SKILLS - Ch. 41 - Dressings/Bandages...

Which of the following are necessary to prepare the patient for changing the dressing on an open abdominal wound? (Select all that apply) A. Assessing size, location, and condition of wound. B. Explaining procedure to the patient C. Reviewing all blood results D. Asking patient to rate his or her pain level E. Assessing patient for allergies

A. Assessing size, location, and condition of wound. B. Explaining procedure to the patient D. Asking patient to rate his or her pain level E. Assessing patient for allergies Assessing pain level serves as baseline to measure response to dressing therapy. Assessing size, location, and condition of wound helps to plan for proper dressing type and supplies needed. Patient's with allergies may have allergic reaction to these supplies; explaining procedure to patient helps promote cooperations and decreases anxiety.

Normal wound healing requires a physiological wound environment that includes which of the following? (Select all that apply) A. Control of bacterial burden B. Adequate moisture C. Temperature control D. Tissue eschar

A. Control of bacterial burden B. Adequate moisture C. Temperature control The key principles of a physiological wound environment include adequate moisture, control of temperature, pH, and bacterial burden to promote healing. Eschar or necrotic tissue forms in deep infected wounds.

A patient with a large surgical wound that is healing by secondary intention has an order for the wound to be packed with gauze that has been moistened in saline. Which of the following steps in packing a wound is incorrect? A. Pack the wound gently. B. Cover moist gauze packing with dry sterile gauze. C. Avoid placing gauze into the sinus tract or an undermined area of the wound. D. In the case of a deep wound, wear sterile gloves.

C. Avoid placing gauze into the sinus tract or an undermined area of the wound. It is important to be sure that any dead space from sinus tracts, undermining, or tunneling is loosely packed with gauze. Loose packing facilitates wicking of drainage. A dry cover gauze pulls moisture from the wound. It is necessary to wear sterile gloves when packing a deep wound.

A patient was originally in the intensive care unit and has been moved out to the general surgery unit. The patient is obese and has an 8-inch abdominal incision. The nurse makes rounds and begins to check the patient's dressing when the patient tells the nurse, "I think I felt something just give way in my belly." The nurse removes the gauze dressing over the incision and sees that the wound has Serosanguineous drainage. What should be her next step? A. Notify the patient's health care provider. B. Check the patient's blood pressure and heart rate. C. Cover the wound with gauze moistened in sterile saline. D. Instruct the patient to lie on the right side.

C. Cover the wound with gauze moistened in sterile saline. The first step is to cover the wound with gauze moistened in saline to protect the wound. The nurse should then have the patient lie still without turning. It is important to monitor vital signs and notify the health care provider.

END OF CHAPTER QUESTIONS

END OF CHAPTER QUESTIONS

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2. Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.) a. Burns b. Surgical incisions c. Infected wounds d. Deep pressure ulcers

a. Burns c. Infected wounds d. Deep pressure ulcers Healing by secondary intention occurs when a wound is left open. Healing results in the formation of granulation tissue from the bottom of the wound and eventual epithelialization from the sides of the wound to close the defect. During the process of epithelialization, epithelial cells migrate and proliferate from the wound edges to cover the wound surface. Burns, infected wounds, and deep pressure ulcers heal in this manner.

8. How should the nurse proceed when applying a pressure bandage? a. Elevate the extremity or area of bleeding. b. Wrap pressure-bandage gauze in a proximal-to-distal direction. c. Apply pressure to diminish the pulse to the distal body part. d. Wrap tape around the circumference of the site to secure the gauze padding.

a. Elevate the extremity or area of bleeding. As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity.

5. The nurse is demonstrating a dressing change to a nursing student. What key safety features should be emphasized during the process? (Select all that apply.) a. Knowing the type of wound b. Knowing the expected amount of drainage c. Knowing the patient's blood type d. Knowing whether drainage tubes are present

a. Knowing the type of wound b. Knowing the expected amount of drainage d. Knowing whether drainage tubes are present It is important to: Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing. Knowing the patient's blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done.

3. Hydrocolloid dressings are used for which of the following? (Select all that apply.) a. Maintaining a moist wound environment b. Autolytic debriding of necrotic wounds c. Absorption of moderately draining wounds d. Protecting from friction

a. Maintaining a moist wound environment b. Autolytic debriding of necrotic wounds c. Absorption of moderately draining wounds Hydrocolloid dressings comprise elastomeric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction.

1. Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.) a. Maintains a moist environment. b. Prevents the spread of microorganisms. c. Increases patient comfort. d. Controls bleeding.

a. Maintains a moist environment. b. Prevents the spread of microorganisms. c. Increases patient comfort. d. Controls bleeding. Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding.

15. When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as: a. an expected occurrence. b. a wound infection requiring a culture. c. an adverse reaction to the hydrocolloid components. d. excessive exudate requiring a different type of dressing.

a. an expected occurrence. Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odor. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound.

1. The nurse is caring for a patient who is bleeding. To control bleeding, apply a _____ dressing. a. pressure b. alginate c. foam d. hydrocolloid

a. pressure Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate.

6. What should the nurse do for a patient with a sudden severe hemorrhage? a. Go for help. b. Drape the patient. c. Apply direct pressure. d. Put on clean or sterile gloves.

c. Apply direct pressure. Apply direct pressure immediately. Seek assistance after pressure is applied. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities.

10. The patient is being sent home from the hospital after a cardiac catheterization. What should the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site? a. Call the physician. b. Call 9-1-1. c. Apply pressure to the site. d. Apply a new bandage.

c. Apply pressure to the site. Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site.

16. What should the nurse remember to do when applying a hydrocolloid dressing? a. Apply granules after applying the wafer. b. Never use a secondary dressing. c. Hold the dressing in place. d. Use silk tape to hold the dressing in place.

c. Hold the dressing in place. Hold the dressing in place for 30 to 60 seconds after application. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case of a deep wound, hydrocolloid granules or paste is applied before the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic, paper tape around the edges of the hydrocolloid dressing.

7. What should the nurse anticipate might happen to a patient if bleeding cannot be controlled? a. Skin dryness b. Bradycardia c. Hypovolemic shock d. Hypertension

c. Hypovolemic shock Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shock. Hypertension is an increase in blood pressure.

11. The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon? a. Pull the pipe out in the direction of entry. b. Push the pipe through to the other side, then out. c. Leave the pipe in place. d. Apply direct pressure to the insertion site of the pipe.

c. Leave the pipe in place. If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures. Do not push or apply direct pressure to the insertion site, as this may cause more damage to internal organs.

14. In what type of wound is a foam dressing contraindicated? a. Shallow stage II ulcer b. Exudative stage II ulcer c. Wound that has tunneling d. Wound that is infected

c. Wound that has tunneling Foam dressings are not appropriate when there is wound tunneling because the dressing expands, which can enlarge the tunnels. International pressure ulcer guidelines recommend foam for use on exudative stage II and shallow stage II pressure ulcers. Foam dressings are also used to dress infected wounds.

A patient developed a 2-cm stage 1 pressure ulcer over the sacrum. A transparent dressing has been in place for 2 days. The nurse on the evening shift notices that the skin under the dressing appears broken. The patient complains of tenderness when the nurse palpates the skin. The nurse also notices drainage under the transparent film. What action should the nurse take in this situation? A. Remove the dressing and obtain an order for a wound culture. B. Record observations and keep the dressing in place. C. Increase the frequency of changing the transparent dressing. D. Consider irrigating the wound.

A. Remove the dressing and obtain an order for a wound culture. The wound is inflamed and shows signs of infection. Removal of the dressing is necessary. A wound culture will determine the type of bacteria growing in the wound. It would also be appropriate to consider using a different type of dressing. Irrigation is likely not necessary.

Match the following wound drainage with the appropriate definition: Serous. A. Yellow, green, or brown drainage Serosanguineous. B. Indicates fresh bleeding, bright red Sanguineous. C. Pale, red, more watery draingage Purulent. D. Clear, watery plasma

Serous. D. Clear, watery plasma Serosanguineous. C. Pale, red, more watery draingage Sanguineous. B. Indicates fresh bleeding, bright red Purulent. A. Yellow, green, or brown drainage

A patient underwent a cardiac catheterization in the area of the right groin and has been taken to the recovery room. The patient has a history of being on warfarin. The RN assigned to the patient identifies bright red blood oozing from the patient's groin area. Place in order the steps the nurse should take to correctly apply a pressure bandage. 1. Seek assistance from a second nurse. 2. Apply manual pressure to the groin area immediately. 3. Identify the source of bleeding. 4. Second nurse unwraps a roller bandage and prepares lengths of adhesive tape as first nurse applies pressure. 5. Place adhesive strips 7 to 10 cm beyond width of gauze dressing with even pressure on both sides of the second nurse's fingers close to central bleeding source. 6. Rapidly cover bleeding area with multiple thicknesses of gauze compresses. A. 1, 2, 3, 4, 6, 5 B. 2, 1, 3, 4, 6, 5 C. 4, 1, 2, 3, 5, 6 D. 3, 2, 1, 4, 5, 6

B. 2, 1, 3, 4, 6, 5 The nurse, knowing that the patient has had a cardiac catheterization, applies pressure quickly to the groin area, the site of the arterial puncture. She then seeks assistance from a second nurse, who prepares the dressing materials for a pressure bandage.

Of the following dressings, which would be the most appropriate for a shallow wound with minimal exudate? (Select all that apply) A. Damp-to-dry gauze dressing B. Calcium alginate dressing C. Hydrogel dressing D. Transparent film dressing E. Hydrocolloid dressing

D. Transparent film dressing E. Hydrocolloid dressing Transparent film dressings have absorbent capacity and are indicated as a primary dressing for superficial wounds with minimal-or-no exudate. Hydrocolloid dressings contain gel-forming agents and are indicated as a primary wound dressing with minimal-to-moderate exudate and without depth.

12. For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond? a. Culture the wound. b. Leave the current dressing in place. c. Apply gauze over the top of the dressing. d. Remove and stretch the film more tightly over the wound.

a. Culture the wound. Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained.

4. The nurse would consider a dry dressing appropriate for a wound that requires which of the following? a. Protection b. Debridement c. Absorption of heavy exudate d. Healing by second intention

a. Protection A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention.

4. In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.) a. Remove the binder and assess the skin and wound every 8 hours. b. Evaluate the patient's ability to breathe deeply and cough effectively every 4 hours. c. Evaluate the patient's pulmonary function every 8 hours. d. Remove the binder at least daily.

a. Remove the binder and assess the skin and wound every 8 hours. b. Evaluate the patient's ability to breathe deeply and cough effectively every 4 hours. Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patient's ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function.

19. Which of the following tasks might be delegated to nursing assistive personnel (NAP)? a. Pressure dressing to an actively bleeding wound b. Chronic wound that needs a nonsterile moist-to-dry dressing change c. Hydrogel dressing change d. Wound assessment during the dressing change

b. Chronic wound that needs a nonsterile moist-to-dry dressing change The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see agency policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated.

17. Which of the following is an appropriate procedure for the nurse to implement during the application of an absorption or alginate dressing? a. Never cut the dressing to fit the wound. b. Irrigate the wound gently to remove residual gel. c. Fill the wound cavity entirely with the dressing material. d. Never use a secondary dressing.

b. Irrigate the wound gently to remove residual gel. Cleanse the area gently with moist 4 × 4 sterile gauze pads, swabbing exudate away from the wound, or spray with a wound cleanser. Cleansing effectively removes any residual dressing gel without injuring newly formed delicate granulation tissue formed in the healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid.

18. The nurse is preparing to apply a gauze bandage to a dressing on the patient's wrist. How should the nurse proceed? a. Use a 3-inch bandage. b. Use a 2-inch bandage. c. Apply from the elbow toward the wrist. d. Secure the bandage with a safety pin.

b. Use a 2-inch bandage. When applying a gauze or elastic bandage, select a type of bandage and bandage width dependent on the size and shape of the body part to be bandaged. For example, 3-inch bandages are used most commonly for the adult leg. A smaller, 2-inch bandage normally is used for the upper extremity. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage.

13. The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed? a. Apply a film dressing after culturing the wound. b. Apply a film dressing after cleansing the area. c. Choose another type of dressing for this wound. d. Keep the wound open to air.

c. Choose another type of dressing for this wound. If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, rather than transparent film dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and family that collection of wound fluid under the dressing is not "pus," but rather is a result of normal interaction of body fluids with the dressing.

3. The nurse is caring for a patient who has a wound healing by primary intention that has little to no drainage. Which dressing is most appropriate for this type of wound? a. Moist-to-dry dressing b. Hydrocolloid dressing c. Dry dressing d. Hydrogel dressing

c. Dry dressing Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris. Hydrogel dressings (e.g., hydrogel wound dressings, primary wound dressings, etc.) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues.

2. The nurse is changing a dry, woven gauze dressing when it is observed that the gauze has inadvertently stuck to the wound. What should the nurse do? a. Pull the dressing off to aid in debridement. b. Recover the dressing and leave in place. c. Moisten the gauze to minimize trauma. d. Ensure that the shiny side of the dry gauze dressing does not stick.

c. Moisten the gauze to minimize trauma. When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma. Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound.

9. Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond? a. Initiate intravenous (IV) therapy. b. Order blood for transfusions. c. Remove and reapply any dressings. d. Monitor vital signs every 15 minutes.

d. Monitor vital signs every 15 minutes. Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). Intravenous (IV) therapy and blood transfusions require a provider's order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.

5. The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by: a. filling two-thirds of the wound cavity. b. leaving saline-soaked folded gauze squares in place. c. putting the dressing in very tightly. d. extending only to the upper edge of the wound.

d. extending only to the upper edge of the wound. Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface. If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed.