PPNC Exam 1 Module 2

C

5 days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports that the client is experiencing wound dehiscence? a. increased bowel sounds b. loosening of intact sutures c. sudden increase in serosanguineous drainage d. purplish color of the incision

D

How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? a. red b. black c. green d. yellow

C

What is the term for removal of devitalized tissue in a wound when appropriate for the patient's condition and consistent with the patient's goals? a. Irrigation b. Sterile technique c. Debridement d. Exudate

D

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma b. Place a pouching system over the ostomy c. Add 1/16-1/8 ring bigger than stoma d. Drain and measure the output from the ostomy. e. Check the skin around the stoma for breakdown

d

a client has a large, open abdominal wound. The HCP prescription states to cleanse the wound w/ NS, pack it w/ damp gauze, cover w/ abdominal pads, and secure with Montgomery strap 2x/day. Which steps would the nurse take to maintain sterility when changing a dressing? a. use 2 square gauze pads to cleanse the wound, one for each half of the wound b. apply new Mont. staps e/ time dressing is changes c. hold wet gauze with the tips of forceps higher than waist d. cleanse the wound with wet, sterile gauze from the center of the wound outward

A, B

a client is hospitalized with pressur einjuries. Which task(s) could be delegated to UAP? SATA. a. empty wound drainage containers b. report changes in wound appearance c. apply prescribed dressings and medication d. assess and record date about wound appearance e. choose dressings and therapies for wound treatment

Type (serous, purulent, serosanguinous); Amount (scant, moderate, large, excessive); color; odor (wafting) (TACO)

assessing exudate

3-5 ; meals; 1/3; 1/8; 1/16

change the ostomy bandage every ____-____ days and before ______. Empty the bag when ____ full. Cut wafer to ____ to _____ larger than stoma

sigmoid colostomy

formed stool, possible irrigation

24 hours to 5 day

how long would you use a VAC for?

inside out; least most

irrigate from the ______ _____ and move from the ______ to ______ infected to prevent contamination of parts of the wound that do not have as high of a bacteria count

ileostomy

liquid/semi-liquid almost non-stop; need to replace FE; 3 L electrolyte replacement a day

transverse

semi-formed, squishy to thick liquid to soft stool

ascending colostomy

semiliquid stool; hasn't been in long enough to become formed; wafer/appliance and bag used

hemostasis, inflammatory, proliferation, maturation

stages of wound healing

D

the nurse is caring for a client after surgical creation of an ostomy. The nurse observes the stool is formed. The stool is this consistency in which part of the colon? a. ileum b. ascending c. transverse d. descending

reduce edema, remove excess fluid and drainage, promote wound healing (draws wound edges together)

what are the objectives of VAC/negative pressure devices?

18 gauge; 35

what gauge angiocatheter do you want to use for irrigating a wound and a _______-mL syringe and fill it with irrigation solution

time and location

what would you label on a culture tube for a wound culture?

A, B, E

when teaching a client with a new colostomy about appliance care an maintenance, which information would the nurse include? SATA. a. change the ostomy pouch on a routine basis b. replace the ostomy wafer weekly or sooner if needed c. remove the ostomy pouch when showering d. empty the pouch when it is 3/4 full e. empty the pouch before exercise and bedtime

D

which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces a large amount of gas? a. milk b. cheese c. coffee d. cabbage

C

which information would the nurse consider when planning care for the postoperative clinet who has a newly constructed conduit diversion (ileal conduit) a. peristalsis of the small intestine segment assists with urine flow b. stool conitnuously oozes from the newly created ileal conduit c. ileal diversion conduits may provide urinary continence d. absorption of nutrients diminishes within the small intestines

D

which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma? a. cut an opening about 1/3 inch larger than the stomal pattern b. avoid use of soap and irritating agents c. eat yogurt and drink buttermilk d. empty the pouch before it is 1/3 full

A, E

which statement describes negative pressure wound therapy? SATA a. a suction pump is used b. necrotizing infections are treated c. oxygen is administered under high pressure d. a low-voltage current is applied to a wound area e. chronic ulcers are reduced by removing fluids from the wound