Foundations Chapter 48 Questions

4 A dressing supports a moist wound environment, not a dry one. The remaining statements indicate understanding. Dressings absorb drainage to promote wound healing, promote hemostasis and thermal insulation, help reduce exposure to microorganisms, and support the wound site.

A nurse discusses the purposes of wound dressings with a nursing student. Which of the nursing student's statements indicates the need for further learning? 1 "Dressings absorb drainage to promote wound healing." 2 "Dressings promote hemostasis and thermal insulation." 3 "Dressings help reduce exposure to microorganisms, and they support the wound site." 4 "Dressings provide a dry environment to facilitate healing."

1, 4, 5 When evaluating a patient's circulation following bandaging of a deep lower leg wound, the nurse will observe the toes for any discoloration that may indicate impaired circulation. The nurse will check numbness, which could indicate impaired venous return. The nurse should also check the capillary refill, which should be less than 3 seconds for healthy circulation. Leg mobility provides information about the neuromuscular system, not the circulatory system. The nurse checks the drainage for signs of infection and to evaluate healing, not to determine healthy circulation.

A nurse is evaluating the circulation of a patient who has a bandage over a deep lower leg wound. What should the nurse check to assess circulation? Select all that apply. 1 The toes 2 Leg mobility 3 Wound drainage 4 Numbness 5 Capillary refill

2 The collagen content of the skin decreases, not increases, with age. The remaining statements indicate understanding. The elasticity of the skin decreases with aging, and the underlying muscle and tissues thin. Because of these changes, the older adult's skin can be easily torn in response to mechanical trauma.

A nursing instructor discusses with a nursing student the changes that occur in the skin with aging. Which of the student's statements indicates the need for further teaching? 1 "The elasticity of the skin decreases with age." 2 "The collagen content of the skin increases with age." 3 "The underlying muscle and tissues become thinner with age." 4 "The older adult's skin can be easily torn in response to mechanical trauma."

1 Normal saline is a noncytotoxic topical fluid that can be used to clean a pressure ulcer. Povidone iodine, hydrogen peroxide, and sodium hypochlorite are cytotoxic fluids that are used to clean highly colonized wounds.

A patient developed a pressure ulcer after knee surgery due to restriction to bed. Which irrigating fluid should the nurse use to clean the ulcer? 1 Normal saline 2 Povidone iodine 3 Hydrogen peroxide 4 Sodium hypochlorite

3 Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. These dressings hydrate wounds and absorb small amounts of exudate. Hydrogel dressings are used for deep wounds with some exudates and can be very soothing to a patient, because they do not adhere to the wound and thus cause little trauma during removal. Film dressings are used for superficial ulcers. Foam dressings are preferred around the drainage tubes to absorb the drainage. Calcium alginate dressings are used for wounds with excessive drainage; the dressing forms a soft gel when it comes in contact with the wound fluid.

A patient developed a pressure ulcer that was deep with the presence of exudates. Which type of dressing is provided to the patient? 1 Film 2 Foam 3 Hydrogel 4 Calcium alginate

4 Polyvinyl alcohol (PVA) is white, soft, and denser foam with small pores that inhibits the excessive growth of granulation tissue in the wound; therefore, this dressing should be used after a patient receives NPWT. Irrigating the wound with solutions such as water or saline removes wound debris. Applying a barrier film to the periwound area maintains an airtight seal and protects the skin from maceration. Black, polyurethane foam is effective in stimulating granulation tissue and wound contraction.

A patient is receiving negative-pressure wound therapy (NPWT). After the primary health care provider places the device, the nurse applies a foam, polyvinyl alcohol (PVA) dressing. What is the purpose of the dressing? 1 To remove wound debris 2 To prevent wound maceration 3 To stimulate wound contraction 4 To prevent excessive growth of granulation tissue

2 An elastic bandage helps immobilize and supports healing of a sprained the ankle. Elastic webbing is used to secure dressings. An elastic pressure bandage is used to create pressure over a body part, for instance, to prevent bleeding. A stretch pressure bandage may be applied to reduce or prevent edema but not to immobilize and prevent pain from a sprain.

A patient reports pain in the ankle joint due to sprain. Which nursing intervention is beneficial to the patient? 1 Applying elastic webbing 2 Applying an elastic bandage 3 Applying an elastic pressure bandage 4 Applying a stretch pressure bandage

2 A patient who has a stage III pressure ulcer has full-thickness skin loss. Purulent drainage with a characteristic odor and a fever are indications of wound infection. Skin discoloration to bluish and purplish color are manifestations of bruising. Internal bleeding manifests as swelling and bluish discoloration at the affected part. Blanchable erythema is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved, but it does not come with fever and purulent discharge.

A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient? 1 Bruising 2 Infection 3 Internal bleeding 4 Blanchable erythema

2 A stage II pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough. A stage I pressure ulcer presents as intact, nonblanchable, red skin, often over a bony prominence. A stage III pressure ulcer involves full-thickness tissue loss so that subcutaneous fat is visible. A stage IV pressure ulcer involves full-thickness tissue loss extending to and exposing bone, tendon, and/or muscle.

A patient who has a stage III pressure ulcer has full-thickness skin loss. Purulent drainage with a characteristic odor and a fever are indications of wound infection. Skin discoloration to bluish and purplish color are manifestations of bruising. Internal bleeding manifests as swelling and bluish discoloration at the affected part. Blanchable erythema is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved, but it does not come with fever and purulent discharge.

4 An acute wound due to trauma needs an immediate intervention, such as the application of a sterile dressing to reduce bleeding and prevent sepsis. The nurse may educate the patient about hygiene and wound care, have the patient change positions to prevent pressure ulcers, and encourage the patient to drink 6 to 8 L of water to promote cell function, but these are all secondary to stopping the bleeding.

A patient who has an acute wound due to trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation? 1 Educating the patient about wound care 2 Positioning the patient in different angles 3 Encouraging the patient to drink 6 to 8 L of water 4 Applying a sterile dressing as per the health care provider's order

2 Evisceration is a medical emergency in which the visceral organs protrude through a wound opening. Immediate application of sterile gauze soaked in sterile saline over the extruding tissues helps to prevent bacterial invasion, infection, and drying of the tissues. Analgesics will be used to reduce pain. Pressure ulcer prevention will not be a primary concern in an emergency situation such as this. Saline-soaked gauze will not prevent edema.

A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action? 1 To reduce pain 2 To prevent infection 3 To prevent pressure ulcers 4 To prevent periwound edema

2 Purulent drainage is thick and yellow, green, tan, or brown. Serous drainage is clear, watery plasma. Sanguineous drainage is bright red, indicating active bleeding. Serosanguineous drainage is pale pink and watery.

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

Poor nutrition Of these factors, the patient's poor nutrition carries the highest risk for the patient developing a pressure ulcer. The better the nutrition, the lower the risk. Moist, not dry, skin puts a patient at a greater risk for developing a pressure ulcer. Although frequent, rather than occasional, activity is ideal for reducing the risk for developing a pressure ulcer, the more immobile the patient is, the greater the chance of pressure ulcer development. Slightly limited sensory perception puts a patient at less of a risk than does very limited or completely limited sensory perception.

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?

1 When a patient reports of severe pain after negative suction wound therapy, the nurse should reduce the suction immediately and provide the patient with analgesics to relieve pain. Notifying the health care provider may not be required, because it is not a serious complication. When the wound appears inflamed and tender with increased drainage, then the nurse should increase the frequency of dressing change; however, this intervention may not reduce the patient's pain. The nurse reinforces the transparent dressing strips for covering the wound when the negative-pressure seal has broken, but not when the patient complains of pain.

After receiving negative suction wound therapy for pressure ulcers, the patient complains of severe pain. What should be the immediate nursing action? 1 Reduce the suction 2 Notify the health care provider 3 Increase frequency of dressing change 4 Reinforce with transparent dressing strips

2, 4, 1, 3 The proliferative phase of wound healing lasts 3 to 24 days. Fibroblasts produce collagen that provides a matrix for granulation. Then, the collagen mixes with the granulation tissue to form a matrix that supports reepithelialization. It also provides mechanical and structural support to a wound. The wound contracts during this process to reduce the area that requires healing. Finally, the epithelial cells migrate from the wound edges to resurface.

Arrange the events that occur during the proliferative phase of wound healing in chronological order. 1. Contraction of the wound 2. Synthesis of collagen from fibroblasts 3. Migration of the epithelial cells from the wound edges 4. Mixing of collagen with granulation tissue

2, 4, 1, 3 Ice bags may be used to prevent edema, control bleeding, and reduce pain. To prepare an ice bag, first check the bag for leaks by inverting it after filling water. Empty the water from the bag and fill two thirds of it with crushed ice. Then, release any air from the bag by squeezing it at the sides. This prevents interference with the conduction of cold. Finally, wipe off the excess moisture, wrap the bag in flannel, a towel, or a pillowcase, and apply the bag to the injury site for 30 minutes.

Arrange the steps for preparing an ice bag in order. 1. Squeeze the bag's sides to release any air. 2. Fill the bag with water, and check it for leaks. 3. Cover the bag with a flannel cover, towel, or pillowcase. 4. Fill two thirds of the bag with crushed ice.

5, 1, 4, 3, 2 If the primary health care provider orders the nurse to irrigate the wound, then the nurse can start the procedure by pouring the ordered solution into sterile irrigation containers. Next, the waterproof pad is placed under the patient. After that, using a syringe, the nurse gently allows the solution to flow over the wound. The irrigation continues until a clear flow of solution flows through the wound, and then the nurse can apply gauze pads around the dry surrounding skin. Finally, the nurse removes and disposes of the gloves, and performs hand hygiene.

Arrange the steps in order that the nurse follows while irrigating a wound. 1. Place waterproof pad under the patient 2. Remove the gloves 3. Apply gauze pads over surrounding skin 4. Allow the solution to gently flow over wound 5. Pour sterile solution into sterile irrigation containers

5, 3, 2, 1, 4 The nurse who is planning for the treatment of a pressure ulcer must first explain the procedure to the patient and the patient's family. Then, the nurse can select the appropriate tape and dressing based on the purpose of dressing and the characteristics of the pressure ulcer. Next, the nurse will drain the ulcer with normal saline or a cleaning agent using irrigating syringes if the ulcer is deep. Then, the nurse applies topical agents such as debriding enzymes, hydrogel, or calcium alginate, and closes the wound. Finally, the nurse repositions the patient off of the pressure areas and pressure points.

Arrange the steps in the order to be followed by a nurse who is caring for a patient who has a pressure ulcer. 1. Apply topical agents 2. Clean the ulcer with normal saline 3. Select the appropriate dressing and tape 4. Reposition the patient comfortably off of the pressure area 5. Explain the procedure to the patient and family

3, 5 The nurse will note the number and types of drains present before irrigation to determine the type and number of the dressings required. This also facilitates safe dressing removal. The nurse will visually examine the wound's color to determine if it is necrotic. The volume of the irrigating fluid is 1.2 to 2 times the estimated wound volume. The health care provider, not the nurse, will determine the type of the irrigation solution to be used.

Before irrigating a patient's wound, the nurse notes the number and types of drains present. What is the rationale behind this? Select all that apply. 1 To determine if the wound is necrotic 2 To determine the volume of the irrigating fluid needed 3 To identify the type and number of the dressings required 4 To determine the type of irrigation solution to use 5 Facilitate safe dressing removal

2, 4, 1, 3 The nurse first cleans the intact skin with a disinfectant solution to remove skin flora. The nurse then uses a 10-mL disposable syringe with a 22-gauge needle for extracting the wound drainage for culture. Then, 0.5 mL of air is drawn into the syringe to ease the suction up to the 10-mL mark. Lastly, the nurse moves the needle back and forward at different angles for two to four explorations, expels the excess air from the syringe, and prepares the syringe for the laboratory.

Chronologically arrange the steps for using a syringe and needle to collect a sample for a wound culture. 1. Applying suction to the 10-mL mark 2. Removing skin flora with a disinfectant solution 3. Moving the needle back and forward at different angles for two to four explorations 4. Using a 10-mL disposable syringe with a 22-gauge needle

1 The nurse's priority is to release the bandage when impaired circulation is observed during evaluation. Once this is done, the nurse can then perform the lower-priority actions of palpating the extremity, assessing the pulse, and reapplying the bandage with less pressure.

During an evaluation of a patient with elastic bandages, the nurse observes signs of impaired circulation in the surrounding area. What should be the nurse's priority action? 1 Release the bandage 2 Palpate the extremity 3 Assess the pulse 4 Reapply the bandage with less pressure

1, 2 A nurse who is treating a deep incision wound should place the gauze into the wound incision without touching the wound area. The wound should be packed loosely to provide wicking of the drainage into the absorbent outer layer of the dressing. The nurse should wet the gauze to provide moisture to encourage wound healing, but the gauze should not be dripping. Excessively moist dressings may damage the periwound skin, and can cause a foul smell and drainage. Gauze should be used only one time for cleaning the wound; using the same gauze a second time may cause contamination of the wound. Montgomery ties are used to secure the wound in place and to prevent maceration of the periwound skin; they may not be a cause for infection. Dressing for a deep incision requires dry and topper gauze to drain out the moisture from the wound and prevent strike-through of the wound drainage respectively.

During assessment, the nurse notes a foul-smelling drainage from the wound with deep tunneling. Which actions of the nurse indicate the need for further teaching? Select all that apply. 1 Covering the entire wound with the gauze 2 Placing the dripping wet gauze into the tunnel 3 Using the gauze only to clean the wound 4 Using the Montgomery ties to secure the dressing 5 Using dry dressing and topper dressing over inner gauze

3, 4 Stage III and IV pressure ulcers are expected to heal through granulation and reepithelialization, so the nurse would educate the patients on these expected changes. The nurse would teach a patient with a stage I ulcer about healing over 7 to 14 days, a patient with a stage II ulcer about healing via reepithelialization, and a patient with an unstageable ulcer about softening the eschar with debridement.

For which pressure ulcers would the nurse include education related to both granulation and reepithelialization? Select all that apply. 1 Stage I 2 Stage II 3 Stage III 4 Stage IV 5 Unstageable

2 For patients who have stage IV pressure ulcers, special support surfaces such as low-air-loss, alternating pressure, and air-fluidized surfaces while for patients with stage I ulcers, higher-specification foam or a similar nonpowered redistribution support surface is used. Both stages require keeping the patient out of a slouched position or prolonged head-of-bed elevation position. Both stages require consulting a seating specialist for the appropriate seating surface for the patient.

How is the nursing care for a patient who has a stage IV pressure ulcer different from that for a patient who has a stage I pressure ulcer? 1 Stage IV requires keeping the patient out of a have slouched position. 2 Stage IV requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface. 3 Stage IV requires keeping the patient out of a prolonged head-of-bed elevation position. 4 Stage IV requires consulting a seating specialist for the appropriate seating surface for the patient.

4 The nurse should recommend the patient consume 30 to 35 kcal per kilogram per day to promote wound healing. The amounts of 15 to 20 kcal, 20 to 25 kcal, and 25 to 30 kcal are not enough.

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing? 1 15-20 kcal 2 20-25 kcal 3 25-30 kcal 4 30-35 kcal

1 The image shows retention sutures, which are placed more deeply than skin sutures. Continuous sutures have a series of stitches, but they are not individually knotted. In intermittent sutures, each individual suture is made in the skin. A blanket suture is a continuous self-locking stitch.

Identify the type of suture depicted in the image. 1 Retention 2 Continuous 3 Intermittent 4 Blanket continuous

4 The medial knee may be at risk for a pressure ulcer in a patient who is in a side-lying position, but not in a supine position. The ischium, elbow, and occipital bone are all sites at risk for pressure ulcers in an immobilized supine patient.

In a supine position, which site is not at risk for a pressure ulcer? 1 Ischium 2 Elbow 3 Occipital bone 4 Medial knee

4 To address the patient's pain and discomfort during a wound care procedure, the nurse administers pain medication 30 to 60 minutes before the procedure, depending on the time of peak action for the prescribed drug. Administering pain medication after the procedure will not provide analgesia during the procedure. Administering pain medication at the beginning of the procedure or 10 to 20 minutes before the procedure will not provide relief quickly enough.

Stage III and IV pressure ulcers are expected to heal through granulation and reepithelialization, so the nurse would educate the patients on these expected changes. The nurse would teach a patient with a stage I ulcer about healing over 7 to 14 days, a patient with a stage II ulcer about healing via reepithelialization, and a patient with an unstageable ulcer about softening the eschar with debridement.

1, 3, 5 An elastic bandage on a sprained ankle will reduce edema, provide support, and provide immobilization. The bandage will not prevent infection, and this is not a concern for a sprain unless open wounds are also present. Because the elastic bandage helps immobilize the ankle, it prevents stretching.

The nurse applies an elastic bandage to a patient who has a sprained ankle. What purpose does the bandage serve? Select all that apply. 1 Reduces edema 2 Prevents infection 3 Provides support 4 Supports stretching 5 Provides immobilization

1, 2, 3 A patient with a score of 16 on the Braden scale indicates that the patient is at risk for pressure ulcers. The patient in this condition should be provided with interventions that protect the heels, because this site is more susceptible to ulcer formation. The patient should frequently be turned to prevent the risk of pressure ulcer development. The patient should also be provided with pressure-redistribution surfaces to prevent ulcer formation. Foam wedges should be provided for the 30-degree lateral position, not the 40-degree lateral position. Application of moisturizer should be avoided in the patient, because it increases the risk of ulcer formation.

The nurse determines the patient's risk of developing ulcers using the Braden Scale and finds the score to be 16. Which nursing interventions are appropriate for the patient to decrease the risk of skin breakdown? Select all that apply. 1 Protecting the patient's heels 2 Turning the patient frequently 3 Providing pressure-redistribution surfaces 4 Providing foam-wedges for 40-degree lateral position 5 Applying a moisturizer to the patient's wound regularly

2 Reviewing the orders for the dressing change procedure indicates to the nurse the type of dressing or applications needed for dressing the wound. The nurse should assess the patient for any allergies to wound cleansing agents or any other agents used while dressing, to prevent adverse reactions. The nurse assesses the patient's and the family's knowledge of wound dressing to determine what will need to be included while teaching them. Reviewing the patient's medical record to learn about the size and location of the wound helps the nurse to plan for the proper type and amount of supplies required for dressing the wound.

The nurse is assisting the primary health care provider in applying moist dressing for a patient who has pressure ulcers. The nurse reviews the orders for the dressing change procedure. What is the rationale behind this nursing action? 1 To prevent adverse reactions 2 To learn the type of dressing that is to be used 3 To determine the specific areas that will be included during patient teaching 4 To plan for the proper type of supplies required for dressing

3 The lateral rotation support surface provides passive motion, turning the patient from side to side on a low-air-loss surface. This type of surface is used in the treatment and prevention of pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss, nonpowered, and air-fluidized bed surfaces are used to treat and prevent other types of skin breakdown.

The nurse is caring for a patient who is diagnosed with venous stasis ulcers. Which support surface should the nurse anticipate for this patient? 1 Low-air-loss bed 2 Nonpowered bed 3 Lateral rotation 4 Air-fluidized bed

2 If the patient or caregiver notices signs of infection, this should be reported to the health care provider. The remaining statements indicate understanding. Thick, yellow drainage with an odor may be a sign of infection. Irrigation can be increased if wound drainage increases. Patients can prepare their own saline solutions by adding 8 teaspoons of salt to 1 gallon of distilled water.

The nurse is discussing home care wound irrigation with a patient and the caregiver. Which of the patient's statements indicates a need for further teaching? 1 "If I observe thick, yellow drainage with an odor, my wound may be infected." 2 "I can continue using normal saline solution if there are signs of infection." 3 "I should increase the frequency of irrigation if wound drainage increases." 4 "I can prepare my own saline solution by adding 8 teaspoons of salt in 1 gallon of distilled water."

3 Asking the patient to rate the pain using a scale of 0 to 10 helps the nurse determine the patient's level of comfort during the procedure. Inspecting the condition of the wound and noting the drainage condition and odor helps determine the status of wound healing, but not the patient's level of comfort. Verifying airtight dressing seal and proper negative pressure helps achieve prescribed vacuum level of the therapy. Comparing the wound size and condition with a baseline wound assessment helps provide objective information of wound healing.

The nurse is evaluating the outcome of a patient provided with negative-pressure wound therapy (NPWT) for pressure ulcers. Which nursing action is appropriate for determining the patient's level of comfort while providing the treatment? 1 Determining the drainage and odor of the wound 2 Verifying proper negative-pressure in the patient's wound 3 Asking the patient to rate the pain using a scale of 0 to 10 4 Comparing the wound size with a baseline wound assessment

3, 1, 2, 6, 4, 5 The nurse will attach the catheter to the filled syringe to allow direct flow of irrigant into the wound during the irrigation process. The tip of the catheter is then inserted into the wound to clean the deep wound. To remove the tip from the fragile inner walls of the wound, the catheter is pulled out about 1 cm. The nurse then flushes the wound with slow and continuous pressure and then pinches off the catheter just below the syringe. The nurse checks the collection basin for the presence of debris and decides if repetition is required.

The nurse is irrigating a deep wound with a small opening. In which order should the following actions be performed? 1. Insert the tip of the catheter into the wound. 2. Pull out the catheter about 1 cm. 3. Fill the syringe, and attach it to the catheter. 4. Pinch off the catheter just below the syringe. 5. Observe for the presence of debris in the collection basin. 6. Flush the wound using slow and continuous pressure.

4 Ointments may decrease friction with the sheets and cover the affected area, encouraging healing and moisture in open ulcers and minimizing patient discomfort. The patient should be repositioned every 90 minutes to reduce pressure over vulnerable areas of the body, but this does not necessarily relieve the patient's discomfort. Elevation of the patient's head of the bed is avoided to minimize further pressure on the sacrum and coccyx. Rubbing or massaging the affected areas may cause tissue damage, so this is avoided.

The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient? 1 Repositioning the patient every 90 minutes 2 Cleaning and massaging around the affected area 3 Elevating the head of the patient's bed to 30 degrees 4 Applying a moisture barrier ointment over the ulcer

2 A pressure ulcer covered in eschar is an unstageable pressure ulcer. The nurse would use an adherent film dressing because it will facilitate softening of the eschar to allow for debridement. No dressing is appropriate for an intact stage I pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. A calcium alginate dressing is appropriate for a clean stage III or stage IV pressure ulcer.

The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient? 1 None 2 Adherent film 3 Composite film 4 Calcium alginate

2 Blanchable erythema is an early indication of pressure; therefore, the nurse knows this finding on the patient's sacral area is due to pressure. Friction may not cause blanchable erythema in the patient, but it increases the risk of developing pressure ulcers. Massage may not be responsible for developing blanchable erythema in the patient, but it reduces the risk of pressure ulcers. Blanchable erythema does not indicate sheering force.

The nurse notes a quarter-sized area of blanchable erythema over the patient's sacral area. The nurse knows this finding is likely due to what? 1 Friction 2 Pressure 3 Massage 4 Sheering force

3 The nurse should remove the bandage from the area to treat the edema and abrasions. Simply loosening the bandage will not allow the nurse to do so. The nurse should loosen the bandage when it becomes very tight and when there is an impaired circulation. The nurse can change the bandage once the skin has been treated. The nurse should inform the health care provider if there is any serious concern of altered circulation.

The nurse observes edema and abrasions at the wound area under an elastic bandage. Which nursing action is the priority? 1 Loosening the bandage 2 Changing the bandage 3 Removing the bandage 4 Reporting to the health care provider

1 The Braden Scale provides a baseline for comparing increased or decreased risk for development of pressure ulcers that helps plan for interventions. If the score is 10 to 12, then the patient is at high risk of developing pressure ulcers; therefore, this patient is considered at a high risk of pressure ulcer development. If the score is 13 to 14, then the patient is at moderate risk of developing pressure ulcers. If the score is lower than 9, it indicates severe complication and the patient should be taken to the intensive care unit immediately. If the score is high, it indicates low risk, and the condition can be managed in a few days with minimal interventions.

The nurse observes that a patient with pressure ulcers has a score on the Braden Scale of 11. What would the nurse suspect from this observation? 1 The patient is at high risk of development of pressure ulcers. 2 The patient is at moderate risk of pressure ulcer development. 3 The patient should be taken to the intensive care unit. 4 The patient's condition can be managed in a few days.

1 Although the patient's skin is currently healthy, the patient's diabetes and limited mobility put this patient at a high risk for developing pressure ulcers. As a preventive measure, the nurse should place a pillow under the calves of the patient to elevate the heels to reduce the risk of heel breakdown. Such patients should be positioned at a 30-degree lateral, not medial, turn position to avoid typical at-risk pressure points. The nurse should use higher-specification foam mattresses rather than standard hospital foam mattresses. Alternating pressure support surfaces are needed for patients who already have ulcers. These are not necessary for this patient.

The nurse performs the skin and risk assessment on a patient who has diabetes and limited mobility due to a fractured left hip and finds that the skin is intact without any skin disintegration. Which nursing intervention should the nurse provide to the patient? 1 Place a pillow under the patient's calves. 2 Position the patient at a 30-degree medial turn. 3 Use standard hospital foam mattresses for the patient. 4 Recommend alternating pressure support surfaces for the patient.

1 The Braden Scale for pressure ulcer development risk has shown insufficient predictive validity and poor accuracy in determining risk for pressure ulcers. It was developed based on risk factors in a nursing home population. The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23. It is the most widely used risk assessment tool for pressure ulcers.

The nursing instructor is discussing the Braden Scale for pressure ulcer development risk with a nursing student. Which of the student's statements is incorrect? 1 "The Braden Scale has shown sufficient predictive validity and accuracy for all patients." 2 "The Braden Scale was developed based on risk factors in a nursing home population." 3 "The Braden Scale contains six subscales, and the total score ranges from 6 to 23." 4 "The Braden Scale is the most widely used risk assessment tool for pressure ulcers."

2, 4 The nurse should remove the dressings at night, not in the morning, and then reapply them in the morning. The nurse should assess the skin of the patient under the bandage at least two times during an 8-hour period; waiting every 12 hours is too long. The remaining statements are correct. The nurse should observe the skin of the patient for pallor and cyanosis. The nurse should observe the mobility of the patient's extremity. The nurse should ask the patient about any discomfort, numbness, or tingling sensations under the bandaged area.

The registered nurse and a nursing student are discussing evaluation of a patient after application of an elastic bandage. Which of the nursing student's statements indicate a need for further learning? Select all that apply. 1 "I will observe the skin for cyanosis." 2 "I will remove the dressings in the morning." 3 "I will observe the mobility of the extremity." 4 "I will assess the skin under the bandage every 12 hours." 5 "I will ask the patient about numbness and tingling in the bandaged areas."

1 The nurse providing wound care should choose a dressing that keeps the periwound skin dry and the surgical wound bed moist to promote healing. The dressing used for wound care should control exudate from the wound, but it should not desiccate the wound bed. Application of pressure while cleaning the periwound and wound may deepen the wound bed. Using sterile normal saline and a sterile gauze to clean the surgical wound reduces the incidences of infection.

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning? 1 Choosing a dressing that keeps the periwound moist 2 Applying a dressing that controls exudates from the wound 3 Cleaning the periwound and wound without applying pressure 4 Using sterile normal saline and a sterile gauze to clean the surgical wound

3 The patient should be positioned so the wound is directly above the collection basin. This allows gravitational flow of the solution through the wound and into the basin. The nurse should place extra towels or padding in the bed to protect it, not remove the bed sheets. The irrigant should be warmed to body temperature, not cooled to room temperature, to reduce vascular constriction. Analgesics should be administered 30 to 60 minutes before starting the irrigation procedure to proactively provide pain relief.

The registered nurse is overseeing a student nurse performing irrigation. Which of the practical nurse's actions is correct? 1 Removing the bed sheets from the bed 2 Cooling the irrigant to room temperature 3 Positioning the patient's wound above the collection basin 4 Administering analgesics immediately after starting the irrigation procedure

3 Application of adhesive remover at the affected area may leave a residue that hinders dressing film adherence the remaining actions are correct. The periwound should be thoroughly dried before dressing, because it promotes wound healing. Hydrocolloid dressing may result in contact dermatitis, so it is necessary to cover the skin near and under the areas of suction. Dressing the wound with hydrocolloid film 3 to 5 cm away from the wound ensures proper wound care.

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning? 1 Drying the periwound thoroughly before dressing 2 Covering the skin near the suction line with at hydrocolloid dressing 3 Applying adhesive remover at the affected site before the dressing 4 Dressing the wound with a hydrocolloid film 3 cm away from the wound

1 The nurse's observations of reddened tissue, drainage, and open areas between the staples are characteristic of infection. The reddened periwound tissue may also indicate inflammation, but the drainage and open areas do not. Impaired skin integrity related to limited mobility would be characterized by pressure ulcers and reactive hyperemia. Impaired physical mobility related to incisional pain would be indicated by the patient reporting pain, resisting assisted movement, and not moving in bed.

Upon assessing a patient's surgical incision on the left hip, the nurse observes reddened periwound tissue, foul drainage, and open areas between the staples. What is the likely nursing diagnosis? 1 Risk for infection 2 Risk for inflammation 3 Impaired skin integrity related to limited mobility 4 Impaired physical mobility related to incisional pain

1, 2, 5 Impairment of circulation with an elastic bandage can lead to edema or localized pooling, diminished or absent pulse and cyanosis or pallor of the skin of the extremity. Circulation impairment can cause numbness or tingling sensation but not increased tenderness. It may also result in coolness of the extremity, not increased temperature.

Upon evaluation of a patient with an elastic bandage on his or her arm, which observations indicate impaired circulation? Select all that apply. 1 Pooling 2 Reduced pulses 3 Increased tenderness 4 Increased temperature 5 Discoloration of the skin

3 Calcium alginate helps keep wounds moist and absorbs the excess drainage. Hydrogel is used when wound hydration is required, thus facilitating moist wound healing. Normal saline is a nonirritant topical agent used to clean the wound and periwound area to prevent infection from microorganisms. Debriding enzymes are used in the case of necrotic wounds.

Upon observation the nurse sees the leakage of serous fluid from a patient's ulcer dressing. Which type of topical agents should the nurse use in this situation? 1 Hydrogel 2 Normal saline 3 Calcium alginate 4 Debriding enzymes

1 A warm, moist application does not promote sweating, so it limits unnecessary fluid loss. A dry, not moist, application does not cause skin maceration. Dry, not moist, heat retains temperature longer, because evaporation does not occur. Dry heat carries less risk for burns skin than does moist heat.

What is the advantage of a moist application in wound healing? 1 Does not promote sweating 2 Does not cause skin maceration 3 Retains temperature longer 4 Less risk for burns to the skin than dry applications

3 Because the skin of older patients has reduced elasticity and is thinner, the nurse should protect the patient's skin from injury during dressing removal by pushing the skin away from the adhesive. Pulling the skin from the adhesive, pulling the adhesive from the skin, and pushing the adhesive away from the skin may tear the patient's skin.

What action will the nurse take while removing a dressing on an older adult patient? 1 Pull the skin from the adhesive 2 Pull the adhesive from the skin 3 Push the skin away from the adhesive 4 Push the adhesive away from the skin

4

What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing? 1 15-20 mL 2 20-25 mL 3 25-30 mL 4 30-35 mL

1 The nurse should recommend that the patient consume 1.25 to 1.5 g of protein per kilogram of body weight a day to support wound healing. The amounts of 2 to 3.5 g, 3.5 to 4.5 g, and 5.15 to 6.5 g are too much.

What amount of protein per kilogram of body weight a day should the nurse recommend a patient consume to support wound healing? 1 1.25 to 1.5 g 2 2 to 3.5 g 3 3.5 to 4.5 g 4 5.15 to 6.5 g

1 The amount of zinc recommended for wound healing is 15 to 30 mg. The amounts of 30 to 50 mg, 25 to 60 mg, and 50 to 70 mg are more than is necessary.

What amount of zinc is recommended for wound healing? 1 15-30 mg 2 30-50 mg 3 25-60 mg 4 50-70 mg

1, 3, 5 Hydrogel dressings are easy to remove, as they do not adhere to the wound. Hydrogel dressings also debride the necrotic tissue and provide a moist environment for the wound. Hydrogel dressings may not minimize skin trauma but do reduce pain. They also do not permit viewing of the wound.

What are the advantages of using hydrogel dressing? Select all that apply. 1 Allows for easy removal 2 Minimizes skin trauma 3 Debrides necrotic tissue 4 Permits viewing of wound 5 Provides a moist environment

1, 2 Black polyurethane foam heals the granulating wound by contraction, edema reduction, and fluid removal. White, polyvinyl alcohol (PVA) soft foam heals the wound by restricting the growth of the granulation tissue. The wound cannot be measured with black polyurethane foam. Solid skin barriers protect the periwound skin from pressure arising from the application of tapes; black polyurethane foam does not.

What are the functions of black polyurethane foam in wound healing? Select all that apply. 1 Contracts the wound 2 Absorbs fluids from the wound 3 Restricts the growth of granulation tissue 4 Helps to determine depth of the wound 5 Protects the periwound tissue from pressure

1, 3, 5 In the case of a wound caused by a surgical incision, healing occurs by epithelialization, the edges are clean and intact, and healing is quick with minimal scar formation. Wound contraction is present, not absent. Granulation tissue forms.

What are the implications for healing of a surgical incision? Select all that apply. 1 Heals by epithelialization 2 Lacks wound contraction 3 Clean and intact wound edges 4 Lacks granulation tissue formation 5 Heals quickly with minimal scar formation

2, 4, 5 The application of heat is helpful in promoting the movement of waste products and nutrients, improving blood flow to injured body parts, and aiding in the delivery of leukocytes to the wound site. Therapeutic application of cold reduces tissue oxygen needs and blood flow to injured body parts.

What are the therapeutic benefits of heat application? Select all that apply. 1 It decreases tissue oxygen needs. 2 It promotes the movement of waste products. 3 It reduces blood flow to injured body parts. 4 It improves blood flow to injured body parts. 5 It improves delivery of leukocytes to the wound site.

1, 2, 4 Bandages used over dressings may secure splints, reduce or prevent edema, and secure dressings. Bandages used over dressings help immobilize sprained joints, not facilitate movement, and they increase pressure instead of reducing it.

What are the therapeutic benefits of using bandages over dressings? Select all that apply. 1 Secures splints 2 Prevents edema in the lower legs 3 Facilitates mobility of sprained joints 4 Secures dressings 5 Reduces pressure

4 Sanguineous drainage indicates fresh bleeding and is bright red. Serosanguineous drainage is pink. Serous drainage is clear. Purulent drainage is thick and yellow.

What color is sanguineous drainage on a patient's dressing? 1 Pink 2 Clear 3 Yellow 4 Bright red

3 Clean gloves are required when applying an ace bandage if wound drainage is present to prevent contamination. Clips, bandages, and adhesive tapes may be necessary, but the wound drainage makes preventing contamination a concern, and these materials do not address that.

What equipment is required if wound drainage is present when applying an ace bandage? 1 Clips 2 Bandages 3 Clean gloves 4 Adhesive tape

4 The color of the wound tissue represents a balance between necrotic tissue and new scar tissue, which allows the health care team to determine which wound irrigation products will best promote new tissue growth. Assessing the size of the wound helps determine the volume of irrigant to be used. Assessing the amount of drainage determines progress in the healing of the wound. The condition of the dressing provides an initial assessment of present wound drainage.

What is assessed to determine which wound irrigation products will best promote new tissue growth? 1 Size of the wound 2 Amount of drainage 3 Condition of dressing 4 Color of wound tissue

2 In a stage III pressure ulcer, there is full-thickness skin loss. Slough may be present, but it does not obscure the depth of tissue loss. In a stage IV pressure ulcer, there is full-thickness tissue loss, exposing bone, tendon, or muscle. In a stage I pressure ulcer, there may be discoloration of the skin, warmth, edema, hardness, or pain. In a stage II pressure ulcer, partial-thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough.

What is characteristic of stage III pressure ulcers? 1 Underlying muscle is exposed 2 Slough may be present with slough, but it does not obscure the depth of tissue loss. 3 Discoloration of the skin, warmth, edema, hardness, and/or pain may be present. 4 It presents as a shallow, open ulcer with a red-pink wound bed without slough.

3 A 19-gauge angiocatheter provides ideal pressure for cleaning and removing debris from the wound. A 35-mL, not 25 mL, syringe is used for irrigation delivery system. The pressure settings on the irrigation delivery system should range from 8 to 15 psi; 18 psi is too high. Normal saline solution may be used, but other irrigation solutions are preferred.

What is required for a wound irrigation delivery system? 1 A 25-mL syringe 2 A capacity for pressure of 18 psi 3 A 19-gauge angiocatheter 4 A 2% normal saline solution

3 An elastic bandage would be applied over an arterial puncture site to create pressure. It is the purpose of the underlying dressing, not the bandage, to prevent infection. An elastic bandage is used for immobilization for a case of a sprain or fracture. An elastic bandage would be used for wound support on a wound much larger than an arterial puncture.

What is the rationale behind applying an elastic bandage over an arterial puncture site? 1 To prevent infection 2 To immobilize the body part 3 To create pressure 4 To support the wound

2 Cleaning the ulcer thoroughly by using a syringe with a cleaning agent helps to remove any wound debris. The dressings to the wound help reduce pain. Dressing the ulcer wound helps to maintain moist environment to the wound, thus healing the wound. When the nurse uses gloves, it helps to prevent the transmission of microorganisms.

What is the rationale behind cleaning the wound with normal saline using an irrigating syringe? 1 To reduce the pain 2 To remove wound debris 3 To provide a moist environment to the wound 4 To reduce the transmission of microorganisms

3 Vitamin A promotes epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. Protein quickens fibroplasia. Vitamin C acts as an antioxidant. Zinc encourages collagen formation.

What is the role of vitamin A in wound healing? 1 Quickens fibroplasia 2 Acts as an antioxidant 3 Promotes wound closure 4 Encourages collagen formation

1, 4 Before application of an abdominal binder, the nurse must assess the patient's ability for effective coughing and deep breathing. Checking skin integrity, circulation, and wound characteristics is a part of evaluation after the binder has been applied.

What must be assessed prior to the application of an abdominal binder? Select all that apply. 1 Effective coughing 2 Circulation 3 Skin integrity 4 Ability for deep breathing 5 Wound drainage

1 The nurse will determine the volume of the wound by measuring its length, width, and depth. The volume if the irrigant chosen is 1.2 to two times the estimated wound volume. The amount of drainage is assessed to measure progress in the healing of the wound. Drainage odor is assessed to identify the presence of infection. The color of the wound tissue is assessed to identify necrotic tissue and new scar tissue.

What must be assessed to decide the volume of irrigant necessary for cleaning the wound? 1 Size of the wound 2 Amount of drainage 3 Odor of the drainage 4 Color of the wound tissue

1000 The amount of vitamin C recommended for wound healing is 1000 mg/day in order to promote collagen synthesis, maintain capillary wall integrity, help fibroblast function, promote immunity, and provide antioxidant benefits.

What quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day

2, 4, 5 For an immobile patient whose skin is intact but is at high risk for impaired skin integrity, the nurse should plan to use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. The nurse should also use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. Avoiding should also be part of the nursing plan prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. The nurse should consider using either low-air-loss, alternating pressure, or air-fluidized support surface for patients who already have pressure ulcers. The nurse will also consider using a wheelchair cushion for a patient who has a sacral or coccyx pressure ulcer.

What should the nurse consider when developing a nursing plan for an immobile patient whose skin is intact but is at a high risk for impaired skin integrity? Select all that apply. 1 Consider either a low-air-loss, alternating pressure, or air-fluidized support surface. 2 Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. 3 Consider the use of a wheelchair cushion. 4 Use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. 5 Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx.

1 Involving the patient who has impaired skin integrity and his or her family in choosing interventions is part of the planning phase. Applying the standards of practice outlining the expected outcomes is part of the evaluation phase. Examining the patient's skin for impairment of skin integrity is part of the assessment phase. Asking the patient for his or her perception of skin integrity after the intervention is part of the evaluation phase.

What step is a component of the planning phase for a patient who has impaired skin integrity? 1 Involve the patient and family in choosing interventions. 2 Apply standards of practice outlining expected outcomes. 3 Examine the patient's skin for impairment of skin integrity. 4 Ask the patient for his or her perception of skin integrity after the intervention.

2 Bright red fluid indicative of active bleeding is considered sanguineous wound drainage. Clear, watery plasma is considered serous wound drainage. Thick and yellow, green, tan, or brown fluid is considered purulent wound drainage. A pale pink, watery mixture of clear and red fluid is considered serosanguineous wound drainage.

What type of wound drainage is considered sanguineous? 1 Clear, watery plasma 2 Bright red, active bleeding 3 Thick and yellow, green, tan, or brown 4 Pale pink, watery mixture of clear and red fluid

10 When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary if the patient has not had one within 10 years.

When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past _____ years. Record you answer using whole number.

4 The nurse should clean away from the wound to prevent contamination. Two separate swabs are to be used: one to clean from the top of the incision toward the draining site and another to clean from the bottom of the incision toward the draining site. Irrigation fluid should flow from the least to most contaminated area to prevent transmission of bacteria. Application of pressure while cleaning the wound should be avoided, but gentle friction may be applied while cleaning the traumatic wound with the noncytotoxic solution.

When cleaning a wound, which action is incorrect? 1 Using two separate swabs to clean the affected site 2 Irrigating from the least to most contaminated area 3 Applying noncytotoxic solutions using gentle friction 4 Cleaning from the surrounding skin to the site of incision

1 When putting an elastic bandage on a patient, the nurse applies additional rolls without leaving any skin surface uncovered to prevent the formation of wrinkles. Overlapping turns of one-half to two-thirds width of the bandage roll helps prevent uneven bandage tension and impairment of circulation. Performing hand hygiene aids in reducing transmission of microorganisms. Unrolling and slightly stretching the bandage helps maintain uniform bandage tension.

When putting an elastic bandage on a patient who has a wound, the nurse applies additional rolls of gauze covering the entire skin surface. What is the rationale behind this nursing action? 1 To prevent wrinkling 2 To prevent circulatory impairment 3 To reduce transmission of microbes 4 To maintain uniform bandage tension

4 The nurse should clip the suture material nearest to the skin edge on one side and pull from the other side. Sutures should be cut away from the knot and nearest to the skin edge, not the knot, as possible. Sutures should never be pulled through the visible part of the suture through the underlying tissue, because this can lead to infection.

Which action is involved in safely removing retention sutures? 1 Cut the suture at the end nearest to the knot. 2 Cut the suture as farthest to the skin edge as possible. 3 Pull the visible part of the suture above the skin through underlying tissue. 4 Clip suture materials nearest to the skin edge on one side, and pull from the other side.

1 It is correct to allow the solution to flow from the least to most contaminated area to prevent the spread of contamination. Low, not high, pressure is sufficient for flushing out exudate and debris. The wound should be irrigated with the syringe tip over the drainage site, not into it. Gentle, not rigorous, friction is better for applying solutions locally to the skin to maintain its integrity.

Which action taken during wound irrigation is correct? 1 Allowing the solution to flow from the least to most contaminated area 2 Applying high pressure to flush out exudate and debris 3 Applying the syringe tip into the drainage site 4 Using rigorous friction when applying solutions locally to the skin

3, 4 Whereas all patients diagnosed with pressure ulcers could potentially benefit from support hydration, nutritional support, and the evaluation of pressure-redistribution needs, only patients diagnosed with clean stage IV and unstageable pressure ulcers would need surgical consultation for closure (stage IV) or surgical consultation for debridement (unstageable). Support hydration, nutritional support, and evaluation of pressure-redistribution needs are interventions more appropriate for pressure ulcers in stages I-III.

Which adjuvant treatments are only considered for patients diagnosed with clean stage IV or unstageable pressure ulcers? Select all that apply. 1 Support hydration 2 Nutritional support 3 Surgical consultation for closure 4 Surgical consultation for debridement 5 Evaluation of pressure-redistribution needs

1, 3, 4 The benefits of using moist applications when treating wounds include softening the exudate, conforming well to most body areas, and penetrating deeply into the tissue layers. Decreased risk for burns and retaining temperature longer because evaporation does not occur are both benefits of using dry, not moist, applications.

Which advantages should the nurse include in a teaching session on the benefits of using moist applications for treating a wound? Select all that apply. 1 Softens wound exudate 2 Decreases the risk for burns 3 Conforms well to most body areas 4 Penetrates deeply into tissue layers 5 Retains temperature longer because evaporation does not occur

1, 2, 4 Binders over dressings secure splints, reduce edema, and create pressure over body parts. They also immobilize body parts, thus preventing freedom of movement. It is the role of the dressing underneath the binding to prevent infection, but the binding itself does not.

Which are benefits of using a binder over or around a dressing? Select all that apply. 1 Securing a splint 2 Reducing edema 3 Allowing the body part freedom to move 4 Creating pressure over the body part 5 Preventing infection

1, 2 Although binders and bandages over dressings have a number of therapeutic benefits, they do not necessarily promote circulation or prevent infection. They do, however, prevent edema, secure the dressings, and crease pressure.

Which are not benefits of binders and bandages over wound dressings? Select all that apply. 1 Promoting circulation 2 Preventing infection 3 Preventing edema 4 Securing the dressings 5 Creating pressure

3 Macrophages are called garbage cells because they ingest bacteria, dead cells, and debris from wounds. Neutrophils ingest bacteria and small debris. Erythrocytes are red blood cells. T-lymphocytes are cells that play an important role in immunity.

Which blood cells are known as garbage cells? 1 Neutrophils 2 Erythrocytes 3 Macrophages 4 T-lymphocytes

1 Figure-eight dressings are used to cover joints because they provide a snug fit and immobilization. Cylindrical body parts like the thighs, upper arms, and lower arms should be dressed in a spiral manner.

Which body parts should be dressed in a figure-eight manner? 1 Joints 2 Thighs 3 Lower arms 4 Upper arms

1, 3 Trauma and surgical incision can cause acute wounds. Pressure, vascular compromise, and repetitive insults to tissue can cause chronic, not acute, wounds.

Which can cause an acute wound? Select all that apply. 1 Trauma 2 Pressure 3 Surgical incision 4 Vascular compromise 5 Repetitive insults to tissue

4 Hydrogel covered with foam is appropriate for a pressure ulcer that requires protection and the absorption of moisture. A gauze dressing is often used for a clean stage II or IV ulcer. Adherent film dressings are appropriate for unstageable ulcers, and calcium alginate dressings are used when the ulcer is producing significant exudate.

Which dressing should the nurse use to protect and absorb moisture when providing care to a patient with a pressure ulcer? 1 Gauze 2 Adherent film 3 Calcium alginate 4 Hydrogel covered with foam

3 Montgomery ties are used for dressing pressure ulcer wounds in a patient. A linen bag is used while implementing negative-pressure wound therapy. The Braden Scale is used to assess the risk of pressure ulcers, but it may not be used while dressing the pressure ulcer wounds. A waterproof underpad is used while irrigating the wound.

Which equipment is used by the primary health care provider while applying moist dressing to a patient who has pressure ulcers? 1 Linen bag 2 Braden scale 3 Montgomery ties 4 Waterproof underpad

3 The nurse should use a 35-mL syringe with a 19-gauge soft angiocatheter when irrigating a surgical wound. The other syringes are not appropriate when irrigating a surgical wound. They are more appropriate for other irrigation procedures.

Which equipment should the nurse have available when irrigating a surgical wound? 1 A catheter tip 20-mL syringe 2 A catheter tip 60-mL syringe 3 A 35-mL syringe with a 19-gauge soft angiocatheter 4 A 20-mL syringe with a 17-gauge soft angiocatheter

3 Applying heat to an abscessed tooth may increase a patient's risk for infection due to the possibility of rupture, but it will not necessarily increase the risk for burns. Because very young patients have thin skin, they are at an increased risk for burns during heat therapy. Because areas of edema and peripheral vascular disease both cause a patient to have decreased sensory perception, patients with these conditions are also at an increased risk for burns during heat therapy.

Which factor does not put a patient at risk for burns during heat therapy? 1 Very young age 2 Areas of edema 3 Abscessed tooth 4 Peripheral vascular disease

3 Continuous exposure of the skin to body fluids may cause skin breakdown, thus causing pressure ulcers. Therefore, exposure of the skin to gastric secretions poses the highest risk for skin breakdown. This is mainly due to the digestive quality that is responsible for the skin irritation. Ascitic fluids, biliary secretions, and purulent wound exudates carry a moderate risk of skin breakdown.

Which fluids if exposed to the skin pose the highest risk for skin breakdown? 1 Ascitic fluids 2 Biliary secretions 3 Gastric secretions 4 Purulent wound exudates

4 The role of nursing assistive personnel (NAP) in providing care to a patient who has a chronic wound is to report changes in the skin integrity to the nurse immediately. The NAP should not clean the wound in case of any drainage, but should notify the nurse immediately. The NAP should not perform the sterile dressing, but can perform the nonsterile dressing for the chronic wound. The NAP should report to the nurse if the dressing of the wound is dislodged, but should not redress the wound.

Which intervention can be performed by nursing assistive personnel (NAP) while caring for a patient who has a chronic wound? 1 Cleaning the wound if there is any drainage 2 Performing sterile dressing of the wound 3 Redressing the wound if the dressing becomes dislodged 4 Reporting changes in the skin integrity to the registered nurse immediately

2 Irrigating the wound with a saline solution two times per day is an intervention that supports the wound care nursing intervention classification (NIC). Repositioning the patient every 90 minutes, avoiding the use of massage around the open area, and elevating the head of the patient's bed to no more than 30 degrees are interventions that are part of the pressure management NIC.

Which intervention is part of the nursing intervention classification (NIC) for wound care? 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Elevating the head of the patient's bed to no more than 30 degrees

1, 3, 5 Repositioning the patient every 90 minutes, avoiding the use of massage around the open area, and elevating the head of the bed to no more than 30 degrees are parts of the nursing intervention classification (NIC) of pressure management. Irrigating a wound with a saline solution and dressing the area twice a day are interventions that are parts of the NIC of wound care.

Which interventions are part of the nursing intervention classification (NIC) of pressure management? Select all that apply. 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Dressing the area two times per day per provider prescription 5 Elevating the head of the patient's bed to no more than 30 degrees

2, 3, 4 For a patient at risk for skin breakdown due to urinary incontinence, the nurse should reposition the patient off at-risk areas often, apply a moisture-barrier cream, and cleanse the perineal area with an on-rinse cleaner. Whereas providing adequate fluid intake and protecting pressure points from medical devices are appropriate interventions for a patient who is at risk for skin breakdown, these do not address the risk for skin breakdown due to urinary incontinence.

Which interventions should the nurse implement when providing care to a patient at risk for skin breakdown due to urinary incontinence? Select all that apply. 1 Provide adequate fluid intake 2 Reposition the patient off at-risk areas often 3 Apply a moisture-barrier ointment 4 Cleanse perineal area with no-rinse cleaner 5 Protect pressure points from medical devices

4 If a primary-intention wound has drainage for more than 3 days after closure, this is a sign of abnormal healing. Slough tissue in the wound base, a fruity, earthy, or putrid odor, and a dry or moist granulation tissue bed are signs of abnormal healing of a secondary-intention wound.

Which is characteristic of abnormal healing of a primary wound? 1 Slough tissue in the wound base 2 A fruity, earthy, or putrid odor 3 A dry or moist granulation tissue bed 4 Drainage for more than 3 days after closure

4 Gauze dressing supplies are required for wound irrigation. Clips, safety pins, and bandages are required for applying elastic bandages, but not for wound irrigation.

Which is required for wound irrigation? 1 Clips 2 Bandages 3 Safety pins 4 Gauze dressing supplies

1 The most effective intervention for compromised skin integrity and wound care is prevention of skin breakdown. Whereas administering medication, implementing wound care, and monitoring wound healing are all important nursing actions, prevention is the first step.

Which is the most effective intervention for compromised skin integrity? 1 Preventing breakdown 2 Administering medication 3 Implementing wound care 4 Monitoring wound healing

4 The application of light, not hard, traction is appropriate in order to minimize pulling of the skin. Loosening the ends, pulling the tape in the direction of hair growth, and using adhesive remover to loosen the tape are appropriate actions for removing tape from the patient's skin during wound care.

Which nursing action during removing tape from the patient's skin during wound care requires correction? 1 Loosening the ends 2 Pulling the tape in the direction of hair growth 3 Using adhesive remover to loosen the tape 4 Applying hard traction to the skin next to the wound

4 The nursing action that is appropriate for a patient who has intact skin but is at high risk for impaired skin integrity of the heels is to place a pillow under the calves to decrease the risk for heel breakdown. Avoiding prolonged elevation of the head of the bed is appropriate for a high-risk patient who already has a pressure ulcer. Ordering a standard hospital foam mattress is appropriate for a high-risk patient who is not at risk for impaired skin integrity. Considering an alternating pressure support surface is appropriate for a patient who is already diagnosed with an ulcer.

Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels? 1 Avoid prolonged elevation of the head of the bed 2 Order a standard hospital foam mattress 3 Consider an alternating pressure support surface 4 Place a pillow under the calves

4 The bandage should be reapplied at a different area with less pressure if the skin under the elastic bandage breaks. Assessing the pulse, palpating the extremity, and reapplying the bandage over the same area with less pressure are appropriate actions when the bandage has impaired circulation, not when it has broken the skin.

Which nursing action is appropriate when the skin under the elastic bandage breaks? 1 Assess the pulse 2 Palpate the extremity 3 Reapply the bandage on the same area with less pressure 4 Reapply the bandage at a different area with less pressure

2, 4, 5 Appropriate nursing actions for cleaning the area surrounding a drain site include cleaning from an isolated site to the surrounding skin, cleaning away from the wound when using sterile gauze, and allowing irrigating solution to flow from the least to the most contaminated area. The nurse should never reuse gauze to clean across the site. The nurse should use gentle, not hard, friction when applying solutions locally to the skin. Gentle friction should be used.

Which nursing actions are appropriate for cleaning the area surrounding a drain site? Select all that apply. 1 Reuse gauze to clean across the site 2 Clean from the drain site to the surrounding skin 3 Use hard friction when applying solutions locally to the skin 4 After applying a solution to sterile gauze, clean away from the wound 5 Allow irrigating solution to flow from the least to most contaminated area

1, 2, 3 Appropriate nursing actions when removing tape from the patient's skin during wound care include loosening the ends, pulling the tape in the direction of hair growth, and using adhesive remover to loosen the tape. The application of light, not hard, traction is appropriate for minimizing pulling of the skin. It is appropriate to gently pull the outer end parallel, not perpendicular, to the skin surface.

Which nursing actions are appropriate when removing tape from the patient's skin during wound care? Select all that apply. 1 Loosen the ends 2 Pull the tape in the direction of hair growth 3 Use adhesive remover to loosen the tape 4 Apply hard traction to the skin next to the wound 5 Gently pull the outer end perpendicular to the skin surface

2 Whereas all of these interventions are appropriate for a patient with impaired skin integrity, the intervention that is specific to a patient at risk for infection is obtaining a wound culture as needed. Applying a moisture barrier is appropriate when the patient's skin integrity is compromised due to limited mobility. Providing analgesics and using correct repositioning techniques are appropriate interventions for impaired physical mobility related to incisional pain.

Which nursing intervention is appropriate for a patient who is at risk for infection due to a surgical incision at the right hip? 1 Applying moisture barrier cream 2 Obtaining a wound culture as needed 3 Providing analgesics prior to wound care 4 Using correct repositioning techniques

4 Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one specific to a patient at risk for skin breakdown due to friction and sheer is to provide a trapeze to facilitate movement in the bed. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition.

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to friction and shear? 1 Keep the skin dry and free of maceration 2 Provide pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed

1 Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one specific to a patient at risk for skin breakdown due to moisture is to keep the skin dry and free of maceration. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear.

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to moisture? 1 Keep the skin dry and free of maceration 2 Provide a pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed

3 The nurse must notify the health care provider when a wound does not appear to be healing. Applying alginate dressings or more absorbent gauze or increased frequency of irrigation are interventions appropriate for an increase in wound drainage.

Which nursing intervention is appropriate for a wound that does not appear to be healing? 1 Applying alginate dressing 2 Applying more absorbent gauze 3 Notifying the health care provider 4 Increasing the frequency of irrigation

3, 4, 5

Which nursing interventions are appropriate for a patient who is at risk for pressure ulcer development due to impaired mobility or friction and shear? Select all that apply. 1 Assisting with meals 2 Applying a moisture barrier cream 3 Establishing a schedule for repositioning 4 Limiting head elevation to 30 degrees 5 Repositioning with a transfer board surface

1 The finer the sutures, the more minimal the tissue injury. Deep sutures are composed of an absorbable, not nonabsorbable, material that disappears over time. All sutures are foreign bodies, and so they can all cause local inflammation. Retention sutures are placed more deeply than skin sutures.

Which statement is true regarding sutures? 1 Fine sutures cause minimal tissue injury. 2 Deep sutures are composed of nonabsorbable material. 3 Continuous sutures are least likely to cause inflammation. 4 Retention sutures are placed more superficially than skin sutures.

3, 4, 5 When a patient reports of sensation under the dressing, then the nurse should immediately observe the wound for increased drainage. The nurse should also inform the primary health care provider immediately, because sensation under the wound is a serious complication. If the nurse observes protrusion of underlying organs, then the nurse should protect them by covering the wound with a sterile moist dressing. The nurse should not apply pressure on the wound in this condition, because sensation under the wound is a serious complication; pressure should be applied when the nurse observes bleeding in the wound while dressing. The nurse should instruct the patient to lie still and not move around, to manage the condition.

Which nursing interventions are appropriate when a patient complains of sensation under the dressing? Select all that apply. 1 Apply pressure over the wound 2 Instruct the patient to walk for some time 3 Observe the wound for increased drainage 4 Report to the primary health care provider immediately 5 Cover the wound with a sterile moist dressing if underlying organs protrude

1, 2, 4, 5 Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence, such as applying barrier creams for patients who are incontinent; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces, such as repositioning the patient every 2 hours and using a draw sheet during repositioning; and (3) education, such as information related to preventing skin breakdown. Conducting a nutritional assessment is important; however, this is a part of assessment and is not necessary every 8 hours.

Which nursing interventions minimize the risk for pressure ulcer development? Select all that apply. 1 Repositioning the patient every two hours 2 Using a draw sheet to assist with repositioning 3 Conducting a nutritional assessment every 8 hours 4 Applying barrier creams for patients who are incontinent 5 Providing education related to preventing skin breakdown

2 One role of vitamin A in healing is to promote wound closure. Protein promotes collagen formation and immunity, vitamin C promotes collagen synthesis and immunity, and zinc promotes collagen formation and protein synthesis.

Which nutrient supports healing by promoting wound closure? 1 Protein 2 Vitamin A 3 Vitamin C 4 Zinc

4 While the nurse will need to be aware of factors contributing to inflammation and infection, this is a separate assessment from that for the risk of pressure ulcer development. However, to assess a patient's risk for pressure ulcer development, the nurse must understand the pathogenesis of pressure ulcers, factors contributing to pressure ulcer formation, and factors contributing to wound healing.

Which piece of knowledge does a nurse not require for assessing a patient's risk for developing pressure ulcers? 1 Pathogenesis of pressure ulcers 2 Factors contributing to pressure ulcer formation 3 Factors contributing to wound healing 4 Factors contributing to inflammation and infection

3 Stage IV pressure ulcers are expected to heal through granulation and reepithelialization. Wound care for a stage I pressure ulcer is aimed at slow healing without epidermal loss over 7 to 14 days. Stage II pressure ulcers are expected to heal through reepithelialization. Wound care for an unstageable pressure ulcer includes debridement done to soften the eschar.

Which pressure ulcer is expected to heal through granulation and reepithelialization? 1 Stage I 2 Stage II 3 Stage IV 4 Unstageable

2 The ischium pressure ulcer site is just below the buttock on the upper thigh. The sole pressure ulcer site is found on the bottom of the foot. The sacrum pressure ulcer site is on the tailbone, or just above the gluteal area. The scapula pressure ulcer site is found on the shoulder blade.

Which pressure ulcer site is found immediately distal to the buttock? 1 Sole 2 Ischium 3 Sacrum 4 Scapula

3 Blanchable erythema is an early indication of pressure that resolves without tissue loss if the pressure is removed. Pallor or molting is a sign of persistent hypoxia. Dark red or purple discoloration may indicate potential damage to blood vessels and tissue. Nonblanchable erythema is a sign of a stage I pressure ulcer.

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? 1 Pallor or molting 2 Dark red or purple discoloration 3 Blanchable erythema 4 Nonblanchable erythema

4 A nonbacteriostatic saline solution is used to clean the wound before obtaining a culture because it won't kill the microorganisms; they must be present in order to determine the cause of infection. Povidone-iodine, hydrogen peroxide, and sodium hypochlorite solutions are cytotoxic, so culture results may be skewed.

Which solution is used to clean a wound before obtaining a culture? 1 Povidone-iodine 2 Hydrogen peroxide 3 Sodium hypochlorite 4 Nonbacteriostatic saline

3 Cold application decreases muscle tension and helps relieve pain. Heat, not cold, application causes vasodilation, reduced blood viscosity, and increased tissue metabolism due to increase in blood flow.

Which statement is true regarding cold application? 1 It causes vasodilation. 2 It reduces blood viscosity. 3 It decreases muscle tension. 4 It increases tissue metabolism

1 Hydrogel dressings are used for partial thickness and full thickness wounds, and enhance autolytic debridement. Some hydrogels require a secondary dressing; these dressings hydrate wounds and are used for painful wounds, as they do not adhere to the wound bed. Hydrogel dressings are used to relieve pain in the wounds. Hydrogel dressings are sheet dressings or gauze dressings impregnated with glycerin-based amorphous gel, but not saline solution.

Which statement is true regarding hydrogel dressings? 1 They enhance autolytic debridement. 2 They may not require secondary dressing. 3 They are not used to relieve pain in the wounds. 4 They are sheet dressings impregnated with saline solution.

3 The volume of the irrigant for cleaning the wound should be around 1.2 to two times the estimated volume of the wound. The volume of the syringe for sterile irrigation is 35 mL, not 20 mL. The gauge size of the angiocatheter used for sterile irrigation is 19, not 12. Choice of irrigation delivery system is based on the amount of pressure desired.

Which statement is true regarding irrigation equipment used for cleaning wounds? 1 Sterile irrigation involves a 20-mL syringe. 2 A 12-gauge sterile soft angiocatheter is used for sterile irrigation. 3 The volume of the irrigant should be higher than the volume of the wound. 4 The irrigation delivery system is chosen based on the volume of the irrigant.

2 The dermis and the inner layer of the skin provide tensile strength and mechanical support to the muscles, bones, and inner organs. The stratum corneum promotes, not prevents, absorption of topical medications. Fibroblasts, not the basal layer of the epidermis, are responsible for collagen formation. The skin has two layers only: the epidermis and the dermis.

Which statement regarding the skin is true? 1 The stratum corneum prevents entrance of topical medications. 2 The dermis and the inner layer of the skin provide tensile strength. 3 The basal layer of the epidermis is responsible for collagen formation. 4 The three layers of the skin are the epidermis, dermis, and endodermis.

2, 4, 5 The pulsatile high-pressure lavage can be used for necrotic wounds to clear necrotic tissue. The amount of the irrigating fluid to be used depends on the size of the wound. It can be used for a patient on anticoagulant therapy but with caution. The lavage should not be used when muscle is exposed because it may damage soft tissue. The pressure of the lavage should be between 8 and 15 psi, not 15 and 22, during irrigation.

Which statements are true regarding pulsatile high-pressure lavage? Select all that apply. 1 It can be used on the exposed muscle to clear debris. 2 It is used for necrotic wounds. 3 The pressure setting should between 15 and 22 psi during irrigation. 4 The size of the wound determines the amount of irrigation to be done. 5 It can be used for a patient who is on anticoagulant therapy.

3 A lateral rotation support surface is useful in treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss and nonpowered support surfaces help in preventing and treating skin breakdown. An air-fluidized bed support surface prevents skin breakdown and may also be used to protect newly flapped or grafted surgical sites.

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? 1 Low-air-loss surface 2 Nonpoweredsurface 3 Lateral rotation surface 4 Air-fluidized bed

1 The task of applying an elastic bandage can be delegated to nursing assistive personnel (NAP). The task of performing wound irrigation cannot be delegated to NAP, because it requires a sterile technique for wound care. The task of implementing negative-pressure wound therapy cannot be delegated to NAP. NAP are not allowed to assess patients for the risk of pressure ulcers; only health care providers can perform this assessment.

Which task can be delegated to nursing assistive personnel (NAP) in caring for a patient who has pressure ulcers? 1 Applying an elastic bandage 2 Performing wound irrigation 3 Implementing negative-pressure wound therapy 4 Assessing the patient for the risk of additional pressure ulcers

1, 3 Topical solutions for cleansing a clean and granulating wound should be noncytotoxic agents such as water and normal saline; these prevent the damage or the killing of the fibroblasts and the healing tissues. Acetic acid, hydrogen peroxide, and sodium hypochlorite are cytotoxic agents; these can be used for cleaning highly colonized wounds.

Which topical solutions can be used to clean a granulating wound? Select all that apply. 1 Water 2 Acetic acid 3 Normal saline 4 Hydrogen peroxide 5 Sodium hypochlorite

1 Hydrogel dressings hydrate the wounds and provide a moist environment. Therefore, these dressings are preferred for dry wounds. Hydrocolloid dressings help in the healing of clean granulating wounds and autolytically debride necrotic wounds. Calcium alginate dressings should not be used in dry wounds, because they require secondary dressing. Debriding enzymes should be applied only over the necrotic areas of the wounds; they are not used specifically for dry wounds

Which type of dressing is preferred for dry wounds? 1 Hydrogel 2 Hydrocolloid 3 Calcium alginate 4 Debriding enzymes

1 Hydrogel dressings hydrate the wounds and provide a moist environment. Therefore, these dressings are preferred for dry wounds. Hydrocolloid dressings help in the healing of clean granulating wounds and autolytically debride necrotic wounds. Calcium alginate dressings should not be used in dry wounds, because they require secondary dressing. Debriding enzymes should be applied only over the necrotic areas of the wounds; they are not used specifically for dry wounds.

Which type of dressing is preferred for dry wounds? 1 Hydrogel 2 Hydrocolloid 3 Calcium alginate 4 Debriding enzymes

1 The palm is a body extremity. Elastic net should be used for dressing extremities; it should be placed over the gauze dressing of the palmer surface to secure the dressing. Precut gauze is used when the wound drains. A topper dressing helps prevent strike-through of the wound drainage. Hydrocolloid gauze provides a moist environment for the wound to heal.

Which type of gauze should be used for dressing a wound on the palm? 1 Elastic net 2 Precut gauze 3 Topper dressing 4 Hydrocolloid gauze

1 A stage I pressure ulcer is an intact ulcer that can be dressed with a transparent or hydrocolloid dressing. Composite film, hydrocolloid, and hydrogel dressings are appropriate for stage II pressure ulcers. Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings are appropriate for stage III pressure ulcers. Hydrogel covered with foam, calcium alginate, and gauze dressings are appropriate for stage IV pressure ulcers.

Which type of ulcer can be dressed with a transparent or hydrocolloid dressing? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

4

Which type of wound drainage is shown in the image? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

4 Black tissue is characteristic of an eschar. Because the eschar obscures the depth of the wound, this ulcer is unstageable. Stage I ulcers manifest as localized nonblanchable redness over intact skin. Stage II ulcers are characterized by partial-thickness dermis loss. Stage III ulcers are characterized by full-thickness skin loss to the extent that subcutaneous fat may be visible.

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

1 The Braden Scale provides a baseline for comparing increased or decreased risk for development of pressure ulcers that helps plan for patient interventions. The lower the Braden Scale score, the worse the prognosis of the disease. The patient is considered to be at a very high risk for developing pressure ulcers if the score is 9 or below; therefore, the patient with a score of 8 would be at a very high risk for pressure ulcer development. If the score is 10 to 12, then the patient is at high risk for developing pressure ulcers. If the score is 13 to 14, then the patient is at moderate risk for developing pressure ulcers. A score of 15 to 18 indicates risk of the general population when it comes to developing pressure ulcers.

While assessing a patient with the Braden Scale, the nurse suspects that the patient is at very high risk of pressure ulcer development. What might be the patient's score? 1. 8 2. 10 3. 13 4. 17

4 The nurse may assess the patient for periwound edema and pain by palpating the affected area for tenderness. An abrasion is a small superficial wound with little damage to the capillaries. Swelling, bluish discoloration, sensation, and warmth are signs of a hematoma. Evisceration is an emergency condition in which visceral organs protrude out through the wound opening. Abrasion, hematoma, and evisceration can be observed with visual inspection; palpation is not necessary.

While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. What is the rationale behind this nursing action? 1 To assess for the risk of abrasion 2 To assess for the risk of hematoma 3 To assess for the risk of evisceration 4 To assess for the risk of periwound edema

2 Debriding enzymes should not be applied to the surrounding skin or periwound area, because they cause burning sensations and paresthesia around the wound. The foam should be applied only after packing the wound with alginate, because it holds the alginate against the wound surface. However, foam may not induce a burning sensation in the wound area. Dry gauze should be applied directly over the wound, because it covers the wound base and maintains hydrogel wound interface. Debriding enzyme ointments should be applied as a thin layer only to the necrotic area of ulcer, because a thin layer acts more effectively than a thick layer.

While caring for a patient who had hip replacement surgery and developed pressure ulcers, the nurse applies debriding enzymes on the ulcer region. After few hours, the patient complains of burning sensation in the wound area. Which nursing action is responsible for the patient's condition? 1 The nurse applied foam directly over the ulcer. 2 The nurse applied ointment to the surrounding skin. 3 The nurse applied gauze dressing directly over the ulcer. 4 The nurse applied a thin ointment layer over the necrotic area of ulcer.

2, 3, 5 Maceration is a serious complication. Therefore, the nurse should report the condition to the health care provider immediately. When the ulcer becomes macerated, the nurse should consider the use of a liquid skin barrier on the periwound skin to reduce the macerated wound. The exposure of surrounding skin to topical agents and moisture should be reduced to decrease further complication. Wound cultures should be obtained in serious conditions, such as when there are deeper ulcers with foul-smelling drainage or when there is severe pain at the wound site. The nurse should consult with the primary health care provider about a change in the analgesic when the ulcer becomes deeper, with increased drainage that causes severe pain. However, in this condition, this intervention would not be beneficial to the patient.

While caring for a patient who has pressure ulcers, the nurse finds that the skin surrounding the ulcer has become macerated. Which nursing intervention would be most appropriate to manage the patient's condition? Select all that apply. 1 Obtaining necessary wound cultures 2 Reporting to the primary health care provider 3 Applying liquid skin barrier on the periwound skin 4 Changing the analgesic used for curing the wound 5 Reducing the exposure of wound to topical agents

4, 5 A chronic wound may require several dressings to heal completely. In such dressings, the removal of tape may cause the skin to stretch and may also induce tension, which leads to skin damage and, thus, pressure ulcers. Solid skin barriers protect the skin from increasing the tension of the adhesive tape. Montgomery ties are used for repeated dressing changes. Elastic net and rolled gauze aid in supporting the dressings, but do not prevent pressure ulcer development. Topper dressing is a thicker dressing that prevents strike-through of wound drainage and provides a surface to tape the dressing in place; it does not prevent ulcer development.

While changing the wet-to-dry dressing, the nurse notes a dime-sized ulcer under the adhesive tape. What should be applied to secure the wound? Select all that apply. 1 Elastic net 2 Rolled gauze 3 Topper dressing 4 Solid skin barrier 5 Montgomery ties

1 Pressure ulcers develop when drainage tubing and other medical devices are placed over a patient's bony areas, the risk sites for pressure ulcers; therefore, this patient developed pressure ulcers, because the drainage tubes of the NPWT unit were placed over the elbow. The transparent film over a wound dressing should be removed by stretching it horizontally to prevent skin breakdown. Raising the tubing connectors above the NPWT unit provides for drainage of the fluid into the tubes. The nurse should place the NPWT system in "de-vac" for 30 to 60 minutes before changing the dressing; this helps to loosen the foam dressing and provides for easy removal of the dressing.

While treating a patient with negative-pressure wound therapy (NWPT) for radiation-damaged skin on the forearm, the nurse observes pressure ulcers on the elbow. Which nursing action is responsible for the patient's condition? 1 The nurse placed the tubing over the elbow. 2 The nurse removed the transparent film by stretching it horizontally. 3 The nurse raised the tubing connectors above the level of the NWPT unit. 4 The nurse kept the system in "de vac" mode for 30 minutes before changing the dressing.

1 Holding the syringe tip 2.5 cm above the wound prevents syringe contamination in a wound with a wide opening. Using a 35-mL syringe provides proper flushing of the wound. Using a 19-gauge angiocatheter allows the direct flow of irrigant fluid into the wound. Inserting the tip of the catheter into a wound with a small opening and pulling it out about 1 cm keeps the tip from touching the fragile inner walls.

Why will a nurse hold a syringe tip 2.5 cm above a wound with a wide opening during irrigation? 1 To prevent syringe contamination 2 To provide proper flushing of the wound 3 To permit direct flow of the irrigant into the wound 4 To prevent the tip from touching the wound's fragile inner walls