Module 18 PNP

Identify the functions of dressings.

-maintaining a moist environment -control bleeding and drainage -Protection from outside contaminants and further tissue injury -increased patient comfort

Which of the following lab results or measurements indicate a risk for impaired wound healing?

-A BMI (body mass index) of 35 (elevated) -Fasting blood glucose of 215 mg/dl (elevated) -A serum albumin of 2.9 g/dl (decreased) -A hemoglobin of 10.0 g per dL (decreased)

Which of the following is an example of healing by secondary intention? (Select all that apply.)

-A full-thickness pressure ulcer -A dog bite -A burn

Which of the following regarding removal of the old dressing on a surgical incision are accurate?

-If dressing is over a hairy area, remove tape in the direction of hair growth. -Use caution to avoid tension on any drains that are present.

The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding?

-The nurse instructs the NAP to empty the drain every 8-12 hours or when it is 2/3 full and document the amount as output on the intake and output record -The nurse ensures the drainage device appears deflated after it is emptied.

The nurse is teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should the nurse include in the teaching?

-Turning patients at least every 2 hours -Use of pillow bridging when needed -Positioning the patient in the 30-degree lateral position -Using a turn sheet to reposition patients

It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion?

-Yellow-tinged drainage -Temperature 100.3°F (37.94°C) -Increased complaints of pain at wound site -White blood cell count 13,000 mm3 (elevated) -Foul odor noted from previous dressing

Match the correct type of dressing to the description.

1. The layer of dressing in contact with the wound- primary dressing 2.Least irritating material- dry gauze 3.Nonstick; has a shiny appearance and wicks drainage to the center layer- tefla gauze 4. The layer of dressing that provides protection- secondary dressing

Which of the following patients is at greatest risk for developing a wound infection?

A diabetic obese patient who smokes.

The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states the patient has a hematoma on the right knee. The nurse knows to expect to see:

A localized collection of blood underneath the tissues that often takes on a bluish discoloration.

The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?

Apply sterile saline-soaked towels to the area

How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?

By compressing the drain reservoir

A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?

Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.

When is a surgical wound at greatest risk for hemorrhage?

During the first 24 to 48 hours after surgery.

Which of the following is a method of wound debridement?

Moist-to-dry dressing

A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?

Montgomery ties

A nurse is applying a wound V.A.C. dressing independently for the first time. What action, if made by the nurse, indicates that further instruction is needed in performing this procedure?

The nurse applies new gloves, irrigates the wound with normal saline, and then gently blots it dry. The nurse measures the wound, removes and discards gloves, and applies a new pair of gloves. The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas.

Which of the following may indicate an increased risk for wound dehiscence?

There is an increase in serosanguineous drainage from the wound

Why does a wound bed need to stay moist?

To support healing by enabling granulation tissue to grow

The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?

You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling."

The nurse may use clean gloves for changing the dressing on which of the following?

chronic pressure ulcer

A patient with lung cancer received radiation therapy to reduce the size of the tumor prior to a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient's chest cavity and an opening on the patient's back. The nurse is aware the patient is at increased risk for:

fluid and electrolyte imbalance

The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection:

two to three days after injury