Foundations Test #2 Chapter 32*

The following laboratory criteria indicate that a patient is nutritionally at risk for development of a pressure injury:

Albumin level <3.2 mg/dL (normal, 3.4 to 5.4 g/dL) Prealbumin <15 mg/dL (normal 19 to 38 mg/dL) Total lymphocyte count <1,000/mm3 (normal, 1,500 to 4,000/mm3) Hemoglobin A1c >6.5% (normal <6%) Glucose >126 mg/dL (fasting normal <110 mg/dL)

What diseases can contribute to bad circulation and prevent effective wound healing?

Vascular disorder, cardiac disorder, hypertension, diabetes mellitus

The nurse notes an unexpected decrease in drainage in a patients T drain tube. What action should the nurse take? a. assess for any kinks in the tube b. increase suction c. document the notice d. change dressing

a

Would heat or cold be applied to direct trauma, chronic pain, spasms, and sprains

cold

What medications decrease the process of healing?

corticosteriods, chemo, prolonged antibiotics

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

d

How often should negative pressure therapy be changed in a patient with and infected and a patient with a noninfected wound

infected should be changed every 12-24hr noninfected should be changed every 48-72 hr

What conditions are at most risk for dehiscence and evisceration of a wound?

obese malnourished smoke tobacco anticoagulants infected wound coughing/vomitting/straining

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: Stage 1 Stage 2 Stage 3 Stage 4

stage 2

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a b c d

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least 1 in beyond the end of the new dressing if one is being applied. f. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a b e

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.

a c e

New tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. What is this phase of healing? a. inflammatory b. proliferation c. hemostasis c. maturation

b

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? a. "Dehiscence is not anything that you need to worry about." b. "Dehiscence is when a wound has partial or total separation of the wound layers." c. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." d. "Dehiscence is the softening of tissue due to excessive moisture."

b

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? a. transparent film b. hydrocolloid c. hydrogel d. alginate

b

What type of dressing would be applied to Wounds that are small; partial thickness, stage 1 and allow o2 exchange? a. hydrocolloid b. transparent c. hydrogels

b

Wounds healed by ___________intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated. a. primary b. secondary c. tertiary

b

a patients wound is healing due to the approximate edge made by the surgeon. this is an example of what type of wound healing? a. tertiary b. primary c. secondary

b

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. a. The patient takes time to think about responses to questions. b. The patient is 86 years old. c. The patient reports inability to control urine. d. The patient is scheduled for a hip arthroplasty. e. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.

b c d f

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development? a. Hemoglobin A1C 5% b. Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) c. Albumin 2.8 mg/dL (28.0 g/L) d. White blood cell count 14,800 mm3 (14.8 x 109/L)

c

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? a. Infection of the wound b. Herniation of the wound c. Dehiscence of the wound d. Evisceration of the viscera

c

After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. What is this phase of healing? a. inflammatory b. proliferation c. hemostasis c. maturation

c

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? a. primary intention b. secondary intention c. tertiary intention d. quadratic intention

c - Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. Notify the health care provider of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c. Place the patient in the low Fowler's position

c b a