Advanced Patho/Pharm: Wound Healing, Aging, & Pain Management NCLEX ?'s

A surgeon is placing a hollow, open ended rubber tube in a client with an abscess. One end is in the abscess and the other passes through a hole in the skin. what type of drain is it? A. hemovac B. jackson-pratt C. penrose D. T-tube

Answer: C

A nurse is collecting a wound culture from two different site. Which of the following actions should the nurse take while performing this procedure? Select all that apply A. insert a swab into the wound B. press and rotate the swab several times over the wound surfaces C. place the swab in the culture tube when done D. use the same swab for both wound sites E. touch the swab to the intact skin at the wound edges F. tap the outside of the culture tube with the swab before placing it in the tube

Answer: a, b, c

A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? A. Change the hydrocolloid dressing daily. B. Change the hydrocolloid dressing every 3 to 5 days. C. Apply the hydrocolloid dressing over a dry, sterile dressing. D. Apply the hydrocolloid dressing over a normal saline-soaked dressing.

Answer B Rationale: A hydrocolloid dressing contains hydroactive particles embedded in a polymer base that are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and should be changed every 3 to 5 days (or more frequently if drainage from the wound is excessive). It is not applied over a dry, sterile dressing or a normal saline-soaked dressing because it then would not be able to act as a protective gel.

The health care provider has prescribed a topical anti-inflammatory cream for a client with a muscular sprain. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates an understanding of this prescribed treatment? A. "The medication is addicting." B. "The medication will act as a local anesthetic." C. "I will apply a heating pad to the area after applying the medication." D. "The medication may make me sleepy but will stop the muscle spasms."

Answer B Rationale: A topical anti-inflammatory cream may be prescribed for temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These types of products contain combinations of antiseptics, local anesthetics, analgesics, and counterirritants. A heating pad should not be applied because irritation or burning of the skin may occur. The medication is not addicting, does not act in a systemic manner, and does not cause sleepiness.

Sodium hypochlorite is prescribed for a client with a leg wound that is draining purulent material. The home health nurse teaches a family member how to perform wound treatments. Which statement, if made by the family member, indicates a need for further teaching? A. "A fresh solution needs to be prepared frequently." B. "I should rinse the solution off immediately after the irrigation." C. "The solution should not come in contact with normal skin tissue." D. "I will soak a sterile dressing with solution and pack it into the wound."

Answer D Rationale: Sodium hypochlorite is a solution used for irrigating and cleaning necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. The solution loses its potency during storage, so fresh solution should be prepared frequently. The solution should not come into contact with healing or normal tissue and should be rinsed off immediately after irrigation.

A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? A. Foam B. Alginate dressing C. Hydrocolloid dressing D. Semipermeable transparent film

Answer D Rationale: The client's wound has moderate drainage. Recall that foam, alginate, and hydrocolloid dressings are applied to wounds with moderate to heavy drainage. Semipermeable transparent films are applied to dry wounds.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which of the following actions is appropriate? A. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed B. Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture impervious dressing C. Fill the wound with sterile saline gel and cover with a large transparent dressing D. Instill 50 mL of normal saline into the wound and loosely cover with packing material.

Answer: A Rationale: Loosely pack dampened dressing material to prevent too much pressure on the wound bed.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which of the following modifications is most appropriate? A. reduce the time interval between dressing changes B. discontinue application of saline-moistened packing and apply hydrocolloid dressing C. assure that the packing material is completely saturated when placed in wound D. use less packing material

Answer: A Rationale: reduce the time interval between dressing changes

The nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement. which of the following wound dressings/products is most appropriate to use on the wound? A. An alginate dressing, such AlgiCell B. A hydrogel dressing, such as aquasorb C. A transparent film, such as tegaderm D. An antimicrobial dressing, such as silvasorb.

Answer: A.

You are caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states "my pain medication is effective, but will this pain ever go away?" which of the following responses is correct? A. if the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain B. incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe C. if the prescribed analgesics are controlling the pain we do not worry about the severity of the pain D. it is unusual for you to still have severe pain. I will contact your surgeon

Answer: B

A nurse is caring for a client who will be undergoing removal of the gall bladder. Which type of drain should the nurse expect the surgeon to place in the client's common bile duct to drain bile while the surgical site is healing? A. jackson-pratt drain B. penrose drain C. T-tube drain D. hemovac drain

Answer: C