quiz 2

Alginates

are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue.

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

hydrocolloid dressings

alginates, antimicrobials, and composites

work with heavy drainage and infected wounds

Hydrogels

work with wounds that have minimal exudate

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? a) Administer analgesics 30 minutes prior to the treatment to act on pain receptors. b) Use an aquathermia pad during the treatment to create heat and circulate the water. c) Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. d) Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a) Clean the wound from the bottom to the top, and outside to center. b) Clean the wound from the top to the bottom, and center to outside. c) Once the wound is cleaned, dry the area with an absorbent cloth. d) Use clean technique to clean the wound.

Clean the wound from the top to the bottom, and center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom, and from the center to the outside. Dry the area with a gauze sponge in the same manner and apply ointment and dressing

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Pick the crusts off the sutures with the forceps before removing them. b) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c) Do not attempt to remove the sutures because they need more time to heal. d) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing sutures

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

Decubitus ulcer

Which is not a protective function of the skin? a) Sebum gives the skin an acidic pH, which retards the growth of microorganisms. b) It contains cells such as macrophages that protect it. c) Microorganisms that inhibit the growth of pathogens are present on the skin. d) Keratin protects against the sun's ultraviolet rays.

Keratin protects against the sun's ultraviolet rays

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Recognize that this is ischemia, followed by reactive hyperemia. Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? a) Assure that the packing material is completely saturated when placed in the wound. b) Use less packing material. c) Reduce the time interval between dressing changes. d) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead

Reduce the time interval between dressing changes. Explanation: Reducing the time interval between the dressing changes allows for the dressing change to occur without causing pain and promoting secondary intention. If the dressing becomes dry, the more pain the client experiences and damage to the newly formed epithelial and granulating tissue. The packing material should be completely saturated when placed in the wound. Using less packing material impairs secondary intention. A hydrocolloid dressing is not indicated.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? a) Dermis b) Subcutaneous tissue c) Epidermis d) Muscle layer

Subcutaneous tissue

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a) The nurse packs the wound cavity tightly with dressing material. b) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. c) The nurse uses wet-to-dry dressings continuously. d) The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? a) Transparent b) Bandage c) Hydrocolloid d) Gauze

Transparent

A client's risk for the development of a pressure ulcer is most likely due to which lab result? a) albumin 2.5 mg/dL b) hemoglobin A1C 7% c) glucose 110 mg/dL d) sodium 135 mEq/L

albumin 2.5 mg/dL Explanation: An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure ulcer. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure ulcers due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure ulcers. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure ulcer

Hydrogels

are used with dry wounds or wounds with minimal drainage.

Hydrocolloids

are used with light to moderate drainage in wounds with necrosis or slough.

Transparent dressings

are used with wounds having minimal drainage, small size, and partial thickness.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? a) stimulating the wound bed to promote the growth of granulation tissue b) removing excess drainage and wet tissue to prevent maceration of surrounding skin c) removing dead or infected tissue to promote wound healing d) removing purulent drainage from the wound bed in order to accurately assess it

removing dead or infected tissue to promote wound healing

Hydrocolloids

would be used with light to moderate drainage and no infection

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply

• Clean the wound from top to bottom. • Use a sterile applicator to apply any ointment that is ordered. • Use a new gauze for each wipe of the wound. • Avoid touching the wound bed, whether with gloves or forceps.

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? a) a client who lifts himself up on his elbows b) a client sitting in a chair who slides down c) a client who lies on wrinkled sheets d) a client who must remain on his back for long periods of time

a client sitting in a chair who slides down