Funds CH 35
A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? a) Partial-thickness wound b) Penetrating wound c) Superficial wound d) Full-thickness wound
A
An older adult has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this wound is to: A) elevate the right heel off the surface of the bed. B) request a surgical consult for debridement of the area. C) apply a hydrocolloid to promote autolytic debridement of the wound. D) request an order for an enzymatic debridement medication.
A
Pressure ulcers are directly caused by which of the following conditions at the site? a) Compromised blood flow b) Edema c) Shearing forces d) Inadequate venous return
A
The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity? a) Young adult in traction who has a low-protein diet and dehydration b) Elderly patient diagnosed with well-controlled type 2 diabetes c) Middle-aged adult with metabolic syndrome taking antihypertensives d) Adolescent in bed with influenza having periods of high fever and diaphoresis
A
The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? a) Acute, full-thickness, open b) Chronic, partial-thickness, closed c) Acute, partial-thickness, closed d) Chronic, unstageable, open
A
Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature 100.8°F (38.2°C). The nurse would suspect that the patient has what kind of complication? A) Infection at the incision site B) Dehiscence of the wound C) Hematoma under the skin D) Formation of granulation tissue
A
To obtain the most accurate culture information of a chronic wound, the nurse would recommend: A) tissue biopsy. B) swab culture. C) sterile culture. D) needle aspiration culture.
A
What is the primary goal that the nurse should establish for a patient with an open wound? a) The wound will remain free of infection throughout the healing process. b) The client will complete antibiotic treatment as ordered. c) The wound will remain free of scar tissue at healing. d) The client will increase caloric intake throughout the healing process.
A
When applying heat or cold therapy to a wound, what should the nurse do? a) Leave the therapy on each area no longer than 15 minutes. b) Leave the therapy on each area no longer than 30 minutes. c) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. d) When using cold, ensure the temperature is less than 32°F (0°C) before applying it.
A
When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which phase of wound healing? A) Proliferative B) Maturation C) Aggregation D) Inflammatory
A
Which of the following describes the difference between dehiscence and evisceration? a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. c) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
A
Why is the information obtained from a swab culture of a wound limited? a) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b) A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d) A swab culture result does not include bacterial sensitivity information necessary to provide treatment.
A
You are maintaining a client's Penrose wound drain. Which of the following actions should you most expect to take when caring for this type of drain? A) Advance the drain by pulling it out of the wound a specified distance each day. B) Compress the device to create suction. C) Advance the drain by inserting it farther into the wound a specified distance each day. D) Inspect the sutures holding the drain in place for signs of inflammation.
A
Your patient has a deep wound on the right hip, with tunneling at the 8 o'clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? a) Alginate dressing b) Dry gauze dressing c) Hydrogel d) Hydrocolloid dressing
A
Of the following, which is the best choice for performing wound irrigation? a) Water jet irrigation b) 35-mL syringe with a 19-gauge angiocatheter c) 5-mL syringe with a 23-gauge needle d) Bulb syringe
B
Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply. a) Don sterile gloves and personal protective equipment. b) Inspect the drainage tube site and sutures. c) Check that tubing to drainage system is intact. d) Test the suction apparatus at prescribed pressure. e) Document the color, type, and amount of drainage.
A,B,C,D,E
You are caring for an older client who is at high risk for developing pressure ulcers. Which of the following interventions should you take to help prevent pressure ulcers? SELECT ALL THAT APPLY. A) Conduct a pressure ulcer admission assessment using the Braden scale. B) Inspect bony prominences daily in good light. C) Apply moisture barrier creams to perineal skin after each incontinent episode. D) Bathe the client daily with hot water. E) Offer a drink of water whenever you reposition the client. F) Reposition the client at least every 8 hours.
A,B,C,E
Why is an accurate description of the location of a wound important? Select all that apply. a) Influences the rate of healing b) Determines the appropriate treatment choice c) Will affect the frequency of dressing changes d) Affects patient movement and mobility
A,B,D
The home health nurse learns that an elderly patient isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply. a) Help her to get out of the chair every 2 hours. b) Change her clothing frequently. c) Bath the patient using soap and water. d) Promote intake of green tea throughout the day. e) Encourage her to wear incontinence products.
A,B,E
Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. a) Wet-to-dry dressings b) Sharp debridement c) Whirlpool d) Pulsed lavage
A,C,D
You are preparing to use the Braden scale to assess a client's risk for developing pressure ulcers. Which of the following risk factors does this scale evaluate? SELECT ALL THAT APPLY. A) Sensory perception B) Mental state C) Moisture D) Incontinence E) Activity F) Mobility
A,C,E,F
As you are documenting a client's treated pressure ulcer, you are careful to note its precise location. Which of the following are correct rationales for noting the location of the ulcer? SELECT ALL THAT APPLY. A) The location influences the rate of healing. B) The location determines whether to pursue healing by primary or secondary intention. C) The location determines whether to apply sterile or nonsterile dressings to the wound. D) The location affects the client's ability to move. E) The location can give you clues to the wound's etiology. F) The location influences whether the exudate will be serous or purulent.
A,D,E
A client who is recovering following abdominal surgery is lying in bed coughing when you hear him cry out in alarm. When you ask what is wrong, he says he felt something "pop" in his abdomen. You notice increased serosanguineous drainage near the suture line. Which of the following interventions should you take? SELECT ALL THAT APPLY. A) Maintain the client in bedrest. B) Cover the wound with sterile towels soaked in sterile saline solution. C) Notify the surgeon and ready the patient for surgery. D) Elevate the head of the bed to 20°. E) Have the client flex his knees. F) Apply a binder to the abdomen.
A,D,E,F
On assessing a client, you find a pressure ulcer on the client's back. There is partial-thickness loss of the dermis, and the wound is open but shallow, with a red-pink wound bed. Which stage is this ulcer? A) Stage I B) Stage II C) Stage III D) Stage IV
B
A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? a) Risk for Infection related to subcutaneous injuries b) Risk for Impaired Skin Integrity related to immobility c) Impaired Tissue Integrity related to ventilator dependency d) Impaired Skin Integrity related to ventilator dependency
B
A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? a) Steri-Strips b) Abdominal binder c) T-binder d) Paper tape
B
A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: a) Primary intention healing b) Secondary intention healing c) Tertiary intention healing d) Approximation healing
B
The nurse applying a bioocclusive, transparent dressing on the abdomen of an elderly frail women is concerned about damaging her fragile skin when removing the dressing at a later time. What action should the nurse take to safegaurd the skin? A) Gently cleanse the skin with soap and water first. B) Use a skin sealant before applying the dressing. C) Remove hair from the site using scissors or clippers. D) Change the dressing frequently to avoid excessive adhesion.
B
The nurse in the emergency department admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing? a) Serous b) Sanguineous c) Purosanguineous d) Purulent
B
The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges. The nurse would document this as: A) stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00. B) stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00. C) stage IV pressure ulcer with sinus tract from 12:00 to 3:00. D) tage III pressure ulcer with sinus tract from 12:00 to 3:00.
B
The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound? a) Pressure ulcer b) Venous stasis ulcer c) Diabetic foot ulcer d) Arterial ulcer
B
The patient with a new colostomy refuses to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as disgusting. Based on these data, the priority nursing diagnosis is: A) Anxiety related to colostomy. B) Disturbed Body Image related to colostomy. C) Disturbed Body Image related to incontinence of stool. D) Impaired Skin Integrity related to fecal drainage.
B
What is a common characteristic of aging skin? a) Increased permeability to moisture b) Diminished sweat gland activity c) Reduced oxygen-free radicals d) Overproduction of elastin
B
While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) Sanguineous b) Serosanguineous c) Serous d) Purosanguineous
B
While assessing your client's skin, you observe an irregularly shaped lesion between the inside ankle and the knee. The lesion is red, shiny, taut, and warm. Which type of chronic wound should you suspect in this case? A) Pressure ulcer B) Venous stasis ulcer C) Diabetic ulcer D) Arterial ulcer
B
Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives: a) Can cause cellular toxicity b) Increase the risk of ischemia c) Delay wound healing d) Predispose to hematoma formation
B
You are caring for a client who is at high risk for developing pressure ulcers. Which of the following are intrinsic factors that increase the risk of this client developing pressure ulcers? SELECT ALL THAT APPLY. A) Friction B) Impaired sensation due to spinal cord injury C) Poor nutrition D) Shearing E) Edema F) Compression
B,C,E
Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. a) Granulation b) Hemostasis c) Epithelialization d) Inflammation
B,D
A primary care provider is deciding on a type of debridement for cleaning a client's wound. The method must be selective, meaning that only dead tissue is removed, while healthy tissue is spared. Which of the following methods will meet this criterion? SELECT ALL THAT APPLY. A) Sharp debridement B) Enzymatic debridement C) Wet-to-dry dressings D) Whirlpool treatments E) Autolysis F) Maggot debridement therapy
B,E,F
A client has just been prescribed warfarin, an anticoagulant. Which of the following should you mention to the client as a potential skin-related side effect of this medication? A) Risk for ischemia B) Inhibited wound healing C) Hematoma resulting from minimal pressure D) Increased risk for sunburn
C
A client shows you a wound on his hand that he received about a week ago when he fell. You see that the wound is filling in with a beefy red tissue. The client mentions that the wound still bleeds if he applies too much pressure to it. Which phase of healing is this wound in? A) Hemostasis B) Inflammatory C) Proliferative D) Maturation
C
A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? a) Dry gauze dressing changed twice daily b) Nonadherent dressing with daily wound care c) Hydrocolloid dressing changed as needed d) Wet-to-dry dressings changed three times a day
C
A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? a) Transparent film dressing b) Sheet hydrogel c) Frequent turn schedule d) Enzymatic debridement
C
For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? a) Client will maintain intact skin throughout hospitalization. b) Client will limit pressure to wound site throughout treatment course. c) Wound will close with no evidence of infection within 6 weeks. d) Wound will improve prior to discharge as evidenced by a decrease in drainage.
C
The most appropriate nursing diagnosis for a patient with a draining wound would be: A) Risk for Infection related to dehiscence of wound. B) Body Image Disturbance related to nonhealing surgical wound. C) Risk for Impaired Skin Integrity related to wound drainage. D) Pain related to surgical incision.
C
The nurse admits an older adult patient to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? a) Apply transparent film dressings to buttocks. b) Reassess using the Braden Q scale. c) Conduct another assessment in 3 days. d) Massage areas over the bony prominences.
C
The patient experiences extensive third-degree burns. What type of healing does the nurse expect? Healing by: a) Primary intention b) Second intention c) Tertiary intention d) Primary intention if no infection occurs
C
What intervention would be most appropriate for a wound with a beefy red wound bed? a) Mechanical debridement b) Autolytic debridement c) Dressing to keep the wound moist and clean d) Removal of devitalized tissue and a sterile dressing
C
What is the function of the stratum corneum? a) Provides insulation for temperature regulation b) Provides strength and elasticity to the skin c) Protects the body against the entry of pathogens d) Continually produces new skin cells
C
When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? a) The patient will need to take antibiotics until the wound is completely healed. b) Because the patient's wound was left open, the wound will likely become infected. c) The patient will have more scar tissue formation than there would be for a wound closed at surgery. d) The patient should expect to remain hospitalized until complete wound healing occurs.
C
Which client does the nurse recognize as being at greatest risk for pressure ulcers? a) Infant with skin excoriations in the diaper region b) Young adult with diabetes in skeletal traction c) Middle-aged adult with quadriplegia d) Older adult requiring use of assistive device for ambulation
C
While applying a wet-to-dry dressing, how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a: a) Method of submerging the wound in water, allowing it to soak before drying the wound bed b) Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed c) Means of debriding the wound but also removing granulation tissue from the wound d) Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue
C
You are caring for a client who has developed a pressure ulcer. Because of extensive tissue loss in the area of the ulcer, this wound is being left open and allowed to granulate. Which type of healing is this? A) Regenerative B) Primary intention C) Secondary intention D) Tertiary intention
C
What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply. a) Pressure Ulcer Healing Chart b) PUSH tool c) Braden scale d) Norton scale
C,D
The nurse learns in report that the assigned patient has a stage III pressure ulcer. What type of tissue does the nurse expect to find in the wound? Select all that apply. a) Muscle b) Eschar c) Subcutaneous d) Dermis e) Fascia
C,D,E
A client arrives at the emergency room with a long, bleeding cut down her arm caused by smashing through a car window. You recognize this as which of the following types of wounds? A) Abrasion B) Contusion C) Incision D) Laceration
D
A client arrives with a wound that is oozing with a foul-smelling yellow pus. Which type of wound drainage is this? A) Serous B) Sanguineous C) Serosanguineous D) Purulent
D
A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? a) Stage I pressure ulcer, healing b) Stage II pressure ulcer, healing c) Stage III pressure ulcer, healing d) Stage IV pressure ulcer, healing
D
A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patient's left heel. What is the initial treatment for this pressure ulcer? a) Antibiotic treatment for 2 weeks b) Normal saline irrigation of the ulcer daily c) Debridement to the left heel d) Elevation of the left heel off the bed
D
A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? a) Primary intention b) Regenerative healing c) Secondary intention d) Tertiary intention
D
A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? a) Draw a circle around the area of drainage on a dressing. b) Classify drainage as less or more than the previous drainage. c) Weigh the patient at the same time each day on the same scale. d) Weigh dressings before they are applied and after they are removed.
D
A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage IV pressure ulcer d) Unstageable pressure ulcer
D
A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a "pop" at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound: A) Evisceration B) Fistula C) Hemorrhage D) Dehiscence
D
An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear. What is the Braden score for this patient? a) 0 b) 15 c) 20 d) 23
D
An older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects he has: 1) an infected wound. 2) wound dehiscence. 3) a hematoma. 4) a fistula.
D
The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? a) Alginate b) Antimicrobial petroleum gauze c) Foam dressing d) Antimicrobial collagen dressings
D
The nurse will know ostomy care teaching is most likely successful when the patient with a new ostomy device: A) demonstrates the proper method of cleansing her skin. B) demonstrates proficiency when providing treatment to excoriated skin. C) states she will start caring for the colostomy after she gets home. D) proficiently performs colostomy care prior to discharge.
D
The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client a) Begins an aggressive exercise program b) Follows a diet plan of 1,200 calories per day c) Is fitted for deep-depth diabetic footwear d) Remains free of foot wounds
D
The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? a) Is actively bleeding b) Has swollen, tender insect bite c) Has just sprained her ankle d) Has lower back pain
D
The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: a) The ulcer is completely healed with minimal scarring b) The patient reports no pain at the site c) A minimal amount of drainage is noted d) The wound bed contains 100% granulated tissue
D
The nurse would question a prescription for application of cold therapy to which patient? The patient with a: a) Wound oozing blood b) Sprained wrist c) Infected wound d) Pressure ulcer
D
What is the primary difference between acute and chronic wounds? Chronic wounds: a) Are full-thickness wounds, but acute wounds are superficial b) Result from pressure, but acute wounds result from surgery c) Are usually infected, whereas acute wounds are contaminated d) Exceed the typical healing time, but acute wounds heal readily
D
Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: a) Remove all of the soiled dressings before beginning wound treatment b) Cleanse wounds from most contaminated to least contaminated c) Treat wounds on the patient's side first, then the front and back of the patient d) Irrigate wounds from least contaminated to most contaminated
D
How do the Langerhans cells protect the skin from injury? Langerhans cells: A) contain protein that gives the skin strength and elasticity. B) are able to filter out beta ultraviolet light waves. C) are mobile to phagocytize foreign material. D) are located in the dermal layer of the skin.
c
