Sim Lab - Wound Care

A primary care provider orders the application of a warm, sterile compress to reduce edema in a client's wound. Which step is recommended for this procedure? A) Apply pressure to the compress to mold it around the wound site. B) Cover the site with three layers of gauze and with a clean dry bath towel. C) Place a heating device directly on the dressing. D) Keep the dressing in place for the prescribed amount of time or up to 30 minutes.

D After the prescribed time for the treatment (up to 30 minutes), the external heating device should be removed. The compress should be applied by gently and carefully molding it around the wound site. The site should be covered with one layer of gauze, and the heating device should be placed over a towel covering the dressing.

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it. A) 5, 2, 7, 1, 3, 4, 6 B) 5, 7, 2, 1, 3, 4, 6 C) 5, 1, 2, 7, 3, 4, 6 D) 5, 3, 4, 7, 2, 1, 6

A The expected outcome to achieve when putting on and removing sterile gloves is that the gloves are applied and removed without contamination. The nurse performs this procedure using the steps in the order listed.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? A) Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. B) Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. C) Rotate the swab several times over the wound surface to obtain an adequate specimen. D) Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

C The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action? A) Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. B) Stop the sitz bath, call for help, and help the client to the toilet to sit down. C) Stop the sitz bath and help the client ambulate back to the client room. D) Call a code blue because the client may be experiencing a myocardial infarction.

B If the client complains of feeling light-headed or dizzy during a sitz bath: Stop the sitz bath. Do not attempt to ambulate the client alone. Use call light to summon help. Let the client sit on the toilet until feeling subsides or help has arrived to assist the client back to bed. This does not necessarily warrant a code blue unless the nurse suspects an acute onset of a serious health problem.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? A) The use of gloves eliminates the need for hand hygiene. B) The use of hand hygiene eliminates the need for gloves. C) Hand hygiene is needed after contact with objects near the client. D) Hand lotions should not be used after hand hygiene.

C Hand hygiene must be performed when moving from a contaminated body site to a clean body site during client care and after contact with inanimate objects near the client. Using gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still be used after hand hygiene. Lotions may be used to prevent irritation.

A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field? A) Finish the procedure and perform handwashing immediately afterward. B) Finish the procedure, remove damaged glove, and open new sterile gloves. C) Stop the procedure, remove damaged glove, and open new sterile gloves. D) Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.

D If a hole or tear is noticed in one of the gloves during the procedure, stop the procedure, remove damaged gloves, wash hands or perform hand hygiene (depending on whether soiled or not), and put on new sterile gloves.

A nurse has finished giving care to a client who has a communicable respiratory infection. In which order should the personal protective equipment (PPE) be removed? 1. Gloves 2. Respirator 3. Gown 4. Goggles A) 1, 4, 3, 2 B) 4, 2, 3, 1 C) 1, 2, 4, 3 D) 4, 2, 1, 3

A The order for removal of PPE is gloves, goggles, gown, and respirator.

A nurse has finished providing care for a client who is on Contact Precautions. When removing the protective gown, the nurse should do which action? A) Avoid touching the outer surfaces of the gown. B) Remove the gown before removing gloves. C) Remove the gown immediately after exiting the room. D) Perform hand hygiene before removing the gown.

A When removing a gown, it is important to touch only the inside of the gown. The gown should be removed inside the room and after removing gloves. Hand hygiene should be performed after removal.

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice? A) It is appropriate to use clean technique during this procedure. B) The nurse must diligently apply the principles of asepsis. C) Sterility must be maintained throughout the procedure. D) The nurse should apply chlorhexidine or an alternative disinfectant to the wound bed.

A Chronic wounds and pressure injuries may be treated using clean technique; aseptic technique is not always necessary. Disinfectants are not normally applied to wound beds, except in exceptional circumstances.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? A) Moisten the sutures with sterile gauze, with saline to loosen any crusts. B) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. C) Carefully pick the crusts off the sutures with the forceps before removing them. D) Do not attempt to remove the sutures because the wound needs more time to heal.

A 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 the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

A nurse applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply. A) Apply a bath blanket over the aquathermia pad. B) Use tap water, filling it to the fill mark. C) Leave aquathermia pad in place for as long as the client wants it. D) Assess skin and pain level at baseline and ongoing. E) Check the water level in the aquathermia unit periodically.

A, D, E The nurse would apply a bath blanket over the aquathermia pad to protect skin from direct contact with the heat source. Distilled water is used to the fill mark in the unit. Tap water should not be used because it leads to mineral deposits, making the machine not function properly. The heat therapy is prescribed for a certain time, usually up to 30 minutes, and then it needs to be removed for the prescribed time to prevent the development of rebound phenomenon, when excessive heat leads to tissue congestion and vasoconstriction. Leaving heat therapy in place too long also can lead to skin burns and tissue damage. The nurse would assess skin and pain level at baseline and ongoing throughout the therapy before and after application of the treatment. The aquathermia unit provides moist heat, so the nurse would check the unit to ensure that the water level is at the correct level so the matching works properly. If the water drops below its required level, permanent damage may occur.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. What action violates these principles? A) The nurse performs hand hygiene after touching the client's surroundings. B) The nurse removes her gown and then removes her gloves. C) The nurse performs hand hygiene before putting on gloves. D) The nurse applies nonmedicated hand cream after performing hand hygiene.

B Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.

For which client would the application of a hydrocolloid dressing be most appropriate? A) A client with a sunburn affecting his back and torso B) A client who has a partial-thickness venous ulcer with moderate drainage C) A client whose surgical incision dehisced and became infected D) A client who has just undergone a cholecystectomy (gall bladder removal)

B Hydrocolloids are occlusive or semiocclusive dressings that limit exchange of oxygen between wound and environment; they are appropriate for partial- and full-thickness wounds with light to moderate drainage. A sunburn would not normally warrant this type of wound dressing and they are not used on infected wounds. Hydrocolloid dressings are not used on uncomplicated surgical incisions.

A nurse has put on personal protective equipment (PPE) to perform the dressing change of a client's surgical wound. While the nurse is cleansing the incision, the client begins bleeding and blood hits the nurse's wrist, running down under the cuff of her glove. What is the nurse's best action? A) Perform thorough hand hygiene immediately after completing the dressing change. B) Rinse the infected hand with hydrogen peroxide after applying a sterile bandage to the client's wound. C) Interrupt the dressing change to perform thorough handwashing, and document the exposure according to protocol. D) Remove the contaminated gloves and apply a clean pair of gloves.

C If the nurse is accidentally exposed to blood, it is necessary to stop the task and immediately follow facility protocol for exposure, including reporting the exposure. It would be unsafe to proceed with the dressing change before addressing the exposure. Applying new gloves does not eliminate the exposure.

The nurse is caring for a client who has two Jackson--Pratt drains following her bilateral mastectomy. When emptying a Jackson--Pratt drain, the nurse should prioritize what action? A) Don sterile gloves before manipulating the cap of the drain. B) Cleanse the area around the cap with alcohol for 30 seconds before removing it. C) Pin the drain to the client's gown after pulling the tubing taut. D) Recompress the drain before replacing the cap.

C Recompressing the drain after replacing the cap would force air and exudate into the client, causing pain and posing an infection risk. Gloves are necessary for this procedure, but they do not need to be sterile. It is unnecessary to cleanse the area around the cap with alcohol. It is important that the tubing should not be under tension.

For which client would the use of Standard Precautions alone be appropriate? A) A client with diphtheria who needs assistance with hygiene B) A client with tuberculosis who needs medications administered C) An incontinent client in a nursing home who has diarrhea D) A child with chicken pox who is treated in the ER

C Standard Precautions apply to blood and all body fluids, secretions, and excretions, except sweat. Transmission-Based Precautions are used in addition to Standard Precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes.

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product? A) The dressing allows for absorption of drainage. B) The dressing provides a sterile wound environment. C) The dressing allows oxygen exchange between the wound and environment. D) The dressing may safely be left in place for up to 10 days.

C Transparent films allow for oxygen exchange between the wound and the environment. They do not absorb any drainage and they are normally left in place for up to 72 hours. Sterility is not conferred simply by the application of a wound dressing.

A nurse's gloves became soiled while providing morning care for a client. Which action best demonstrates that the nurse applied principles of infection control? A) Use the nondominant hand to grasp the opposite glove near the cuffed end on the outside exposed area. B) Remove the glove on the nondominant hand by pulling it straight off, keeping the contaminated area on the outside. C) After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. D) After removing the first glove, slide the fingers of the ungloved hand between the remaining glove and the wrist and pull the glove straight off with the contaminated area on the outside.

C When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist and the glove is pulled off and inverted.

A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong-sized catheter to the bedside. What is the nurse's best action? A) Place a sterile drape over the client's penis, obtain the right catheter, and proceed with insertion. B) Teach the client the importance of not touching his penis or the sterile field and obtain the correct catheter. C) Dismantle the sterile field, obtain a new dressing tray and the correct catheter, and then begin the procedure from the beginning. D) Illuminate the client's call light and have a colleague bring the correct catheter to the bedside.

D If you realize a supply is missing after setting up the sterile field, you should call for help. Leaving the sterile field unattended renders it contaminated.

The health care provider orders for the T-Tube to be clamped for 1 hour before and after meals. The client suddenly develops right upper quadrant pain, and nausea. Which priority action should the nurse provide? A) Obtain vital signs. B) Report findings to the surgeon. C) Assess for signs of obstructed bile flow. D) Unclamp the T-Tube.

D The health care provider orders for the T-Tube to be clamped before and after meals to determine if the bile duct is no longer obstructed, then the client will not have any symptoms of obstructed bile flow. Clamping the tube allows the client to be able to receive necessary bile to help in the digestion of fats in the diet. The priority action is to unclamp the T-Tube since the client is exhibiting signs of obstructed bile flow, which include nausea, vomiting, right upper quadrant pain, and feeling of fullness in the right upper quadrant. After performing the priority action, the nurse would obtain vital signs to detect fever and tachycardia, which may occur with bile obstruction. The nurse may assess for additional signs of obstructed bile flow, which include jaundice, best assessed by examining the sclera of the eye for yellowing, and dark foamy urine and clay-colored stools. The nurse would report the findings to the surgeon.