Ch. 31 Prep U

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage? a) Serosanguineous b) Purulent c) Serous d) Sanguineous

a) Serosanguineous

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a) Potassium supplements b) Antihypertensive drugs c) Corticosteroids d) Laxatives

c) Corticosteroids Corticosteroids decrease the inflammatory process, which may delay healing.

A client has developed blisters around the tape that secures the dressing. The nurse should: a) apply skin barrier to protect skin. b) apply tape to the side of the blisters. c) use Montgomery straps. d) apply the dressing with a binder.

d) apply the dressing with a binder.

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy for piles. Which of the following interventions should the nurse follow to apply the T-binder? Select all that apply. a) Clean the insertion in a circular manner b) Pin the tails to the belt of the T-binder c) Pass the tails through the client's legs d) Place the precut drain sponge on the anus e) Fasten the crossbar around the waist

When applying a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy for piles, the nurse fastens the crossbar of the T around the waist. Then the nurse passes the single or double tails between the client's legs and pins the tails to the belt. e) Fasten the crossbar around the waist c) Pass the tails through the client's legs b) Pin the tails to the belt of the T-binder

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate? a) "Dehiscence is when a wound has partial or total separation of the wound layers." b) "Dehiscence is a total separation of the wound with protrusion of the viscera through it." c) "Dehiscence is not anything that you need to worry about." d) "Dehiscence is the softening of tissue due to excessive moisture."

a) "Dehiscence is when a wound has partial or total separation of the wound layers."

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care? a) Cleanse with a new gauze for each stroke. b) Cleanse the wound using parallel stroke from the top to the bottom of the wound. c) Cleanse the wound from the outer area towards the inner area. d) Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing.

a) Cleanse with a new gauze for each stroke.

Choice Multiple question - Select all answer choices that apply. A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. a) Cover wound with a gauze moistened with normal saline. b) Place client in low-Fowler's position. c) Use sterile techniques. d) Reinsert protruding structures and apply a pressure dressing. e) Pack the wound with iodoform gauze.

a) Cover wound with a gauze moistened with normal saline. b) Place client in low-Fowler's position. c) Use sterile techniques.

When performing a dressing change, the home care nurse notes that base of the client's leg wound is red and bleeds easily. Which of the following is the appropriate action by the nurse? a) Document the findings. b) Consult a wound care nurse. c) Notify the physician. d) Send the client to the emergency room.

a) Document the findings.

Choice Multiple question - Select all answer choices that apply. What is true about the dermis? Select all that apply. a) It is the thickest skin layer. b) It contains melanocytes, which produce melanin. c) It is responsible for producing keratin. d) It is the outermost layer. e) It is responsible for producing the proteins collagen and elastin.

a) It is the thickest skin layer. e) It is responsible for producing the proteins collagen and elastin.

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 a hydrocolloid dressing instead. c) Assure that the packing material is completely saturated when placed in the wound. d) Use less packing material.

a) Reduce the time interval between dressing changes.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing describes this? a) Secondary intention b) Tertiary intention c) Maturation d) Primary intention

a) Secondary intention

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow". Based on this classification which of the following nursing actions should the nurse perform? a) Wound irrigation b) Apply moist dressing c) Gentle cleansing d) Debridement

a) Wound irrigation

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a) a sterile, flexible applicator moistened with saline b) a small plastic ruler c) a sterile tongue blade lubricated with water soluble gel d) an otic curette

a) a sterile, flexible applicator moistened with saline

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? a) shearing force b) necrosis of tissue c) ischemia d) friction

a) shearing force

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? a) Herniation of the wound b) Dehiscence of the wound c) Evisceration of the viscera d) Infection of the wound

b) Dehiscence of the wound

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication? a) Dehiscence b) Evisceration c) Hemorrhage d) Fistula

b) Evisceration

Choice Multiple question - Select all answer choices that apply. A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which intervention should the nurse include in the plan to prevent the development of pressure ulcers? Select all that apply. a) Pull client up in bed as needed. b) Turn client every 2 hours while client in bed. c) Encourage client to take fluids every 2 hours. d) Elevate the head of the bed 90 degrees four times daily. e) Provide incontinent care every 2 hours and as needed.

b) Turn client every 2 hours while client in bed. c) Encourage client to take fluids every 2 hours. e) Provide incontinent care every 2 hours and as needed.

While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record? a) Intentional, full-thickness wound b) Unintentional, partial-thickness wound c) Intentional, partial-thickness wound d) Unintentional, full-thickness wound

b) Unintentional, partial-thickness wound

Choice Multiple question - Select all answer choices that apply. A nurse assessing client wounds would document which examples of wounds as healing normally without complications? Select all that apply. a) a wound that takes approximately 2 weeks for the edges to appear normal and heal together b) a wound that does not feel hot upon palpation c) a wound that forms exudate due to the inflammatory response d) a wound with increased swelling and drainage that may occur during the first 5 days of the wound healing process e) incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes f) The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges.

b) a wound that does not feel hot upon palpation c) a wound that forms exudate due to the inflammatory response f) The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. This would be a correct way to document a normally healing wound. A wound that does not feel hot upon palpation would be another example of correctly documenting a wound that has no complications. A wound that is warm to touch is not an abnormal finding. A wound that forms exudate due to the inflammatory response would be correct documentation of a normal finding.

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider? a) Transparent b) Hydrocolloid c) Alginate d) Hydrogel

c) Alginate

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a) Necrosis b) Evisceration c) Desiccation d) Maceration

c) Desiccation

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) Hydrogels b) Transparent films c) Hydrocolloid dressings d) Alginates

c) Hydrocolloid dressings

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. b) Do not attempt to remove the sutures because they need more time to heal. c) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. d) Pick the crusts off the sutures with the forceps before removing them.

c) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a) The nurse uses wet-to-dry dressings continuously. b) The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. c) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. d) The nurse packs the wound cavity tightly with dressing material.

c) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a) a large wound with considerable tissue loss allowed to heal naturally b) a wound left open for several days to allow edema to subside c) a surgical incision with sutured approximated edges d) a wound healing naturally that becomes infected.

c) a surgical incision with sutured approximated edges Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

Which best describes the third phase of the wound healing process: proliferative? a) the onset of vasoconstriction, platelet aggregation, and clot formation b) is marked by vasodilation and phagocytosis as the body works to clean the wound c) The number of fibroblasts decreases, collagen synthesis is stabilized and collagen fibrils become increasingly organized, resulting in greater tensile strength of the wound. d) Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization.

d) Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which of the following actions should the nurse perform in obtaining a wound culture? a) Cleanse the wound after obtaining the wound culture. b) Utilize the culture swab to obtain cultures from multiple sites. c) Stroke the culture swab on surrounding skin first. d) Keep the swab and inside of the culture tube sterile.

d) Keep the swab and inside of the culture tube sterile.

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Contact the surgeon for deibridement. b) Place a TED hose on the client's leg. c) Using sterile technique, debride the wound. d) Off-load pressure from the heel.

d) Off-load pressure from the heel.

A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion? a) Puncture of the skin b) Cutting with a sharp instrument with wound edges in close approximation with correct alignment c) Tearing of the skin and tissue with some type of instrument: tissue not aligned d) Tearing of a structure from its normal position

d) Tearing of a structure from its normal position

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? a) The nurse swabs the wound with povidone-iodine to fight infection in the wound. b) The nurse uses friction when cleaning the wound to loosen dead cells. c) The nurse swabs the wound from the bottom to the top. d) The nurse works outward from the wound in lines parallel to it.

d) The nurse works outward from the wound in lines parallel to it.