Skin Integrity and Wound Care
"Dressings provide a dry environment to facilitate healing." A dressing supports a moist wound environment, not a dry one. The remaining statements indicate understanding. Dressings absorb drainage to promote wound healing, promote hemostasis and thermal insulation, help reduce exposure to microorganisms, and support the wound site.
A nurse discusses the purposes of wound dressings with a nursing student. Which of the nursing student's statements indicates the need for further learning? 1 "Dressings absorb drainage to promote wound healing." 2 "Dressings promote hemostasis and thermal insulation." 3 "Dressings help reduce exposure to microorganisms, and they support the wound site." 4 "Dressings provide a dry environment to facilitate healing."
Normal saline Normal saline is a noncytotoxic topical fluid that can be used to clean a pressure ulcer. Povidone iodine, hydrogen peroxide, and sodium hypochlorite are cytotoxic fluids that are used to clean highly colonized wounds.
A patient developed a pressure ulcer after knee surgery due to restriction to bed. Which irrigating fluid should the nurse use to clean the ulcer? 1 Normal saline 2 Povidone iodine 3 Hydrogen peroxide 4 Sodium hypochlorite
Applying an elastic bandage An elastic bandage helps immobilize and supports healing of a sprained the ankle. Elastic webbing is used to secure dressings. An elastic pressure bandage is used to create pressure over a body part, for instance, to prevent bleeding. A stretch pressure bandage may be applied to reduce or prevent edema but not to immobilize and prevent pain from a sprain.
A patient reports pain in the ankle joint due to sprain. Which nursing intervention is beneficial to the patient? 1 Applying elastic webbing 2 Applying an elastic bandage 3 Applying an elastic pressure bandage 4 Applying a stretch pressure bandage
Release the bandage The nurse's priority is to release the bandage when impaired circulation is observed during evaluation. Once this is done, the nurse can then perform the lower-priority actions of palpating the extremity, assessing the pulse, and reapplying the bandage with less pressure.
During an evaluation of a patient with elastic bandages, the nurse observes signs of impaired circulation in the surrounding area. What should be the nurse's priority action? 1 Release the bandage 2 Palpate the extremity 3 Assess the pulse 4 Reapply the bandage with less pressure
30-35 kcal The nurse should recommend the patient consume 30 to 35 kcal per kilogram per day to promote wound healing. The amounts of 15 to 20 kcal, 20 to 25 kcal, and 25 to 30 kcal are not enough.
How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing? 1 15-20 kcal 2 20-25 kcal 3 25-30 kcal 4 30-35 kcal
Evaluation Checking the patient's circulation distal to the bandage is part of evaluating the care. Choosing the dressing type is an example of a planning phrase. Observing the characteristics of the patient's wound is part of the assessment phase. Applying the elastic bandage is considered part of implementation.
The nurse checks the distal circulation of a patient who has a bandage twice in an 8-hour period. Which part of the nursing process is this? 1 Planning 2 Evaluation 3 Assessment 4 Implementation
To learn the type of dressing that is to be used Reviewing the orders for the dressing change procedure indicates to the nurse the type of dressing or applications needed for dressing the wound. The nurse should assess the patient for any allergies to wound cleansing agents or any other agents used while dressing, to prevent adverse reactions. The nurse assesses the patient's and the family's knowledge of wound dressing to determine what will need to be included while teaching them. Reviewing the patient's medical record to learn about the size and location of the wound helps the nurse to plan for the proper type and amount of supplies required for dressing the wound.
The nurse is assisting the primary health care provider in applying moist dressing for a patient who has pressure ulcers. The nurse reviews the orders for the dressing change procedure. What is the rationale behind this nursing action? 1 To prevent adverse reactions 2 To learn the type of dressing that is to be used 3 To determine the specific areas that will be included during patient teaching 4 To plan for the proper type of supplies required for dressing
Adherent film A pressure ulcer covered in eschar is an unstageable pressure ulcer. The nurse would use an adherent film dressing because it will facilitate softening of the eschar to allow for debridement. No dressing is appropriate for an intact stage I pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. A calcium alginate dressing is appropriate for a clean stage III or stage IV pressure ulcer.
The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient? 1 None 2 Adherent film 3 Composite film 4 Calcium alginate
Pressure Blanchable erythema is an early indication of pressure; therefore, the nurse knows this finding on the patient's sacral area is due to pressure. Friction may not cause blanchable erythema in the patient, but it increases the risk of developing pressure ulcers. Massage may not be responsible for developing blanchable erythema in the patient, but it reduces the risk of pressure ulcers. Blanchable erythema does not indicate sheering force.
The nurse notes a quarter-sized area of blanchable erythema over the patient's sacral area. The nurse knows this finding is likely due to what? 1 Friction 2 Pressure 3 Massage 4 Sheering force
To prevent the dressing from slipping The nurse uses rolled gauze or elastic net while dressing wounds on the extremities to secure the dressings in place. Placing the patient in a comfortable position improves patient comfort, but this is not why using an elastic net is used. Assessing the condition of the wound would help to determine the rate of healing. Removing gloves and disposing of them in bags after dressing the wound would reduce transmission of infection to other parts of the body; applying an elastic net may not help reduce the transmission of infection.
The nurse uses an elastic net as additional dressing in a patient's leg region. What is the rationale behind this nursing action? 1 To improve patient comfort 2 To determine the rate of healing 3 To prevent the dressing from slipping 4 To reduce transmission of infection to other parts of the body
"The Braden Scale has shown sufficient predictive validity and accuracy for all patients." The Braden Scale for pressure ulcer development risk has shown insufficient predictive validity and poor accuracy in determining risk for pressure ulcers. It was developed based on risk factors in a nursing home population. The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23. It is the most widely used risk assessment tool for pressure ulcers.
The nursing instructor is discussing the Braden Scale for pressure ulcer development risk with a nursing student. Which of the student's statements is incorrect? 1 "The Braden Scale has shown sufficient predictive validity and accuracy for all patients." 2 "The Braden Scale was developed based on risk factors in a nursing home population." 3 "The Braden Scale contains six subscales, and the total score ranges from 6 to 23." 4 "The Braden Scale is the most widely used risk assessment tool for pressure ulcers."
30-35 mL Because adequate hydration is essential for cell functioning an therefore wound healing, the nurse should encourage the patient to drink 30 to 35 mL per kilogram per day. The amounts of 15 to 20 mL, 20 to 25 mL, and 25 to 30 mL are not enough.
What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing? 1 15-20 mL 2 20-25 mL 3 25-30 mL 4 30-35 mL
1.25 to 1.5 g The nurse should recommend that the patient consume 1.25 to 1.5 g of protein per kilogram of body weight a day to support wound healing. The amounts of 2 to 3.5 g, 3.5 to 4.5 g, and 5.15 to 6.5 g are too much.
What amount of protein per kilogram of body weight a day should the nurse recommend a patient consume to support wound healing? 1 1.25 to 1.5 g 2 2 to 3.5 g 3 3.5 to 4.5 g 4 5.15 to 6.5 g
1600-2000 To consume enough vitamin A to support proper wound healing, the nurse should recommend 1600 to 2000 retinol equivalents per day. The amounts of 1200 to 1400, 1400 to 1500, and 1500 to 1600 are not enough.
What amount of retinol equivalents for vitamin A per day should the nurse recommend a patient to consume to support proper wound healing? 1 1200-1400 2 1400-1500 3 1500-1600 4 1600-2000
The tissue is damaged. The nonblanchable erythema indicates that the tissue was under pressure and caused inflammation, leading to tissue damage. The tissue is infected when there is drainage from the wound or sutures at the surgical site. The tissue appears mottled or exhibits pallor when it is under hypoxia. The tissue with erythema is an early indication of pressure to the tissue.
What does the nonblanchable erythema indicate about the skin? 1 The tissue is infected. 2 The tissue is damaged. 3 The tissue is under hypoxia. 4 The tissue is under pressure.
Clean gloves Clean gloves are required when applying an ace bandage if wound drainage is present to prevent contamination. Clips, bandages, and adhesive tapes may be necessary, but the wound drainage makes preventing contamination a concern, and these materials do not address that.
What equipment is required if wound drainage is present when applying an ace bandage? 1 Clips 2 Bandages 3 Clean gloves 4 Adhesive tape
A 19-gauge angiocatheter A 19-gauge angiocatheter provides ideal pressure for cleaning and removing debris from the wound. A 35-mL, not 25 mL, syringe is used for irrigation delivery system. The pressure settings on the irrigation delivery system should range from 8 to 15 psi; 18 psi is too high. Normal saline solution may be used, but other irrigation solutions are preferred.
What is required for a wound irrigation delivery system? 1 A 25-mL syringe 2 A capacity for pressure of 18 psi 3 A 19-gauge angiocatheter 4 A 2% normal saline solution
Does not promote sweating A warm, moist application does not promote sweating, so it limits unnecessary fluid loss. A dry, not moist, application does not cause skin maceration. Dry, not moist, heat retains temperature longer, because evaporation does not occur. Dry heat carries less risk for burns skin than does moist heat.
What is the advantage of a moist application in wound healing? 1 Does not promote sweating 2 Does not cause skin maceration 3 Retains temperature longer 4 Less risk for burns to the skin than dry applications
Size of the wound The nurse will determine the volume of the wound by measuring its length, width, and depth. The volume if the irrigant chosen is 1.2 to two times the estimated wound volume. The amount of drainage is assessed to measure progress in the healing of the wound. Drainage odor is assessed to identify the presence of infection. The color of the wound tissue is assessed to identify necrotic tissue and new scar tissue.
What must be assessed to decide the volume of irrigant necessary for cleaning the wound? 1 Size of the wound 2 Amount of drainage 3 Odor of the drainage 4 Color of the wound tissue
1000 The amount of vitamin C recommended for wound healing is 1000 mg/day in order to promote collagen synthesis, maintain capillary wall integrity, help fibroblast function, promote immunity, and provide antioxidant benefits.
What quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day
Involve the patient and family in choosing interventions. Involving the patient who has impaired skin integrity and his or her family in choosing interventions is part of the planning phase. Applying the standards of practice outlining the expected outcomes is part of the evaluation phase. Examining the patient's skin for impairment of skin integrity is part of the assessment phase. Asking the patient for his or her perception of skin integrity after the intervention is part of the evaluation phase.
What step is a component of the planning phase for a patient who has impaired skin integrity? 1 Involve the patient and family in choosing interventions. 2 Apply standards of practice outlining expected outcomes. 3 Examine the patient's skin for impairment of skin integrity. 4 Ask the patient for his or her perception of skin integrity after the intervention.
Bright red, active bleeding Bright red fluid indicative of active bleeding is considered sanguineous wound drainage. Clear, watery plasma is considered serous wound drainage. Thick and yellow, green, tan, or brown fluid is considered purulent wound drainage. A pale pink, watery mixture of clear and red fluid is considered serosanguineous wound drainage.
What type of wound drainage is considered sanguineous? 1 Clear, watery plasma 2 Bright red, active bleeding 3 Thick and yellow, green, tan, or brown 4 Pale pink, watery mixture of clear and red fluid
10 years When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary if the patient has not had one within 10 years.
When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past _____ years. Record you answer using whole number.
Joints Figure-eight dressings are used to cover joints because they provide a snug fit and immobilization. Cylindrical body parts like the thighs, upper arms, and lower arms should be dressed in a spiral manner.
Which body parts should be dressed in a figure-eight manner? 1 Joints 2 Thighs 3 Lower arms 4 Upper arms
Direct trauma The nurse should apply cold therapy in instances of direct trauma to diminish swelling and pain. Heat therapy rather than cold therapy is used for patients recovering from rectal surgery or experiencing hemorrhoids and vaginal inflammation.
Which condition warrants the use of cold therapy? 1 Direct trauma 2 Rectal surgery 3 Painful hemorrhoids 4 Vaginal inflammation
Montgomery ties Montgomery ties are used for dressing pressure ulcer wounds in a patient. A linen bag is used while implementing negative-pressure wound therapy. The Braden Scale is used to assess the risk of pressure ulcers, but it may not be used while dressing the pressure ulcer wounds. A waterproof underpad is used while irrigating the wound.
Which equipment is used by the primary health care provider while applying moist dressing to a patient who has pressure ulcers? 1 Linen bag 2 Braden scale 3 Montgomery ties 4 Waterproof underpad
Alteration in nerve pathways Alterations in nerve pathways put patients diagnosed with spinal cord injuries at risk for heat therapy injuries. Thinner skin layers in children increase the risk for burns with the application of heat therapy. Rupture and systemic infection are risk factors when applying heat to an abscessed tooth. Decreased peripheral circulation is a risk factor for heat therapy injuries in patients with diabetes and arteriosclerosis.
Which factor increases the risk for injury when applying heat therapy to a wound for a patient with a spinal cord injury? 1 Thinner layers of skin 2 Alteration in nerve pathways 3 Rupture and systemic infection 4 Decreased peripheral circulation
Gastric secretions Continuous exposure of the skin to body fluids may cause skin breakdown, thus causing pressure ulcers. Therefore, exposure of the skin to gastric secretions poses the highest risk for skin breakdown. This is mainly due to the digestive quality that is responsible for the skin irritation. Ascitic fluids, biliary secretions, and purulent wound exudates carry a moderate risk of skin breakdown.
Which fluids if exposed to the skin pose the highest risk for skin breakdown? 1 Ascitic fluids 2 Biliary secretions 3 Gastric secretions 4 Purulent wound exudates
Gauze dressing supplies
Which is required for wound irrigation? 1 Clips 2 Bandages 3 Safety pins 4 Gauze dressing supplies
Preventing breakdown The most effective intervention for compromised skin integrity and wound care is prevention of skin breakdown. Whereas administering medication, implementing wound care, and monitoring wound healing are all important nursing actions, prevention is the first step.
Which is the most effective intervention for compromised skin integrity? 1 Preventing breakdown 2 Administering medication 3 Implementing wound care 4 Monitoring wound healing
Applying hard traction to the skin next to the wound The application of light, not hard, traction is appropriate in order to minimize pulling of the skin. Loosening the ends, pulling the tape in the direction of hair growth, and using adhesive remover to loosen the tape are appropriate actions for removing tape from the patient's skin during wound care.
Which nursing action during removing tape from the patient's skin during wound care requires correction? 1 Loosening the ends 2 Pulling the tape in the direction of hair growth 3 Using adhesive remover to loosen the tape 4 Applying hard traction to the skin next to the wound
Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges is an accurate nursing action when framing the periwound area with skin sealant. Extending it to 1 to 2 cm (0.4 to 0.8 in) or 2 to 4 cm (0.8 to 1.6 in) is not enough. Extending it to 4 to 6 cm (1.6 to 2.4 in) is more than necessary.
Which nursing action is appropriate when framing the periwound area with skin sealant? 1 Extending the sealant 1 to 2 cm (0.4 to 0.8 in) beyond the wound edges 2 Extending the sealant 2 to 4 cm (0.8 to 1.6 in) beyond the wound edges 3 Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges 4 Extending the sealant 4 to 6 cm (1.6 to 2.4 in) beyond the wound edges
Using a standard surface An appropriate nursing action for a patient who is at no risk for skin breakdown is to use a standard surface. The patient who is at risk for skin breakdown would benefit from using a pillow under the calves, an active support surface, and a pressure-redistribution seat cushion.
Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown? 1 Using a standard surface 2 Using a pillow under the calves 3 Using an active support surface 4 Using a pressure-redistribution seat cushion
Place a pillow under the calves The nursing action that is appropriate for a patient who has intact skin but is at high risk for impaired skin integrity of the heels is to place a pillow under the calves to decrease the risk for heel breakdown. Avoiding prolonged elevation of the head of the bed is appropriate for a high-risk patient who already has a pressure ulcer. Ordering a standard hospital foam mattress is appropriate for a high-risk patient who is not at risk for impaired skin integrity. Considering an alternating pressure support surface is appropriate for a patient who is already diagnosed with an ulcer.
Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels? 1 Avoid prolonged elevation of the head of the bed 2 Order a standard hospital foam mattress 3 Consider an alternating pressure support surface 4 Place a pillow under the calves
1 Loosen the ends 2 Pull the tape in the direction of hair growth 3 Use adhesive remover to loosen the tape Appropriate nursing actions when removing tape from the patient's skin during wound care include loosening the ends, pulling the tape in the direction of hair growth, and using adhesive remover to loosen the tape. The application of light, not hard, traction is appropriate for minimizing pulling of the skin. It is appropriate to gently pull the outer end parallel, not perpendicular, to the skin surface.
Which nursing actions are appropriate when removing tape from the patient's skin during wound care? Select all that apply. 1 Loosen the ends 2 Pull the tape in the direction of hair growth 3 Use adhesive remover to loosen the tape 4 Apply hard traction to the skin next to the wound 5 Gently pull the outer end perpendicular to the skin surface
Provide a pressure-redistribution surface Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one that applies specifically to a patient at risk for skin breakdown due to decreased sensory perception is to provide a pressure-redistribution surface. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear.
Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception? 1 Keep the skin dry and free of maceration 2 Provide a pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed
Provide a trapeze to facilitate movement in bed Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one specific to a patient at risk for skin breakdown due to friction and sheer is to provide a trapeze to facilitate movement in the bed. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition.
Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to friction and shear? 1 Keep the skin dry and free of maceration 2 Provide pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed
Keep the skin dry and free of maceration Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one specific to a patient at risk for skin breakdown due to moisture is to keep the skin dry and free of maceration. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear.
Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to moisture? 1 Keep the skin dry and free of maceration 2 Provide a pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed
Consult a dietician for nutritional assessment Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the the one specific to a patient at risk for skin breakdown due to poor dietary intake is to consult a dietician for a nutritional assessment. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear.
Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to poor dietary intake? 1 Keep the skin dry and free of maceration 2 Provide pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed
Vitamin A Vitamin A helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis. Zinc promotes collagen formation, protein synthesis, cell membrane, and host defenses. Protein promotes fibroplasia, angiogenesis, collagen formation, and wound remodeling. Vitamin C promotes collagen synthesis, capillary wall integrity, and immunologic function.
Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? 1 Zinc 2 Protein 3 Vitamin C 4 Vitamin A
Retaining hair around the wound Retaining hair around the wound edges can cause an air leak, so this action requires correction. Using a skin barrier, drying around the wound thoroughly, and filling uneven wound surfaces with a hydrocolloid product are all appropriate and will help maintain an airtight seal.
Which of a novice nurse's actions would necessitate intervention when providing care for a patient who is prescribed negative-pressure wound therapy? 1 Retaining hair around the wound 2 Using a skin barrier around the wound 3 Drying around the wound thoroughly 4 Filling uneven wound surfaces with a hydrocolloid product
"It causes maceration of the skin." A disadvantage of using moist applications for wound therapy is that it can cause maceration of the skin. Increased loss of body fluid, increased drying of the skin, and lack of penetration to deep tissues are disadvantages of dry, not moist, applications for wound therapy.
Which patient statement indicates understanding of the disadvantages of using moist applications for wound therapy? 1 "It increases body fluid loss." 2 "It causes maceration of the skin." 3 "It causes increased drying of the skin." 4 "It does not penetrate deep into tissues."
They enhance autolytic debridement. Hydrogel dressings are used for partial thickness and full thickness wounds, and enhance autolytic debridement. Some hydrogels require a secondary dressing; these dressings hydrate wounds and are used for painful wounds, as they do not adhere to the wound bed. Hydrogel dressings are used to relieve pain in the wounds. Hydrogel dressings are sheet dressings or gauze dressings impregnated with glycerin-based amorphous gel, but not saline solution.
Which statement is true regarding hydrogel dressings? 1 They enhance autolytic debridement. 2 They may not require secondary dressing. 3 They are not used to relieve pain in the wounds. 4 They are sheet dressings impregnated with saline solution
The volume of the irrigant should be higher than the volume of the wound. The volume of the irrigant for cleaning the wound should be around 1.2 to two times the estimated volume of the wound. The volume of the syringe for sterile irrigation is 35 mL, not 20 mL. The gauge size of the angiocatheter used for sterile irrigation is 19, not 12. Choice of irrigation delivery system is based on the amount of pressure desired.
Which statement is true regarding irrigation equipment used for cleaning wounds? 1 Sterile irrigation involves a 20-mL syringe. 2 A 12-gauge sterile soft angiocatheter is used for sterile irrigation. 3 The volume of the irrigant should be higher than the volume of the wound. 4 The irrigation delivery system is chosen based on the volume of the irrigant.
It indicates potential damage to blood vessels. Nonblanchable erythema indicates potential damage to blood vessels and tissue damage. Mottling or pallor may occur due to tissue hypoxia that alters circulation, but it is not due to nonblanchable erythema. Blanchable, not nonblanchable, erythema is an early indication of pressure in pressure ulcers. Blanchable, not nonblanchable, erythema is an area of erythema that turns white under the application of pressure.
Which statement is true regarding nonblanchable erythema? 1 It occurs due to tissue hypoxia. 2 It is an early indication of pressure. 3 It indicates potential damage to blood vessels. 4 It turns white under the application of pressure.
Fine sutures cause minimal tissue injury. The finer the sutures, the more minimal the tissue injury. Deep sutures are composed of an absorbable, not nonabsorbable, material that disappears over time. All sutures are foreign bodies, and so they can all cause local inflammation. Retention sutures are placed more deeply than skin sutures.
Which statement is true regarding sutures? 1 Fine sutures cause minimal tissue injury. 2 Deep sutures are composed of nonabsorbable material. 3 Continuous sutures are least likely to cause inflammation. 4 Retention sutures are placed more superficially than skin sutures.
Applying an elastic bandage The task of applying an elastic bandage can be delegated to nursing assistive personnel (NAP). The task of performing wound irrigation cannot be delegated to NAP, because it requires a sterile technique for wound care. The task of implementing negative-pressure wound therapy cannot be delegated to NAP. NAP are not allowed to assess patients for the risk of pressure ulcers; only health care providers can perform this assessment.
Which task can be delegated to nursing assistive personnel (NAP) in caring for a patient who has pressure ulcers? 1 Applying an elastic bandage 2 Performing wound irrigation 3 Implementing negative-pressure wound therapy 4 Assessing the patient for the risk of additional pressure ulcers
Securing the dressing using special tapes The NAP can secure the dressing using special tapes in case the dressing becomes loose. The NAP cannot dress the wounds, and cannot assess the patient's condition. The assessment of patient comfort is done by a nurse using a scale of 0 to 10. The nurse also assesses if there is any patient allergy to the wound dressing agents. The nurse teaches the patient and the patient's family how to change the dressing.
Which task can be delegated to nursing assistive personnel (NAP)? 1 Assessing the patient's level of comfort 2 Securing the dressing using special tapes 3 Assessing the patient's allergy to the wound dressing agents 4 Teaching the patient and the family the steps of dressing change
Hydrogel Hydrogel dressings hydrate the wounds and provide a moist environment. Therefore, these dressings are preferred for dry wounds. Hydrocolloid dressings help in the healing of clean granulating wounds and autolytically debride necrotic wounds. Calcium alginate dressings should not be used in dry wounds, because they require secondary dressing. Debriding enzymes should be applied only over the necrotic areas of the wounds; they are not used specifically for dry wounds.
Which type of dressing is preferred for dry wounds? 1 Hydrogel 2 Hydrocolloid 3 Calcium alginate 4 Debriding enzymes
Transparent film dressings Transparent film dressings are used for stage I pressure ulcers or a partial thickness wounds. Gauze sponges are the oldest and the most common dressings that are used for simple, uncomplicated wounds or wounds with minimal drainage; they are not specifically preferred for stage I pressure ulcers. Hydrogel dressings are used for partial thickness and full thickness wounds. Hydrocolloid dressings are used for shallow to moderately deep dermal ulcers.
Which type of dressing is used for stage I pressure ulcers? 1 Gauze sponges 2 Hydrogel dressings 3 Hydrocolloid dressings 4 Transparent film dressings
Dry gauze the patient who has a necrotic ulcer requires dressing that causes debriding of the necrotic tissue. When debriding enzymes are used, a moist contact dressing should be placed directly over the wound. Dry gauze should be placed over the contact dressing which dries the wound and thus, facilitates removal of the dead tissues. Moist gauze is used for providing moisture to the wound for healing. Hydrocolloid and transparent film dressing are used when moisture is required for wound healing.
Which type of gauze should a nurse use when a patient has a necrotic ulcer? 1 Dry gauze 2 Moist gauze 3 Hydrocolloid 4 Transparent film dressing
Elastic net The palm is a body extremity. Elastic net should be used for dressing extremities; it should be placed over the gauze dressing of the palmer surface to secure the dressing. Precut gauze is used when the wound drains. A topper dressing helps prevent strike-through of the wound drainage. Hydrocolloid gauze provides a moist environment for the wound to heal.
Which type of gauze should be used for dressing a wound on the palm? 1 Elastic net 2 Precut gauze 3 Topper dressing 4 Hydrocolloid gauze
To remove the debris from the wound The nurse irrigates the wound until there is a clear flow of solution to remove any debris from the wound. Skin damage can be reduced by pushing the skin away from the tape while pulling the adhesive from the skin. The moist environment that heals the wound is provided by dressing the wound with moist gauze. To prevent contamination of the previously cleaned area, the wound should be cleaned from its center to its surrounding skin.
While dressing a patient's wound, the nurse irrigates the wound until there is a clear flow of the solution. What is the rationale behind this nursing action? 1 To reduce the chance of skin damage 2 To remove the debris from the wound 3 To provide a moist environment to the wound 4 To prevent contamination of the previously cleaned area
To hold contaminated dressings to be discarded Cuffing a waterproof bag allows for a large opening, permitting placement of contaminated dressings without the nurse having to touch the refuse bag itself. Bedding may be protected by placing padding or an extra towel on the bed. Transmission of microorganisms is reduced by the nurse wearing sterile gloves. A gown, mask, or goggles may be worn to protect the nurse from splashes of blood and body fluids.
Why should the nurse form a cuff on a waterproof bag and place it near the bed while performing wound irrigation? 1 To protect the bedding 2 To hold contaminated dressings to be discarded 3 To reduce the transmission of microorganisms 4 To protect the nurse from splashes of blood and body fluids
