Chapter 29

The nurse is repositioning her patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the HOB should be placed at: a. flat. b. 90 degrees. c. 30 degrees. d. 45 degrees.

ANS: C When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

The nurse knows that mechanical debridement involves all of the following except: a. wet to dry dressings. b. whirlpool baths. c. damp to dry dressing. d. enzymatic dressing.

ANS: D Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

The nurse knows that a hydrocolloid dressing is appropriate for the following type of wound: a. A wound with a large amount of drainage b. A wound that is tunneling c. A postsurgical incision with staples d. A wound with a moderate amount of drainage

ANS: D Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when she walks into the room. In addition to notifying the physician, what should the nurse do? a. Cover the wound with a sterile gauze pad. b. Cover the wound with a transparent dressing. c. Put pressure on the wound with a sterile gauze pad. d. Cover the wound with gauze soaked with normal saline.

ANS: D If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the physician immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.

The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if: a. the nurse asks the UAP to assess the wound. b. the nurse asks the UAP to report increased wound drainage. c. the nurse asks the UAP to observe changes in dietary intake. d. the nurse asks the UAP to change the dressing.

ANS: A Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

The nurse knows the following wound would be classified as a closed wound: a. A large bruise on the side of the face b. A surgical incision that is sutured closed c. A puncture wound that is healing d. An abrasion on the leg

ANS: A In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin's surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.) a. A patient who has diabetes b. A patient with COPD on long-term steroid therapy c. A patient with on bed rest who is repositioned d. A patient who is obese and sweats excessively

ANS: A, B, C, D Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal antiinflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.) a. Activity b. Friction and shear c. Moisture d. Sensory perception e. Cognition

ANS: A, B, C, D The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

The nurse knows that the cause of pressure ulcers includes the following factors: (Select all that apply.) a. Intensity of the pressure b. Duration of the pressure c. The tissue's ability to tolerate the pressure d. The person's age

ANS: A, B, C, D The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue's ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

The nurse is performing a focused wound assessment on a patient. The following should be included in the documentation: (Select all that apply.) a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment d. Patient's pain level e. Presence of drainage

ANS: A, B, C, E A focused wound assessment includes an evaluation of the wound's location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient's response to the wound or wound treatment. The patient's pain level would be documented with his/her pain assessment.

The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.) a. Edema b. Shivering c. Bleeding d. Circulatory issues

ANS: A, B, D Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy.

The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is: a. the wound will be completely healed in 72 hours. b. the wound will show signs of healing within 2 weeks. c. the patient will develop no new pressure ulcers. d. the patient will ambulate twice a day.

ANS: B A stage III pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? a. "The wound will be red." b. "The wound will have pus." c. "The wound will be warm." d. "The wound will need to be treated."

ANS: B An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105 per gram of tissue sampled when cultured. The wound will need to be treated for the infection.

The nurse knows a stage III pressure ulcer is: a. a pressure ulcer that involves exposure of bone and connective tissue. b. a pressure ulcer that does not extend through the fascia. c. a pressure ulcer that does not include tunneling. d. a partial-thick wound that involves the epidermis.

ANS: B Stage III pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage IV pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage II pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is: a. the patient will remain free of wound infections during the hospitalization. b. the patient will report pain management strategies and reduce pain to a tolerable level. c. the patient will turn self in bed using over trapeze every two hours using assistance when needed. d. the patient will consume adequate nutrition to meet nutritional requirements within 1 week.

ANS: B The patient will report pain management strategies to reduce pain to a tolerable level is an appropriate goal for Impaired physical mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for Impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for Acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Imbalanced nutrition: less than body requirement.

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions should the nurse perform? (Select all that apply.) a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. d. Secure the device to the patient's gown above the level of the wound. e. Check for kinks in the tubing.

ANS: B, C, E Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient's hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What should the nurse do first? a. Notify the physician. b. Notify the wound care nurse. c. Stop the procedure. d. Give the patient pain medication.

ANS: C If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient's response.

The nurse is explaining to the student nurse the purpose of occlusive dressings. Which statement by the student nurse indicates a lack of understanding? a. "Occlusive dressings are used for autolytic debridement." b. "Hydrocolloids are a type of occlusive dressing." c. "Occlusive dressings can be used on infected wounds." d. "Occlusive dressings support the most comfortable form of debridement."

ANS: C Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in infected wounds. It is the most comfortable form of debridement for the patient.

The nurse understands the rationale for drying a wound after irrigation is: a. to ensure the new dressing adheres to the wound. b. to ensure the new dressing remains occlusive. c. to prevent skin breakdown from moisture. d. to prevent infection from irrigate solution.

ANS: C Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether or not it is occlusive. The drying does not prevent infection.

The nurse is caring for a patient with a Penrose drain. She knows the patient will require the following care: a. The drain must be compressed after emptying to work properly. b. The drain must be connected to suction if ordered. c. The drain is not sutured in place so care is taken to not dislodge it. d. The suction pulls drainage away from the wound as it re-expands.

ANS: C The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

The nurse knows the layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect is: a. stratum germinativum. b. epidermis. c. subcutaneous layer. d. stratum corneum.

ANS: C The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

The nurse is educating the patient about the use of heat/cold therapy at home. The following statement by the patient indicates the need for further education? a. "I should fill my ice bag 2/3 full of ice." b. "I should use distilled water in my Aqua-K pad." c. "I can warm up my hot pack in the microwave." d. "I should check the order for how long to leave the compress on."

ANS: C Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically designed for this type of heating. Ice bags are filled two thirds full, distilled water is used in Aqua-K pads, and application time for heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a "popping sensation" and a wetness in her dressing. The nurse immediately suspects: a. a wound infection. b. the stitches came loose. c. wound dehiscence. d. wound crepitus.

ANS: C Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

The nurse knows to irrigate a deep wound with: a. A 5-mL syringe. b. A 10-mL syringe. c. A 3-mL syringe. d. A 30-mL syringe.

ANS: D A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi (Rodeheaver and Ratcliff, 2007).

The nurse knows the following types of wounds heal by tertiary intention: a. An acute wound in which the patient has sutures placed when it happened b. A pressure ulcer that was treated with dressing changes and healed c. An acute wound in which surgical glue was used to close the wound d. A wound that was left open initially and closed later with sutures

ANS: D When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.