Chapter 22: Surgical Wound Care

36. The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by formation.

ANS: collagen Collagen forms as an immature scar over a new surgical wound. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334 OBJ: 1 TOP: Immature scarring KEY: Nursing Process Step: Implementation

37. The nurse encourages a patient recovering from a hysterectomy to drink at least mL of fluid a day.

ANS: 2000 two thousand A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 335 OBJ: 2 TOP: Fluid intake KEY: Nursing Process Step: Implementation

38. When preparing to remove a dressing, the nurse should don gloves.

ANS: clean To remove a dressing, clean gloves are appropriate. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337 OBJ: 7 TOP: Removal of a dressing KEY: Nursing Process Step: Implementation

12. Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together? a. Fibrin b. Thrombin c. Protime d. Calcium

ANS: A Fibrin in the clot begins to hold the wound together. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation

25. The nurse assessing a patient's wound notes a clear watery drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

ANS: A Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment

7. The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant? a. From the area of least contamination to the area of most contamination b. Forcefully into the wound c. Gently over the skin into the wound d. From a distance of about 12 inches

ANS: A The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound. PTS: 1 DIF: Cognitive Level: Application REF: Page 343 OBJ: 11 TOP: Wound irrigation KEY: Nursing Process Step: Implementation

34. Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.) a. Normal saline b. Lactated Ringer c. Acetic acid d. Dakin e. Lysol

ANS: A, B, C, D Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 341 OBJ: 7 TOP: Wet-to-dry dressings KEY: Nursing Process Step: Implementation

35. What are the advantages of a transparent dressing? (Select all that apply.) a. Adheres to undamaged skin b. Contains the exudate c. Reduces wound contamination d. Serves as a barrier to external bacteria e. Slows epithelial growth

ANS: A, B, C, D Transparent dressings have the advantages of adhering to undamaged skin, containing the exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding epithelial growth. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 341-342 OBJ: 7 TOP: Transparent dressings KEY: Nursing Process Step: Planning

33. Which are the phases of wound healing? (Select all that apply.) a. Reconstruction b. Hemostasis c. Inflammation d. Granulation e. Maturation

ANS: A, B, C, E The steps in wound healing are hemostasis, inflammation,reconstruction, and maturation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334-335 OBJ: 1 TOP: Wound healing KEY: Nursing Process Step: Implementation

8. The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement? a. Call the RN b. Cover the bowel with a sterile saline dressing c. Turn the patient to the side of the evisceration d. Raise the patient up to a high Fowler position

ANS: B Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler position to relieve strain on the suture line. PTS: 1 DIF: Cognitive Level: Application REF: Page 347, Box 14-3 OBJ: 8 TOP: Evisceration KEY: Nursing Process Step: Implementation

29. The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates? a. Cellulitis b. Dehiscence c. Evisceration d. Extravasation

ANS: B Dehiscence is separation of a surgical incision or rupture of a wound closure. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 347, Table 14-3 OBJ: 8 TOP: Dehiscence KEY: Nursing Process Step: Assessment

13. What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain? a. Healing b. Inflammatory c. Reconstruction d. Maturation

ANS: B During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 335, 337 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Assessment

4. What is the advantage of an occlusive dressing? a. Allows air to the incision b. Keeps the incision moist c. Delays epithelialization d. Does not have to be changed

ANS: B Occlusive dressings keep the incision moist and increase epithelialization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 338 OBJ: 7 TOP: Occlusive dressings KEY: Nursing Process Step: Implementation

26. The nurse assessing a patient's wound notes thick, yellow drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

ANS: B Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment

21. What is the classification for the Jackson-Pratt drainage removal system? a. Sterile drainage system b. Closed drainage system c. Open drainage system d. Self-measuring drainage system

ANS: B The Jackson-Pratt removal system is a type of closed drainage system. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 351 OBJ: 10 TOP: Drainage KEY: Nursing Process Step: Implementation

31. A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer. The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese. The nurse assesses the ulcer to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What nursing diagnosis will be identified as a priority? a. Infection b. Altered nutrition: more than body requirements c. Impaired skin integrity d. Altered peripheral tissue perfusion

ANS: B The nurse's assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority nursing diagnosis for this patient is Altered Nutrition: more than body requirements related to diet noncompliance. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 361 OBJ: 14 TOP: Nursing Diagnosis KEY: Nursing Process Step: Diagnosis

3. The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting? a. Serosanguineous b. Sanguineous c. Serous d. Purulent

ANS: B The term sanguineous means bloody. It is indicative of active bleeding. PTS: 1 DIF: Cognitive Level: Application REF: Page 337, Table 14-2 OBJ: 1 TOP: Drainage KEY: Nursing Process Step: Assessment

24. The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus? a. Improves overall tissue perfusion b. Promotes release of oxygen to tissues c. Causes hemoglobin to have a greater affinity for oxygen d. Causes hemoglobin to have a decreased affinity for oxygen

ANS: C Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 336, Table 14-1 OBJ: 6 TOP: Diabetes mellitus KEY: Nursing Process Step: Implementation

18. The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings? a. Pain shock b. Dehydration c. Internal hemorrhage d. Acute infection

ANS: C If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 347 OBJ: 3 TOP: Postoperative KEY: Nursing Process Step: Assessment

16. The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change? a. After the dressing change b. At least 15 minutes before the dressing change c. At least 30 minutes before the dressing change d. At least 1 hour before the dressing change

ANS: C It may help to give an analgesic at least 30 minutes before exposing the wound. PTS: 1 DIF: Cognitive Level: Application REF: Page 339 OBJ: 7 TOP: Wounds KEY: Nursing Process Step: Implementation

28. The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

ANS: C Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment

15. The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing? a. Every 30 minutes b. Every 60 minutes c. Every 2 to 4 hours d. Every 5 to 8 hours

ANS: C The nurse inspects the dressing every 2 to 4 hours for the first 24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 335 OBJ: 6 TOP: Wounds KEY: Nursing Process Step: Assessment

17. The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed? a. Destruction of tissue b. Bleeding c. Mechanical debridement d. Prevention of infection

ANS: C The primary purpose of a wet-to-dry dressing is to debride a wound mechanically. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 339 OBJ: 7 TOP: Wounds KEY: Nursing Process Step: Implementation

2. What technique will the nurse implement to assist the postoperative patient to cough? a. Support the patient's back b. Offer an antitussive c. Splint the abdomen with a pillow d. Lean patient against the bedside table

ANS: C To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line. PTS: 1 DIF: Cognitive Level: Application REF: Page 335 OBJ: 8 TOP: Suture lines KEY: Nursing Process Step: Implementation

6. The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the hand-held showerhead from the wound when irrigating the wound? a. 2.5 inches b. 6 inches c. 12 inches d. 18 inches

ANS: C When wound irrigation is done at home with a hand-held showerhead, the showerhead should be held approximately 12 inches from the wound. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 346 OBJ: 11 TOP: Wound irrigation KEY: Nursing Process Step: Implementation

1. The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal? a. Primary intention b. Secondary intention c. Tertiary intention d. Deliberate intention

ANS: C When wounds are kept open by a drain, they heal by tertiary intention. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 335 OBJ: 4 TOP: Tertiary intention KEY: Nursing Process Step: Implementation

10. The physician has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage? a. Weigh the patient to estimate the weight of the saturated dressing b. Reinforce the dressing c. Circle and date the outline of the exudate on the dressing d. Count each dressing as 1 mL of drainage

ANS: C Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled. PTS: 1 DIF: Cognitive Level: Application REF: Page 351 OBJ: 7 TOP: Draining wounds KEY: Nursing Process Step: Assessment

14. What marked advantage does primary intention have over other phases of wound healing? a. Healing is rapid b. Healing rarely becomes infected c. Minimal scarring results d. Healing is painless

ANS: C Wounds that heal by primary intention have minimal scarring. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 334 OBJ: 4 TOP: Wounds KEY: Nursing Process Step: Implementation

32. The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service? (Select all that apply.) a. Positive pressure is applied by this device b. Healing is facilitated by decrease in drainage c. Promotes formulation of granulation tissue d. Reduces local and peripheral edema e. Drops bacterial level in wound

ANS: C, D, E Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 353-354, 355-357 Skill 14-7 OBJ: 12 TOP: Vacuum-assisted device KEY: Nursing Process Step: Implementation

11. The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively? a. Dirty wound b. Clean-contaminated wound c. Contaminated wound d. Clean wound

ANS: D A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 333 OBJ: 5 TOP: Wounds KEY: Nursing Process Step: N/A

20. The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal? a. 50 mL b. 100 mL c. 200 mL d. 300 mL

ANS: D Drainage greater than 300 mL in 24 hours is considered abnormal. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 351 OBJ: 3 TOP: Drainage KEY: Nursing Process Step: Assessment

30. The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the physician. What is an advantage of gauze bandages? a. Provision of warmth b. Applies strong pressure c. Antibacterial effects d. Prevents skin maceration

ANS: D Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation that helps prevent skin maceration (the softening and breaking down of skin from prolonged exposure to moisture). Flannel bandages provide warmth. Elastic bandages are effective for pressure application. Gauze bandages do not have antibacterial effects. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 338 OBJ: 13 TOP: Bandages and binders KEY: Nursing Process Step: Assessment

9. The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented? a. Remove 7 more alternate staples and securely tape with Steri-Strips b. Cover with moist dressing and apply a binder c. Continue to remove staples as ordered because this is an expected outcome d. Leave the 12 staples in place and record the separation

ANS: D If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation. PTS: 1 DIF: Cognitive Level: Application REF: Page 348 OBJ: 9 TOP: Staple removal KEY: Nursing Process Step: Implementation

27. The nurse assessing a patient's wound notes pale red watery drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

ANS: D Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment

23. The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide? a. Smoking increases the amount of tissue oxygenation. b. Smoking increases the amount of functional hemoglobin in blood. c. Smoking may decrease platelet aggregation and cause hypercoagulability. d. Smoking interferes with normal cellular mechanisms that promote release of oxygen.

ANS: D Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 336, Table 14-1 OBJ: 6 TOP: Smoking KEY: Nursing Process Step: Implementation

19. What is the usual length of time before suture removal? a. 2 to 3 days b. 4 to 5 days c. 5 to 6 days d. 7 to 10 days

ANS: D Sutures are generally removed within 7 to 10 days. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 348 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation

22. The nurse is caring for a patient with a surgical wound. How can the nurse promote healing? a. Offer fluids every 4 hours b. Encourage the consumption of large meals c. Encourage up to 1000 mL of daily fluid intake d. Encourage the consumption of small frequent meals

ANS: D To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 335 OBJ: 2 TOP: Wound healing KEY: Nursing Process Step: Implementation

5. When removing the dressing on a patient, the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement? a. Call the RN b. Gently remove the gauze with sterile forceps c. Cover with occlusive dressing d. Moisten the dressing with sterile water

ANS: D When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it. PTS: 1 DIF: Cognitive Level: Application REF: Page 339 OBJ: 7 TOP: Dry dressings KEY: Nursing Process Step: Implementation