations? Select all that apply. A: A teenager with multiple body piercings B: A homosexual in a monogamous relationship C: A client receiving radiation therapy D: A client undergoing cardiac monitoring E: A client with diabetes

Ans:A, C, E Feedback:Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory disorders are not risk factors.

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A: A clean separation of skin and tissue with a smooth, even edge B: A separation of skin and tissue in which the edges are torn and irregular C: A wound in which the surface layers of skin are scraped away D: A shallow crater in which skin or mucous membrane is missing

Ans:B Feedback:A laceration wound can be described as a separation of skin and tissue in which the edges are torn and irregular. An incision wound is described as a clean separation of skin and tissue with a smooth, even edge. An abrasion is a wound in which the surface layers of skin are scraped away. Ulceration is a shallow crater in which skin or mucous membrane is missing.

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A: Administer pain medications on a p.r.n. and regular basis. B: Assist in moving to prevent strain on the suture line. C: Tell the client that a mild fever is a normal response. D: If a scar forms over a joint, it may limit movement.

Ans:B Feedback:The proliferative phase of wound healing begins within two to three days of the injury. Collagen synthesis and accumulation continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations.

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A: Change position at least once each shift. B: Implement a turning schedule every two hours. C: Use ring cushions for heels and elbows. D: Do not turn; use pressure-relieving support surface.

Ans:B Feedback:To protect clients at risk from the adverse effects of pressure, implement turning using an every-2-hour schedule in the health care setting. More frequent position changes may be necessary. Never use ring cushions or "donuts."

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound? A: Stage I pressure ulcer B: Stage II pressure ulcer C: Stage III pressure ulcer D: Stage IV pressure ulcer

Ans:C Feedback:Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial and may present as a blister or abrasion.

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client? A: Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin. B: Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. C: Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. D: Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

Ans:C Feedback:Deep tissue injury may be difficult to detect in individuals with dark skin tones. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A: Saline-moistened dressing B: Dressing secured with Montgomery straps C: Hydrocolloid dressing D: Foam dressing

Ans:C Feedback:Hydrocolloid dressings are used for wounds that are shallow to moderate depth with minimal drainage. Saline-moistened dressing is often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings are recommended for chronic wounds.

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A: Beta-hemolytic streptococcus B: Age C: Venous insufficiency D: Hemangioma

Ans:C Feedback:Leg and foot ulcers occur from various causes, but the most common are ulcers secondary to venous insufficiency, arterial insufficiency, and neuropathy.

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A: "Oh, for gosh sakes...it doesn't look that bad!" B: "I understand, but you are going to have to look someday." C: "I respect your wish not to look at it right now." D: "You won't be able to go home until you look at it."

Ans:C Feedback:The sight of the wound may disturb a client. If the wound involves a change in normal body functions or appearance, the pclient may not want to look at the wound. With patience and emotional support, clients learn to cope with and adapt to their wounds in time.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A: Taking medications as prescribed B: Proper intake of food and fluids C: Thorough hand hygiene D: Adequate sleep and rest

Ans:C Feedback:The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections.

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? A: "I will drink a lot of orange juice and drink milk, too." B: "I will take the zinc supplement the doctor recommended." C: "I will restrict my diet to fats and carbohydrates." D: "I will drink 8 to 10 glasses of water every day."

Ans:C Feedback:Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins C and D, zinc, and adequate fluids are also necessary for wound healing.

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education? A: "I understand the rebound effect of heat." B: "I will put the heat packs only on the sore on my leg." C: "I will only leave the heat packs on for 20 minutes." D: "I will leave the heat packs on for an hour."

Ans:D Feedback: Initially, temperature receptors in the skin are strongly stimulated. This response decreases rapidly for the first few seconds after being stimulated and more slowly for the next 30 minutes as the receptors adapt to the temperature. Be sure to tell clients that increasing the temperature or lengthening the time of application can seriously damage tissues.

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A: Question the physician about the accuracy of this agent. B: Refuse to use 0.9% normal saline on a wound. C: Document the rationale for not changing the dressing. D: Continue with the dressing change as planned.

Ans:D Feedback:Although various antiseptic cleaning agents could be used to clean a wound, sterile 0.9% normal saline is usually the agent of choice. Other agents may be caustic to skin and tissues.

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A: An infant B: A young adult C: A middle adult D: An older adult

Ans:D Feedback:An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process.

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A: Do not use irrigation to clean the wound before changing the dressing. B: Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it. C: Exert light pressure to pack the wound tightly with moistened dressing. D: Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

Ans:D Feedback:Answer D is the correct step in the procedure. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom, and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The dressing should be gently and loosely packed inside the wound.

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A: Secure the heating pad to the client's clothing with safety pins. B: Place a heavy towel or blanket over the heating pad to maximize heat effects. C: Use a heating pad with a selector switch that can be turned up by the client if needed. D: Place a heating pad anteriorly or laterally to, not under, the body part.

Ans:D Feedback:Guidelines include: Place a heating pad anteriorly or laterally to, not under, the body part. If the heating pad is between the client and the mattress, heat dissipation may be inadequate, leading to burning of the client or the bed linens. Avoid using pins to secure a heating pad because there is a danger of electric shock if a pin touches a wire. Do not cover the heating pad with anything that might be heavy; heat may accumulate and burn the client when it cannot dissipate normally from the pad. Use a heating pad with a selector switch that cannot be turned up beyond a safe temperature.

Which of the following is an indication for the use of negative pressure wound therapy A: Bone infections B: Malignant wounds C: Wounds with fistulas to body cavities D: Pressure ulcers

Ans:D Feedback:Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008; Thompson, 2008).

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A: Document the assessments and intervention. B: Reinforce the dressing with additional layers. C: Administer pain medications intramuscularly. D: Notify the physician and prepare for surgery.

Ans:D Feedback:Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.

What are the two major processes involved in the inflammatory phase of wound healing? A: Bleeding is stimulated, epithelial cells are deposited B: Granulation tissue is formed, collagen is deposited C: Collagen is remodeled, avascular scar forms D: Blood clotting is initiated, WBCs move into the wound

Ans:D Feedback:The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation.