Nursing skill Quiz 1

Transparent dressing (tegaderm)

-stage 1-2 -Prevents skin breakdown and prevents entrance of moisture and bacteria but allows oxygen and moisture vapor permeability.

A (measurement in inch or inches) margin at each edge of an opened drape is considered un-sterile, since the edges are in contact with un-sterile surfaces.

1 inch

Provide meds before dressing

1/2 hour

1. What is the maximum temperature of the water in a hot water bottle for an adult?

125 F

AIDET

Acknowledge, Introduce, Duration, Explain, Thank

Which of the following group of clients are standard precautions used for?

All hospitalized clients regardless of their diagnosis or possible infection status

What factors does the nurse consider when selecting a dressing for a wound?

All of the above

Therapeutic Applications

Circulation, Mobility, Sensation, Skin Temp, pulses, capillary refill, any bleeding conditions. Record

Select the four characteristics of drainage that should be noted when a dressing is changed.

Color, odor, consistency, amount

Abdominal binders are used primarily for what purposes?

Comfort, Immobilize wound, apply pressure and support, secure dressing, promote healing, prevent injury, warmth, muscle control.

As you are removing the wrapping from a sterile bowl, an edge of the wrapper touches the sterile field you have just set up. You would continue with the procedure because the wrapper is sterile.

False

Heat is often applied to prevent swelling?

False

It is permissible to reserve one corner of a sterile field for disposal of nonsterile items.

False

It is safe to fold and pin a heating pad to keep it in place?

False

Your patient has a large volume of sanguineous drainage requiring every 2 hour dressing changes. What are some concerns for this patient?

Fluid loss Infection Compromised skin integrity from frequent dressing changes

Where is the best site to obtain a wound culture?

From granulation tissue.

A client is admitted into the hospital for Tuberculosis and placed in isolation. In what sequence should the nurse remove the protective barriers when leaving the isolation room?

Gloves, wash hands, goggles, gown, mask, and then wash hands.

What is granulation tissue and what would it indicate to the nurse?

Granulation tissue is healing tissue that indicates to the nurse the wound was healing.

How is MRSA is primarily transmitted?

Hands

What is the most effective way to prevent the spread of infection?

Handwashing

Secondary intention healing

Healing from the inside out edges cant meet, must granulate

After giving an injection, what should be done with the needle?

Leave uncapped or safety capped and discard in a designated receptacle.

What is rebound phenomenon and why is it important?

Maximum therapeutic effect occurs in 20-30 minutes. Some patients cannot feel or report too hot or too cold.

Asepsis

Medical clean absence of almost all organisms

Risk factors of healing

Obesity, Age, Blood Flow, and Tobacco

Serosanguineous

Pale, red, watery: mixture of clear and red fluid

Systemic effects of heat

Peripheral vasodialation -> Fainting or Drop in BP

What are the four purposes for dressings?

Provide moist wound healing, prevent injury, absorb drainage, and wound debridement

You are almost finished with changing a sterile dressing on your client. As you are about to place the final 4x4 gauze dressing on the wound your nose itches and as a matter of reflex you touch your nose with your gloved hand. What do you do now?

Remove sterile gloves and don new sterile gloves

Greater risk of infection healing

Secondary intension

Which statement below is true regarding objects used in a sterile field?

Should never be left unattended after opening.

Which of the following are physiologic effects of cold applications?

Slows bacterial growth,Lowers cellular metabolism,Vasoconstriction,Decreases capillary permeability,Reduces inflammatory response,Reduces bleeding

What is the purpose of the spiral-reverse turn method of bandaging?

To wrap a part that is cylindrical in shape such as a forearm or lower leg

Prior to performing a sterile procedure, the nurse should explain the procedure and how the patient can cooperate.

True

The assessments performed with a patient that has a wound includes location of wound, type of wound, presence of infection and lab data such as WBC.

True

The physician orders a damp to damp dressing change. The reason for this is to keep the wound clean to promote healing.

True

Primary intention healing

Two edges seamed together

The physician inserts a Hemovac drain due to excessive drainage from a surgical wound. How do you clean a wound with a drain?

Use a new swab or gauze for each swipe. Clean around the drain after cleansing the rest of the wound

Mrs. Williams has a large abdominal wound that requires frequent dressing changes. A drainage tube is present to aid in removal of wound exudate. How can the nurse control infection during the care of this client ?

Use gown and gloves and other PPE as indicated Keep dressing dry, intact and use sterile technique with wound and drainage tube care Use leak proof container to dispose of soiled dressings

Thermal tolerance

Various areas of the body differ in their response to heat and cold.

Local effects of cold

Vasoconstriction decreased capillary permeability decreased cellular metabolism slowed bacterial growth decreased inflammation local anesthetic effect for sprains, fractures, swelling

Systemic effects of cold

Vasoconstriction BP can increase because shunted to internal organs Shivering -> body`s attempts to warm itself

Local effects of heat

Vasodialation, Increases in Capillary permeability, cellular metabolism, blood flow, and inflammation. Sedative effect Promotes soft tissue healing and used for joints or low back pain

What are four physiologic effects of heat applications?

Vasodilation, increased inflammation, sedative effect, increased capillary permeability

Sanguineous

bloody

Serous

clear, watery plasma

Purulent

containing pus

Rebound phenomenon

maximum therapeutic effect achieved and opposite effect begins 20-30 minutes

Aquathermia pad

tube containing water, with electronic controls.

Hydrocolloid dressing

used for clean stage 2 or shallow stage 3 pressure ulcers