Wound Care

The clinical coordinator is teaching a student nurse about various wound healing processes. Which statement should the nurse make while teaching the student about tertiary intention?

"Initially, wounds should be left open."

A nurse has just finished placing the vacuum-assisted closure (VAC) device to a patient's wound. What amount of pressure should the nurse administer?

5 to 200 MM HG

The nurse is instructed to clean a patient's wounds using a wetting agent that does not delay the healing process. On the basis of this description, which wetting agent would the wound specialist tell the nurse to avoid?

Acetic acid

If a patient with an abdominal incision begins to cough, which intervention is the most appropriate?

Apply a pillow to the incision with slight pressure

A nursing student has been asked to order a tray for a patient with an open wound. Which tray should be ordered to provide the patient with adequate nutrition that will promote wound healing?

Baked fish, legumes, spinach, strawberries, and decaffeinated tea

A preceptor is instructing a graduate nurse on the management of a vacuum-assisted closure device (wound VAC). What information should the preceptor stress to the graduate nurse?

Care must be taken to remove all materials from the wound

A patient is assessed 30 minutes after a cholecystectomy (gallbladder removal), and 2 mL of drainage is noted in the Jackson-Pratt drainage system. After 3 hours the nurse notices that there has been no additional drainage and the patient is complaining of severe pain. What action should the nurse complete first?

Check the drainage system for kinks

What is the nurse's first step when caring for a patient needing wound care?

Checking the medical record for the primary health care provider's prescriptions

A nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. What would be the priority nursing assessment when inspecting the skin that is distal to the bandage?

Circulatory Impairment

The nurse is assessing a patient with a gangrenous leg. While collecting the patient's medical history, the nurse finds that the patient had developed the gangrene after lower-limb surgery. Which class of surgical wound does the nurse expect the patient has?

Class IV

In classifying wounds, which classification results from the presence of gastrointestinal (GI) products?

Contaminated

A few days after a patient's abdominal operation, the nurse observes an increase in the flow of serosanguineous drainage into the wound dressing. What immediate risk to the patient will the nurse assess?

Dehiscence

A student nurse is finishing up a wet-to-dry dressing change. What measure should the student nurse take immediately on completion of the dressing change?

Document the patients therapy and progress

The nurse is instructed to use vacuum-assisted closure (VAC) for a patient with a chronic leg wound. What is the expected outcome of the therapy?

Drop in bacterial count in the wound bed, increased tissue growth

A nurse has just completed irrigation of a wound and will need to apply a transparent dressing. What should the nurse do to ensure that the dressing will adhere to the wound?

Dry skin thoroughly before applying dressing

The nurse is assessing a patient's wound. What measures will the nurse take during the assessment?

Ensure that every abrasion, laceration, and incision is noted. Be alert for signs of redness, swelling, and pain Ensure that the location and appearance of the wound is documented every day.

The nurse is dressing a chronic wound. What type of dressing is the nurse most likely to use?

Foam dressing

An emergency room nurse admits a patient with a wound to the sacral area. What data if obtained during the physical assessment indicate that the patient's wound is infected?

Foul odorous purulent drainage

The physician has ordered for a patient's leg wound to be irrigated using an antiseptic solution. What would the nurse do to reduce the chance of contamination?

Have the solution flow from the least contaminated to the most contaminated area.

Which essential problems should be placed on the nursing care plan of a patient with a wound?

Infection, Nutrition, Skin integrity

A nursing professor asks the student what is the purpose of the vacuum-assisted closure device. What response should the student give?

It reduces edema and increases circulation

While inspecting a patient's wound, the nurse observes that the skin around the wound has softened and is broken. What does this finding indicate about the patient's wound?

It was covered with an occlusive dressing

While caring for a patient, the nurse finds that the patient's wound dressing has become yellow in color. What parameter does the nurse assess further to diagnose the abnormality?

Leukocyte Count

A nurse is trying to remove a bandage when the gauze becomes stuck to the wound bed. What is the most effective method to remove the bandage?

Moisten the gauze with NS

The nurse observes that a keloid has developed on a patient's skin at the site of injury. To what reason does the nurse attribute this formation?

Overgrowth of collegen

A young teen with an incision calls the nurse. The patient states to the nurse, "I feel like something gave way in my wound." The nurse assesses the patient and suspects a possible wound dehiscence. What should the nurse do first?

Place a warm, moist sterile dressing over the area

A patient returns to the gastrointestinal unit at a health care facility. A T-tube is draining normal-colored bile. What essential information about the draining system should be reinforced during patient teaching?

Protecting the skin around the wound

A bandage is applied to the left arm of a patient. When the nurse assesses the patient's arm, it is cool to touch; the pulse is diminished, and the arm appears slightly blue. What should the nurse's immediate intervention be?

Readjust the bandage immediately

A newly postoperative patient is transferred to the postanesthesia care unit (PACU). The nurse places the initials and time on the bandage. When the nurse reassesses the bandage, bleeding is evident. What should the nurse do next?

Reinforce the bandage

An elderly patient with fragile skin will need dressing changes three times daily. Which intervention is essential for the nurse to implement to prevent a problem with skin integrity?

Reinforcing the bandage with paper tape

For removing staples from a surgical incision, which intervention is most appropriate?

Remove every other staple first, and replace with Steri-Strips while ensuring that the incision remains closed.

A patient has come to the postanesthesia care unit (PACU) after hip replacement surgery. After the nursing assessment, the health care team needs to set up a plan of care. What would the nurse anticipate to be the highest priority nursing concern?

Skin integrity

The nurse is caring for a patient with burns. While changing a dressing, the nurse uses a wetting agent that has a deodorizing effect because the patient has necrotic debris. Which wetting agent would the nurse use while dressing the patient's wounds?

Sodium hypochlorite solution

The nurse is caring for a patient who underwent a surgery. Three days after the surgical procedure, the nurse is ordered to remove the sutures but notices a thick liquid oozing from the suture site. What should the nurse do in this situation?

Stop the process and leave the remaining sutures intact

A patient has lacerations on the thigh after a biking accident. What precautions does the nurse take to ensure appropriate wound healing?

The nurse ensures that the surrounding skin is clean and dry. The nurse ensures that therapeutic body position is maintained. The nurse ensures that dressings and drains are positioned correctly. The nurse ensures appropriate nutrition for faster healing.

The nurse is caring for a patient who has undergone abdominal surgery. Following the daily assessment, the nurse finds that the patient has an internal hemorrhage. On the basis of which finding(s) did the nurse make such a conclusion?

The patient has a rapid, thready pulse The patient has abdominal distention The patient has low blood pressure

The nurse is caring for a patient who has undergone an appendectomy. While inspecting the patient's wound dressing, the nurse finds that the gauze is bright red in color. What does the nurse infer from this observation?

The patients sutures have ruptured.

The nurse is assessing a patient's wound. The nurse observes that the scar tissue is thin and pale in color. What can the nurse conclude from this?

The wound has completely healed.

Four hours after surgery, a patient rings the call bell. When the nurse arrives, the patient states that the wound is infected. When the nurse assesses the wound it is red, swollen, and warm to touch. Which statement would be the most appropriate response to the patient?

The wound is not infected, normal healing is occurring.

Three weeks after surgery, an African American patient comes to the clinic for follow-up. The nurse notices an overgrowth of scar tissue at the site. Which conclusion would be an accurate nursing evaluation of the finding?

This may be normal for this patient

The nurse is demonstrating how to care for a wound to a group of students. The nurse dresses the wound after cleaning it with warm water. What is an appropriate reason for the dressing?

To protect the wound To absorb drainage To reduce discomfort

The nurse is caring for a patient with asthma who has undergone surgery. Upon assessing the patient's medical history, the nurse finds that the patient is already using a steroid inhaler for maintenance therapy of asthma. The nurse also finds that the primary health care provider has prescribed vitamin A supplements. What is the probable reason for prescribing vitamin A supplements?

Vitamin A contracts steroid activity

The nurse observes that a burn wound in an elderly diabetic patient is taking a longer time to heal than a similar wound in a 10-year-old child. What factors are known to cause delayed healing?

age, chronic illness

The nurse is caring for a patient with a deep stab wound. What foods does the nurse advise the patient to include in the diet to facilitate faster healing?

milk and eggs baked potatoes dark green vegetables seafood and red meat