Nursing Fundamentals Chapter 26- Wound Care

Prevention of a wound infection requires diligent care from a nurse. The first and most important step for the nurse to take when emptying the patient's Jackson-Pratt drain is to

2. Wash his or her hands.

A patient has wet-to-damp dressings ordered for a wound. A nurse will

3. Change the dressings frequently to prevent drying out.

Upon answering a patient's call light, a nurse finds that the patient's wound has eviscerated. The nurse's first action is to

3. Cover the wound with sterile dressings soaked in saline.

When irrigating a patient's wound with a syringe, a nurse directs the flow of solution from the superior area to the inferior area of the wound. The rationale for this action is to

3. Direct the flow of solution from the least contaminated area to the most contaminated area.

The first step that a nurse must take to contribute to the development of a care plan for a patient with a pressure ulcer is to

3. Gather all of the available data.

When reassessing a patient's wound, a nurse notes redness and swelling, but no drainage. This is indicative of a phase of healing called the

3. Inflammatory phase.

A postoperative patient's wound is producing drainage that is slightly pink. A nurse would identify this type of drainage as

3. Serosanguineous.

A nurse is supervising a student applying a transparent dressing. The nurse intervenes when the student

3. Stretches the dressing tightly against the wound.

A nurse determines that the best way to clean a long incision that is sutured or stapled closed with approximated edges is to

3. Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end of the incision to the inferior end.

During a morning assessment, a nurse notices a change in a patient's wound. Which of the following samples of documentation would indicate a possible infection?

4. "Incision intact, moderate amount of purulent drainage, foul odor."

In explaining to a patient who is being dismissed from the hospital that he has a clean-contaminated wound, the nurse states:

4. "Surgical wounds are exposed to normal flora that resides on the skin. It is important to observe it for signs of infection, such as drainage that turns yellow or green."

A patient who was involved in a motor vehicle accident is admitted to the hospital. The patient was thrown from the vehicle, and the nurse finds several areas where the patient's skin appears to have been scraped away, most likely as a result of hitting the pavement. These types of injuries are termed

4. Abrasions.

Nine days after abdominal surgery, a nurse notices a complete separation of the outer layers of the patient's wound. The nurse identifies this rare and extremely serious condition as

4. Dehiscence.

During an initial assessment, a nurse finds that a patient's bone is visible in the pressure ulcer. The nurse notifies the physician that the pressure ulcer appears to be at stage

4. IV.

A nurse notes that there is a large amount of sanguineous drainage on a patient's dressing. There are no physician orders for a dressing change, so the nurse will

4. Reinforce the dressing with additional dressings.

A patient complains about what appears to be a tunnel-like infection under the skin with a small opening that is draining thick, yellow pus. The nurse identifies this type of wound as a

4. Sinus tract.

A patient with a chronic heart valve problem is experiencing edema caused by deoxygenated blood in the veins of the lower extremities. A nurse should monitor the patient closely for the development of a

4. Sinus tract.

A nurse checks a patient's Jackson-Pratt (JP) drain following surgery. The nurse explains to the patient that a closed drain speeds healing and facilitates wound drainage by

4. Suction.

When assessing a patient's wound, a nurse suspects that the wound most likely has been infected with Clostridia because

1. A crackling sensation can be felt when palpating around the wound.

While assessing a patient's surgical incision, a nurse notes that it is dry, clean, and intact, with edges approximated. The incision is healing by

1. First intention.

About 3 weeks after being admitted to the hospital, a patient's wounds begin to fill in with a red and semitransparent material. The nurse identifies this as

1. Granulation tissue.

A nurse is providing care for a patient who has just had surgery. The nurse understands that the patient's wound will need to be closely monitored for infection because it falls under the classification of

1. Open wounds.

A patient's wound is showing signs of delayed healing. A nurse determines that the patient's diet may be the culprit and instructs the patient to eat more

1. Protein.

A patient's open wound is healing by third intention. The nurse charts:

2. "Wound approximately 2?3? 3?3?, granulation tissue visible, draining serous fluid."

A nurse charts that a patient has a contusion that is approximately 3 inches in diameter on the right thigh. The nurse understands that a contusion is

2. A discoloration of the skin.

A nurse notes an increase in serosanguineous drainage from a patient's incision. The most appropriate action for the nurse to take is to

2. Draw a circle around the drainage and write the date, time, and initials on the dressing.

After assessing a patient with a stage II pressure ulcer, a nurse verifies that the patient is on a diet that will enhance healing. This patient's diet is

2. High protein, high calorie.

A patient's wound, which has a slight amount of drainage, will benefit from a dressing that provides a moist environment. Which type of dressing will the nurse apply?

2. Hydrocolloid

A quadriplegic patient who was admitted for pneumonia was found to have a stage III pressure ulcer. A nurse explains to the patient's mother that she will know that the pressure ulcer is in the reconstruction phase of healing when

2. Pink or red tissue can be seen in the wound.