Ch 14 Surgical Wound Care Practice Questions

What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?

Inflammatory

The nurse assessing a patient's wound notes thick, yellow drainage. How will the nurse most accurately document this finding?

Purulent drainage

What is the best indicator that a wound has become infected?

Purulent drainage is coming from the wound area.

When providing care to a patient with a Hemovac drain, what actions are included in the plan of care?

Record the appearance of the drainage in the nursing progress notes and include the amount in the intake and output calculations.

The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention?

Reduction of stress on the abdominal incision.

When removing staples from a surgical incision, which intervention is most appropriate?

Remove every other staple first, and replace with Steri-Strips while ensuring that the incision remains closed.

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?

Internal hemorrhage

What are the advantages of a transparent dressing? (Select all that apply.)

-Adheres to undamaged skin -Contains the exudate -Reduces wound contamination -Serves as a barrier to external bacteria

The student nurse is changing the patient's dressing. What actions indicate the need for further education? (Select all that apply).

-Clean the wound in circles toward the incision. -Free the tape by pulling it away from the incision. - Remove the soiled dressing with sterile gloves .-Apply the clean dressing with clean gloves.

A patient is 3 days postoperation from abdominal surgery. Which conditions would the nurse assessing the abdominal incision consider normal? (select all that apply)

-Clean, well-approximated edges -staples or sutures intact -A small amount of serous drainage

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take?

-Cover the area with saline-soaked sterile dressings. -Position the client supine with his hips and knees bent.

What are the traditional purposes of a wet-to-dry dressing? (Select all that apply)

-Debridement -Maintenance of moisture at the wound bed.

A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hours while reporting pain at a 2 on scale of 0 to 10 after receiving medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply)

-Impaired circulation -Impaired/suppressed immune system

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply)

-Increase in incisional pain -Fever and chills -Increase in serosanguinous drainage

Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.)

-Normal saline -Lactated Ringer -Acetic acid -Dakin

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.)

-Promotes formulation of granulation tissued. -Reduces local and peripheral edema -Drops bacterial level in wound

Which are the phases of wound healing? (Select all that apply.)

-Reconstruction -Hemostasis -Inflammation -Maturation

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention (select all that apply)

-Stage III ulcer -Open burn area

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?

12 inches

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

2000

How much fluid should the patient consume during the postoperative period?

2000 to 2400 mL

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?

300 mL

Why would a nurse use an irrigant to a wound when performing a dressing change?

Irrigation of a wound allows for debridement and cleansing of the wound.

What is the advantage of an occlusive dressing?

Keeps the incision moist

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?

Leave the 12 staples in place and record the separation

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?

Mechanical debridement

What marked advantage does primary intention have over other phases of wound healing?

Minimal scarring results

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?

Moisten the dressing with sterile water

What is the classification for the Jackson-Pratt drainage removal system?

Closed drainage system

What should the nurse assess and document regarding drainage?

Color, odor, consistency, and amount

When emptying the drainage in a Hemovac reservoir, which nursing action is essential for reestablishing the negative pressure within this drainage device?

Compress the reservoir and close the vent.

A nurse is collecting data on a client who is postoperative following abdominal surgery and discovers bowel protruding from the clients incision. Which of the following actions should the nurse take first?

Contact the rapid response team

What is the usual length of time before suture removal?

7 to 10 days

A nurse is caring for four clients who are 4 days post-operative following abdominal surgery. The nurse should further assess which of the following clients for wound evisceration?

A client who reports feeling his incision separate when he sneezed

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin

What does the term "primary intention" mean?

A surgical wound

Which wound drain is classified as providing gravity assisted drainage?

Penrose

What is the correct procedure for the wet-to-dry dressing method?

Place moist gauze into the wound and remove it when it is dry.

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?

Prevents skin maceration

The patient has just returned from the postanesthesia care (PAC) unit. During report, the nurse is told that the patient has a Penrose drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate?

Gravity is used to drain fluid from the area around the wound with the Penrose drain.

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?

Altered nutrition: more than body requirements

If a patient with an abdominal incision begins to cough, which intervention is the most appropriate?

Apply a pillow to the incision with slight pressure.

Which nursing intervention is most appropriate should the patient's abdominal wound eviscerate?

Apply warm, moist sterile dressings.

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?

At least 30 minutes before the dressing change

The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?

Causes hemoglobin to have a greater affinity for oxygen

What actions can be implemented to reduce surgical wound infection?

Changing the dressing using sterile technique.

What is the nurse's first step when caring for a patient needing wound care?

Checking the medical record for the physician's orders

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?

Circle and date the outline of the exudate on the dressing

The nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. What would be the priority nursing assessment when inspecting the skin that is distal to the bandage?

Circulatory impairment

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?

Clean wound

When classifying wounds, which classification results from the presence of gastrointestinal products?

Clean-contaminated

Which phrase best describes serous drainage?

Clear, watery plasma.

The physician has ordered for a patient's leg wound to be irrigated using an antiseptic solution. What would the nurse do to reduce the chance of contamination?

Have the solution flow from the least contaminated to the most contaminated area

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Cover the bowel with a sterile saline dressing

A nurse is collecting data on a client who is post-operative following abdominal surgery and discovers the client has bowel protruding from the incision. Which of the following actions should the nurse take?

Cover the wound with a nonadherent dressing

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?

Dehiscence

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following action should the nurse take?

Don clean gloves to remove the old dressing

The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?

Encourage the consumption of small frequent meals

How often should a nurse inspect a postoperative surgical wound within the first 24 hours?

Every 2 to 4 hours

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?

Every 2 to 4 hours

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?

Fibrin

The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?

From the area of least contamination to the area of most contamination

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?

Granulation tissue fills the wound during healing

Which nursing entry is the most complete in its description of a wound?

Incisional edges approximated without erythema or exudate; two 4x4s applied.

A nurse is contributing to plan of care for a client who has a wound infection and requires contact precautions. Which of the following actions should the nurse include in the plan of care?

Remove isolation gown before leaving the client's room after providing direct care to the client

The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?

Sanguineous

The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?

Sanguineous drainage

What is the first step when packing a wound?

Select gauze packing material.

The nurse assessing a patient's wound notes pale red watery drainage. How will the nurse most accurately document this finding?

Serosanguineous drainage

The nurse assessing a patient's wound notes a clear watery drainage. How will the nurse most accurately document this finding?

Serous drainage

A patient has come to the PACU after hip replacement surgery. Following the nursing assessment, the health care teams needs to set up a plan of care. What would the nurse anticipate to be the highest priority nursing diagnosis?

Skin integrity, impaired

The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?

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

What technique will the nurse implement to assist the postoperative patient to cough?

Splint the abdomen with a pillow

The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri-Strips applied. During suture removal, the nurse notices the incision edges are slightly separating. What is the best action by the nurse?

Stop the suture removal, apply Steri-Strips where sutures have already been removed, and notify the health care provider.

A nurse is reinforcing teaching with a client who is post-operative following abdominal surgery. Which of the following instructions should the nurse include to reduce the risk of wound evisceration ?

Support your abdomen with a pillow when coughing

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?

Tertiary intention

A nurse is collecting data on a client who is post-operative following abdominal surgery. The nurse should Identify that which of the following findings increases the clients risk for wound evisceration ?

The client is morbidly obese

Why are drainage systems used for various wounds?

The drainage system assists gravity in removing drainage or waste from the wound.

During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding?

The dressing is dry and intact, and the patient's blood pressure has decreased and pulse and respirations have increased.

Which patient is more at risk for wound dehiscence?

The obese patient.

Which statement is correct in regard to the use of an abdominal binder?

The patient must have adequate ventilator capacity.

What does the term "dehiscence" mean?

The wound layers have separated.

Why are staples used to adhere an incision?

They are strong and quick to use.

The health care provider has ordered the patient's wound be irrigated. What is the primary rationale for this procedure?

To remove debris from wound.

The physician has ordered a sterile dry dressing change. What is the most appropriate way to cleanse the wound and surrounding area?

Using an aseptic swab, start from the incision outward, one stroke per swab, then allow to air-dry.

What is serous drainage?

Watery drainage

A gauze dressing permits:

air to reach the wound.

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

clean

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

collagen

The primary purpose of a wet-to-dry dressing is to:

remove debris.

Rest and activity are important to the healing process because:

they cause increased circulation and oxygenation of the wound, which promotes healing.