Chapter 38

C

In what type of wound is a foam dressing contraindicated? a. Shallow stage II ulcer b. Exudative stage II ulcer c. Wound that has tunneling d. Wound that is infected

B

Moist-to-dry dressings consist of gauze moistened with an appropriate solution. What should the nurse do when caring for a patient who has a pressure wound that requires debridement? a. Saturate the primary dressing with saline or lactated Ringer's solution. b. Moisten the primary dressing with saline or lactated Ringer's solution. c. Moisten the primary dressing with acetic acid. d. Moisten the primary dressing with povidone-iodine.

C, D

Negative-pressure wound therapy (NPWT) would be contraindicated in which of the following? (Select all that apply.) a. Dehisced wounds b. Pressure ulcers c. Malignancies d. Necrotic tissue with eschar

ACD

Physiologically, wound healing occurs in the same way for all patients, with some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes which of the following cells? (Select all that apply.) a. Liver cells b. Skin cells c. Renal tubules d. Central nervous system neurons

ABC

You are explaining negative-pressure wound therapy (NPWT) to a patient. Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.) a. NPWT optimizes blood flow. b. NPWT will remove wound fluid. c. NPWT will maintain a moist environment. d. NPWT will apply positive pressure to the wound.

ABCD

You are explaining wound healing to your patient. You are trying to explain the healing process in a full-thickness wound. Which of the following phases should you include in your explanation? (Select all that apply.) a. Hemostasis b. Inflammation c. Proliferation d. Maturation

Secondary

_____________ dressings cover or hold primary dressings in place.

A,B,C,D

Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.) a. Maintains a moist environment b. Prevents the spread of microorganisms c. Increases patient comfort d. Controls bleeding

A

For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond? a. Culture the wound. b. Leave the current dressing in place. c. Apply gauze over the top of the dressing. d. Remove and stretch the film more tightly over the wound.

A

For absorption of heavy exudate from a wound, a nurse selects which of the following dressings? a. Alginates b. Hydrogel c. Hydrocolloid d. Transparent film

D

Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond? a. Initiate intravenous (IV) therapy. b. Order blood for transfusions. c. Remove and reapply any dressings. d. Monitor vital signs every 15 minutes.

D

The nurse answers the patient's call light to find the patient agitated and stating that she "felt something pop." The nurse finds that the patient's abdominal surgical wound has eviscerated. What should the nurse do? a. Try to reinsert the abdominal contents. b. Cover the wound with a dry sterile dressing. c. Notify the surgeon when he makes rounds. d. Cover the wound with a moist saline dressing.

C

The nurse is caring for a patient who had a negative-pressure wound dressing. The nurse realizes that the system is working properly when the vacuum setting is set at which of the following levels? a. -40 mm Hg b. -210 mm Hg c. -125 mm Hg d. -25 mm Hg

B

The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed? a. Change the dressing so she can assess the wound. b. Administer an analgesic 30 to 45 minutes before a dressing change. c. Culture the wound if wound exudate is present. d. Administer an analgesic 30 minutes after a dressing change.

B

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing. Which of the following can be appropriately delegated to the nurse assistant? a. Performing a sterile dressing change b. Observing for any drainage on the dressing c. Performing wound assessment during the dressing change d. Notifying the physician of drainage present on the dressing

C

The nurse is changing a dry, woven gauze dressing when she notices that the gauze has inadvertently stuck to the wound. What should the nurse do? a. Pull the dressing off to aid in debridement. b. Recover the dressing and leave in place. c. Moisten the gauze to minimize trauma. d. Ensure that the shiny side of the dry gauze dressing does not stick.

Primary

A __________ dressing comes in direct contact with the wound bed.

Transparent dressing

A _______________ is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters.

ABCD

How does the skin defend the body? (Select all that apply.) a. Skin serves as a sensory organ for pain. b. Skin serves as a sensory organ for touch. c. Skin serves as a sensory organ for temperature. d. Skin has an acid pH.

A

How should the nurse proceed when applying a pressure bandage? a. Elevate the extremity or area of bleeding. b. Wrap pressure-bandage gauze in a proximal-to-distal direction. c. Apply pressure to diminish the pulse to the distal body part. d. Wrap tape around the circumference of the site to secure the gauze padding.

A,B,C

Hydrocolloid dressings are used for which of the following? (Select all that apply.) a. Maintaining a moist wound environment b. Autolytic debriding of necrotic wounds c. Absorption of moderately draining wounds d. Protecting from friction

A, B

In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.) a. Remove the binder and assess the skin and wound every 8 hours. b. Evaluate the patient's ability to breathe deeply and cough effectively every 4 hours. c. Evaluate the patient's pulmonary function every 8 hours. d. Remove the binder at least daily.

D

The nurse is caring for a patient who has a negative-pressure dressing. The nurse realizes that typically the dressing should be changed: a. every shift. b. daily. c. every 8 hours. d. every 48 hours.

C

The nurse is caring for a patient who has a wound healing by primary intention that has little to no drainage. Which dressing is most appropriate for this type of wound? a. Moist-to-dry dressing b. Hydrocolloid dressing c. Dry dressing d. Hydrogel dressing

B, D

The nurse is caring for a patient who has had major abdominal surgery. She is concerned about the possibility of dehiscence. During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply.) a. Age b. Malnutrition/obesity c. Gender d. Use of steroids

A

The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _____ dressing. a. pressure b. alginate c. foam d. hydrocolloid

C

The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system? a. Decreases the amount of angiogenesis b. Reduces mechanical stretch of tissue c. Dressing should not need to be changed for 48 hours d. Helps create a dry environment

B

What is an appropriate technique for the nurse to implement for drainage evacuation? a. Replace the Hemovac drain fully expanded. b. Attach the drainage tubing to the patient's gown. c. Tilt the evacuator of the Hemovac away from the plug. d. Complete the dressing change before the drainage evacuation.

C

What should the nurse anticipate might happen to a patient if bleeding cannot be controlled? a. Skin dryness b. Bradycardia c. Hypovolemic shock d. Hypertension

D

What should the nurse do for a patient who is having a wet-to-dry dressing applied? a. Moisten the old inner dressing to remove it. b. Pack the gauze in flat pieces into the wound. c. Wet the new inner dressing with a cytotoxic solution. d. Apply a secondary dressing over the inner wet packing.

C

What should the nurse do for a patient with a sudden severe hemorrhage? a. Go for help. b. Drape the patient. c. Apply direct pressure. d. Put on clean or sterile gloves.

A

When teaching about wound care in the home environment, the nurse instructs the patient and caregiver to: a. make normal saline with 8 teaspoons of salt and .1 gallon of distilled water. b. use normal saline for 1 week and then discard it. c. not apply topical anesthetics before wound care. d. call the physician's office to have someone come to the home and complete the wound care.

D

Which of the following approaches is correct technique when wound irrigation is performed? a. Placing the patient in supine position b. Placing the syringe directly into the wound c. Using sterile technique for a chronic wound d. Selecting a soft catheter for deep wounds with small openings

A,C,D

Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.) a. Burns b. Surgical incisions c. Infected wounds d. Deep pressure ulcers

B

Which of the following is an appropriate procedure for the nurse to implement during the application of an absorption or alginate dressing? a. Never cut the dressing to fit the wound. b. Irrigate the wound gently to remove residual gel. c. Fill the wound cavity entirely with the dressing material. d. Never use a secondary dressing.

B

Which of the following tasks might be delegated to nursing assistive personnel (NAP)? a. Pressure dressing to an actively bleeding wound b. Chronic wound that needs a nonsterile moist-to-dry dressing change c. Hydrogel dressing change d. Wound assessment during the dressing change

B

Which situation noticed during evaluation would determine that the staples or sutures should remain in place? a. The wound edges are separated. b. No drainage or erythema is present. c. The patient is anxious about their removal. d. A cosmetically aesthetic result would not be achieved.

ABCD

Wounds that have been approved for treatment using NPWT include which of the following? (Select all that apply.) a. Pressure ulcers b. Diabetic ulcers c. Traumatic wounds d. Venous stasis ulcers

C

You are irrigating a wound and are trying to make sure you get the wound adequately cleansed. Which of the following should you avoid? a. Inserting the tip of a soft catheter into a deep wound b. Using a 19-gauge angiocatheter c. Pushing the tip inside a deep wound that has a small opening d. Using a large syringe

Primary

___________ healing takes place when tissue is cleanly cut and the margins are reapproximated.

Moist to dry

_______________ dressings are used for wounds that require debridement

C

The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed? a. Apply a film dressing after culturing the wound. b. Apply a film dressing after cleansing the area. c. Choose another type of dressing for this wound. d. Keep the wound open to air.

C

The nurse is changing a surgical dressing and is cleansing the wound. She knows that: a. the incision line should be cleansed last. b. she should start at one end of the incision line and swab the entire length. c. she should start at the center of the incision line and swab toward one end. d. she should work in a circular motion around the incision line.

A,B,D

The nurse is demonstrating a dressing change to a nursing student. What key safety features should she emphasize during the process? (Select all that apply.) a. Knowing the type of wound b. Knowing the expected amount of drainage c. Knowing the patient's blood type d. Knowing whether drainage tubes are present

B

The nurse is educating a patient about his role in wound healing. Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level? a. Age b. Smoking c. Underlying cardiopulmonary conditions d. Hemoglobin

D

The nurse is explaining wound healing to a patient. Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound? a. A reduction in the size of the wound is noted. b. The epithelial cells duplicate. c. Synthesis of collagen occurs at the site. d. Blood flow to the wound and arrival of white blood cells are increased.

C

The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock. How should the nurse proceed? a. Use irrigation pressures of less than 4 psi. b. Cleanse in a direction from most contaminated to least contaminated. c. Irrigate so that the solution flows from least contaminated to most contaminated. d. Irrigate with clean irrigation solution only.

B

The nurse is preparing to apply a gauze bandage to a dressing on the patient's wrist. How should the nurse proceed? a. Use a 3-inch bandage. b. Use a 2-inch bandage. c. Apply from the elbow toward the wrist. d. Secure the bandage with a safety pin.

B

The nurse prepares to irrigate the patient's wound. What is the primary reason for this procedure? a. Decrease scar formation. b. Remove debris from the wound. c. Improve circulation from the wound. d. Decrease irritation from wound drainage.

A

The nurse would consider a dry dressing appropriate for a wound that requires which of the following? a. Protection b. Debridement c. Absorption of heavy exudate d. Healing by second intention

D

The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by: a. filling two thirds of the wound cavity. b. leaving saline-soaked folded gauze squares in place. c. putting the dressing in very tightly. d. extending only to the upper edge of the wound.

C

The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon? a. Pull the pipe out in the direction of entry. b. Push the pipe through to the other side, then out. c. Leave the pipe in place. d. None of the above.

C

The physician reports that he is expecting that the patient's wound will have an output of close to 500 mL per day. The nurse anticipates placement of which of the following? a. Dry sterile dressing b. Jackson-Pratt (JP) drain c. Hemovac drain d. No drain

D

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying? a. Place a safety pin on the part of the drain outside the body. b. Replace the cap immediately after emptying. c. Pin the drainage tubing to the patient's gown. d. Place the Hemovac on a flat surface.

D

What should the nurse do when performing suture or staple removal? a. Snip both ends of the sutures. b. Apply tension to the suture line to remove the sutures. c. Pull the exposed surface of the suture through the tissue below the epidermis. d. Apply Steri-Strips if any separation greater than the width of two stitches is present.

C

What should the nurse do when removing intermittent sutures? a. Snip both sides of the suture before removing. b. Snip the suture as close to the knot as possible. c. Snip the suture as close to the skin as possible. d. Pull up the knot to apply as much tension as possible.

C

What should the nurse remember to do when applying a hydrocolloid dressing? a. Apply granules after applying the wafer. b. Never use a secondary dressing. c. Hold the dressing in place. d. Use silk tape to hold the dressing in place.

A

When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as: a. an expected occurrence. b. a wound infection requiring a culture. c. an adverse reaction to the hydrocolloid components. d. excessive exudate requiring a different type of dressing.

D

When is healing by primary intention expected? a. When the wound is left open and is allowed to heal b. When a surgical wound is left open for 3 to 5 days c. When connective tissue development is evident d. When the edges of a clean incision remain close together

D

When should a nurse consider culturing a wound? a. When the tissue is clean and dry b. When exudate is not present c. When the patient is afebrile d. When the surrounding area shows inflammation

NPWT

_______________ is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.