Funds 2 Test 2

Dehiscence

Separation of a surgical incision or rupture of a wound closure

Oxygen is _______________

a drug.

When irrigating, be sure all the solution flows from the ____________ _____________ to the _____________ ________________ area.

solution flows from the least contaminated to the most contaminated area.

Wound healing follows four phases:

hemostasis, inflammatory phase, reconstruction, and maturation.

Occlusive and semiocclusive dressings promote healing by keeping wounds _______yet ________

Occlusive and semiocclusive dressings promote healing by keeping wounds moist yet sterile

To promote healing, closely monitor fluid and nutritional needs of the patient. Patients who are unable to tolerate large meals or solid foods may need to eat ________________________________.

eat small, frequent meals.

Traditionally, the purpose of wet-to-dry dressings was to keep the wound bed moist and to provide ______________ __________________

mechanical debridement

Septicemia occurs when

microorganisms enter blood. It may occur as a result of IV therapy when poor aseptic technique or contaminated equipment is used during IV line insertion and pathogens are introduced into the bloodstream.

serosanguineous

thin and red, composed of serum and blood

serous

thin and watery, composed of the serum portion of blood

What are the advantages of a transparent dressing? 1. 2. 3. 4.

1. Adheres to undamaged skin 2. Contains the exudate 3. Reduces wound contamination 4. Serves as a barrier to external bacteria

The recommended temperature setting for the aquathermia pad is between

105° and 110° F

If blood is to be administered, a catheter with a larger lumen ___g

18

Sutures and staples are generally removed in __ to __ days after surgery, or sooner, if healing is adequate.

7 to 10 days after surgery, or sooner, if healing is adequate.

A ________ dressing is often the choice for management of a wound with little exudate or drainage, such as abrasions and nondraining postoperative incisions.

A dry dressing is often the choice for management of a wound with little exudate or drainage.

After surgery, inspect the dressing hourly during the first __ hours after the procedure. Then, inspect dressings every __ to __ hours for the first 24 hours

After surgery, inspect the dressing hourly during the first 4 hours after the procedure. Then, inspect dressings every 2 to 4 hours for the first 24 hours

Approximately 3 weeks after surgery, _______________ begin to exit the wound. The wound continues to gain strength.

Approximately 3 weeks after surgery, fibroblasts begin to exit the wound. The wound continues to gain strength.

When you find evisceration you should ........................

Cover the organ with a sterile dressing moistened with sterile normal saline solution to help prevent wound contamination and keep contents moist.

Diabetes causes hemoglobin to have greater ________ for oxygen, so it fails to release oxygen to tissues.

Diabetes causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.

_____________ is the removal of fluids from a body cavity, wound, or other source of discharge by one or more methods; it may occur passively on its own or with mechanical assistance

Drainage is the removal of fluids from a body cavity, wound, or other source of discharge by one or more methods; it may occur passively on its own or with mechanical assistance

Systemic Effects of Cold Application Exposure of the skin to cold results in ______________

Exposure of the skin to cold results in vasoconstriction

___________ is fluid, cells, or other substances that have slowly leaked from cells or blood vessels through small pores or breaks in cell membrane.

Exudate is fluid, cells, or other substances that have slowly leaked from cells or blood vessels through small pores or breaks in cell membrane.

Hemostasis begins as soon as the injury occurs. As blood platelets adhere to the walls of the injured vessel, a clot begins to form. _______ in the clot begins to hold the wound together, and bleeding subsides.

Fibrin in the clot begins to hold the wound together.

Healing by secondary intention, when a wound must ______________ during healing, occurs when skin edges are not well approximated or when pus has formed.

Healing by secondary intention, when a wound must granulate during healing,

Systemic Effects of Heat Application Heat produces _________________________

Heat produces vasodilation

Hemostasis (termination of bleeding) begins______________. As blood platelets adhere to the walls of the injured vessel, a clot begins to form. __________________ in the clot begins to hold the wound together, and bleeding subsides.

Hemostasis (termination of bleeding) begins as soon as the injury occurs. As blood platelets adhere to the walls of the injured vessel, a clot begins to form. Fibrin in the clot begins to hold the wound together, and bleeding subsides.

If a dressing is used, you can monitor the amount of exudate by _____________ the soiled dressing 1 g of exudate or drainage equals 1 mL

If a dressing is used, you can monitor the amount of exudate or drainage by weighing the soiled dressing (1 g of exudate or drainage equals 1 mL),

If a dry dressing adheres to a wound, moisten the dressing with _______ ________ solution or ________ __________before removing the gauze. Moistening the dressing decreases the adherence of the dressing & reduces the risk of further trauma to the wound

If a dry dressing adheres to a wound, moisten the dressing with sterile normal saline solution or sterile water before removing the gauze.

Surgical wounds are classified based on the level of contamination. The (CDC) classified wounds by the level and type of contamination. Levels range from ____________ to _______________

Levels range from class I (clean) to class IV (dirty, infected)

When an order for eye irrigation is received, to whom can the nurse delegate the procedure to and why? Another nurse Correct CNA A family member

Only Another nurse

Wounds in which skin edges are close together and little tissue is lost, minimal scarring results. Primary intention healing begins during the _____________ phase of healing;

Primary intention healing begins during the inflammatory phase of healing.

The nurses are preparing an in-service about the vacuum-assisted closure (VAC) device. What accurate information will be included in this in-service? Promotes formulation of __________________ tissue Reduces local and peripheral ___________________ Drops _____________________level in wound

Promotes formulation of granulation tissue Reduces local and peripheral edema Drops bacterial level in wound

Evisceration

Protrusion of an internal organ through a wound or surgical incision

Smoking interferes with normal cellular mechanisms that __________ ____________ _________ to tissues.

Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.

Social factors, including _________________, can impair wound healing.

Social factors, including smoking, can impair wound healing.

tertiary intention (delayed primary intention), the practitioner leaves a contaminated wound open and closes it later, after the infection is controlled, Tertiary intention healing results in _________________scar than does healing by either primary or secondary intention.

Tertiary intention healing results in a larger and deeper scar than does healing by either primary or secondary intention.

The Jackson-Prattevacuator is a type of __________ drainage system that uses a bulb to provide the needed vacuum IT CAN HOLD A MAX OF 30 ML BEFORE NEEDING TO BE EMPTIED AND RESET.

The Jackson-Prattevacuator is a closed drainage system that uses a bulb to provide the needed vacuum IT CAN HOLD A MAX OF 30 ML BEFORE NEEDING TO BE EMPTIED AND RESET.

The risk for infection in a clean surgical wound is less than _________.

The risk for infection in a clean surgical wound is less than 5%.

Wet-to-dry dressings are used in wound management. Traditionally, the purpose of wet-to-dry dressings was to keep the wound bed moist and to provide __________________ _____________________.

Wet-to-dry dressings are used in wound management. Traditionally, the purpose of wet-to-dry dressings was to keep the wound bed moist and to provide mechanical debridement.

If coughing occurs after surgery , apply a pillow, rolled bath blanket, or hands to the incisional area to lessen intraabdominal pressure; this technique is called _______________________.

This technique is called splinting.

To promote healing, closely monitor fluid and nutritional needs of the patient. Unless contraindications exist, encourage an intake of _________ to _________ mL in 24 hours.

To promote healing, closely monitor fluid and nutritional needs of the patient. Unless contraindications exist, encourage an intake of 2000 to 2400 mL in 24 hours.

The term ________ refers to any injury to the body's tissues that involves a break in the skin.

Wound

Irrigations involve a gentle washing of an area with a stream of solution delivered through a __________. Always perform irrigation from the________to the _______ canthus to lessen the chances that contaminants will be absorbed through the nasolacrimal duct

a syringe. Always perform irrigation from the inner to the outer canthus to lessen the chances that contaminants will be absorbed through the nasolacrimal duct

Phlebitis

an inflammation of the vein. It results from mechanical, chemical, or bacterial irritation of the vessel.

sanguineous exudate

composed of or pertaining to blood

Inserting a NG Tube, Measure distance from tip of nose to ________ and from there to _________ ________ of sternum.

from tip of nose to earlobe and from there to xiphoid process of sternum. Tube should extend from nostril to stomach;

Treat exudate or drainage in quantities greater than ____ mL in the first 24 hours as abnormal, and report it immediately.

greater than 300 mL in the first 24 hours

The most common wound irrigant is ________ ________solution

normal saline solution

Commonly used wetting agents include 1 2 3 4

normal saline, lactated Ringer's solution, isotonic solutions, Acetic acid and Dakin's

Purulent

producing or containing pus

Infiltration

seepage of a solution or medication into tissue surrounding the vessel.

Hemostasis

termination of bleeding

When the physician has not ordered a dressing change for a draining wound on a patient in an acute care setting the nurse should assess the amount of drainage and _____________________________________.

the nurse should assess the amount of drainage and Circle and date the outline of the exudate on the dressing. DO NOT CHANGE IT UNTIL Dr orders.

When a patient has a drain in a surgical wound the nurse indicate that the wound will heal with _____________ ______________

the wound will heal with Tertiary intention