Ch. 11 test bank

Nonadherent dressings will not...

Absorb wound drainage or Debride wounds

Transparent Film Dressings are used for

Clean wounds or approximated surgical incisions

Dry dressings will not...

Debride necrotic areas

A full-thickness wound filled with eschar will require interventions such as...

Surgical Debridement to remove the necrotic tissue

Stage II pressure ulcer

Partial-thickness skin loss

Stage I pressure Ulcer

Intact skin with some observable damage such as redness or a boggy feel

A patients temperature has been 101 for several days. The patients normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100 in the body temperature, how many total calories should the patient receive each day?

2140 calories

A patient who has an infected abdominal wound develops a temperature of 104. All the following interventions are included in the patients plan of care. In which order should the nurse perform the following actions? A. Administer IV antibiotics B. Sponge patient with cool water C. Perform wet-to-dry dressing change D. Administer acetaminophen

A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nruse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the infection or fever and should be done last.

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? A. Administered prescribed PRN hydro codons 30 min before the change B. Pour sterile saline onto the new dry dressings after th wound has been packed.

A. Administer prescribed PRN hydrocodone 30 min before Mechanical Debridement with wet-to-dry dressings is painful, and patients should receive pain med before the dressing change begins.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? A. Low serum albumin level B. Serosanguineous drainage C. Deep red and moist wound bed D. Cobblestone appearance of wound

A. Low serum albumin level With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? A. Change the patients bedding frequently B. Apply a hydrocolloid dressing over the ulcer C. Change the patients position every 1 to 2 hours D. Record the size and appearance of the ulcer weekly

C. Change the patients position every 1-2 hours The most important intervention is is to avoid prolonged pressure on bony prominences by frequent repositioning.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F. The patient reports having no discomfort. Which action by the nurse is appropriate? A. Apply a cooling blanket B. Notify the health care provider C. Check the patient's temperature again in 4 hours. D. Give acetaminophen prescribed PRN for pain

C. Check the patient's temp again in 4 hours Mild to moderate temperature elevations (<103) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort.

Leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow green semiliquid material. Which dressing should the nurse apply to the wound? A. Dry gauze dressing B. Nonadherent dressing C. Hydrocolloid dressing D. Transparent film dressing

C. Hydrocolloid Dressing The wound requires Debridement of the necrotic reads and absorption of the yellow-green slough. A dry hydrocolloid dressing such as DuoDERM would accomplish these goals.

The patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? A. Skin flushing B. Muscle cramps C. Rising body temp D. Decreasing blood pressure

C. Rising body temp The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV

C. Stage III A stage III pressure ulcer has full thickness damage and extends into the subcutaneous tissue.

The nurse should plan to use a wet-to-dry dressing for which patient? A. A patient who has pressure ulcer with pink granulation tissue. B. A patient who has a surgical incision with pink, approximated edges C. A patient who has full thickness burn filled with dry, black material D. A patient who has a wound with purulent drainage and dry brown areas

D. A patient who has a wound with purulent drainage with dry brown areas Wet-to-dry dressings are used when there is minimal eschar to be removed Wet-to-dry dressings are not used on uninflected granulating wounds because of the damage to the granulation tissue Wet-to-dry dressings are not needed on approximated surgical incisions

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? A. Monitor WBC counts B. Check the skin for areas of redness C. Measure the temperature every 2 hours D. Ask about feelings of fatigue or malaise

D. Ask about feelings of fatigue or malaise The earliest manifestation of an infection may be "just not feeling well". Common clinical manifestations of inflammation and infection re frequently not present when patients receive immunosuppressive medications

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? A. Eschar B. Slough C. Maceration D. Undermining

D. Undermining Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrow "lip" around the wound, which widens as the wound deepens.

Slough and Maceration refer to ....

Loosening friable tissue

Crusted cover over a wound is called?

Eschar

Stage IV pressure ulcers

Full thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissue

The patient with an open leg lesion has a white blood cell count of 13,500 and a band count of 11%. What prescribed action should the nurse take first? A. Obtain cultures of the wound B. Begin antibiotic administration C. Continue to monitor the wound for drainage D. Redress the wound with wet-to-dry dressings

A. Obtain cultures of the wound The increase in WBC count with the increaed bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the owund, but additional actions are needed as well.