Ch. 7, 8, 38, 39

Primary intention A surgical incision has the wound edges approximated at the time of the operation, is secured w/staples, and is healing by primary intention. There is little need for tissue regeneration. Wounds that are left open to heal by secondary intention are not approximated and are left open. These types of wounds heal slowly bc of the need for connective tissue to fill the area. A wound that heals by tertiary intention is left open for several days, and the edge area is approximated while the center of the wound heals by the formation of granulation tissue.

38. A pt. had surgery to repair an incisional hernia. His surgical incision was approximated and stapled at the time of the procedure. Which type of wound healing is occurring in the surgical site?

I'll irrigate the wound, starting at the bottom and moving to the top. The fluid needs to drain from top to bottom, allowing gravity to help.

38. A pt. has a large abdominal wound, which will require irrigation and packing after discharge from the hospital. Which statement made by the pt. indicates a need for further teaching related to her wound irrigation?

Administer an analgesic 30 min before staple removal. The pt. should be premedicated bc of the wound size. He or she should be positioned as flat as possible. You place the lower tip of the staple remover under the staple, and you do not lift up on the staple when depressing the extractor handles. The incision cleaning is started at the top of the incision and not the sides. When half the staples are removed, it means that every other staple is removed. This allows observation of how the wound is healing. In some instances small strips of tape, called Steri-Strips, will be used where the staples were removed to help stabilize the tissue.

38. A pt. has an extensive abdominal wound and is to have half of the staples removed and the incision line cleaned. Which actions should the nurse take during the preparation and actual interaction with the pt.?

Checking that there is a health care provider's order for the suture removal. If there is no order for the suture removal, none of the other steps need to be taken. Nurses cannot remove staples or sutures merely bc of something the health care provider said.

38. A pt. tells the nurse that the health care provider said his sutures are coming out today. Which nursing action is most important before removing the sutures?

2. Check the seal of the transparent dressing. 3. Check to be sure that the connections to the suction are intact. When you can see air under the negative-pressure wound therapy dressing, this indicates a problem with the seal. A negative-pressure wound therapy dressing should be flat over the wound dressing since all of the air should be removed from the area by the suction. Therefore the appropriate interventions include checking the seal of the transparent dressing for signs that it is not adhering to the skin or dressing and checking that the suction is working by noting that each of the connections from the suction source to the wound is intact. Changing the dressing would not be appropriate until this is done.

38. A pt.'s wound is managed w/negative-pressure wound therapy. When you evaluate the negative pressure wound therapy dressing, you note air under the seal of the transparent dressing. What of the following interventions would be appropriate?

1. Using sterile technique. 4. Directing the flow of solution from healthy tissue to infected tissue. Use sterile technique and direct flow of solution from healthy to infected tissue.

38. In preparing to irrigate a wound, which intervention helps to reduce the risk for infection during wound irrigation?

Serous The type of drainage that is clear like plasma is called serous. Purulent drainage is typically beige or tan, slough is used to describe nonviable yellow tissue (not drainage), and plasma is deep red color.

38. The NAP reports to you that the outer dressing from a pt.'s abdominal wound that is healing by secondary intention has moist, clear, red-tinged drainage. After you verify this finding, how would you describe this type of drainage?

Compress the bulb portion of the container and close the port. A Jackson-Pratt drain is a closed suction setup. Once the collector is drained, push out the air by compressing the drain and closing it. When the collector is drained, all the exudate is removed, and the collector is not pumped.

38. The nurse needs to empty the Jackson-Pratt drain collection device every 8 hr. After draining the fluid from the container, how should he or she reestablish the closed suction system?

2. Pinning the drainage tubing to the pt.'s gown. 5. Emptying the drain now. 6. Squeezing the drain flat before putting in the drainage plug. The drainage needs to be emptied, measured, and recorded. After you have emptied the drainage, you need to depress or squeeze the drain flat before putting in the plug. This helps the suction mechanism to work. Attaching the drain to the pt.'s gown below the level of the wound helps to prevent the drain from pulling and also keeps it in a dependent position to allow for maximum drainage.

38. The nurse notes approximately 60 mL of bright red drainage in the Jackson-Pratt drain 6 hrs. after surgery. Which nursing interventions should be included in the care for this pt.?

Removing the suture in a smooth, continuous manner. The suture should be removed in a smooth, continuous manner. The knot should have been snipped at the end distal to the knot. The scissors should have been held in you dominant hand, and the pickups in your nondominant hand. Disinfectants are never used on living tissue bc of their harsh chemical actions. Antiseptics may be used on skin to remove organisms.

38. The pt. is to have sutures removed from his back after surgery. The nurse is performing the procedure correctly by taking which step?

A moist-to-dry dressing placed on the wound bed. A moist-to-dry dressing mechanically debrides the wound when exudate adheres to the moist gauze. The transparent dressing is indicated after a wound is debrided. Hydrogel debrides a wound through autolysis, and not mechanical debridement. Telfa is a dry nonadherent dressing which is inappropriate for this purpose.

39. A pt. has a small surgical wound with necrotic tissue that requires mechanical debridement. Which of the following dressing options is used in this type of wound treatment?

Asks the pt. to rate his level of pain on a scale of 0 to 10. An increase in pain can be an indicator of neurologic and vascular changes. Options 1 and 2 evaluate circulation. Option 3 evaluates for wound infection.

39. A pt. has an elastic bandage applied to the left leg that holds a large dressing in place over a surgical incision. Which evaluation approach should the nurse use to determine if the pt. has neurologic changes?

Montgomery ties Frequent dressing changes pose a risk of skin abrasion and skin tears from tape removal. A set of Montgomery ties is the best choice to secure the ABD pad.

39. A pt. on the general surgery unit has a 4 in-long incision that has developed a wound infection. On inspection there is a moderate amount of yellowish drainage that has a distinct odor. The health care provider has ordered a foam dressing. A gauze abdominal (ABD) pad is the secondary dressing for covering the foam. Since the dressing has to be changed every 24 hrs., which is the best material to use to secure the ABD pads?

A measured foam pad is placed over the open area along with an occlusive dressing. Negative pressure removes drainage and contracts the wound bed. In NPWT, negative pressure applied through the foam dressing removes exudate and contracts the wound bed to promote healing. Exudate is pulled out, not pushed into the wound. The wound bed is not flooded, and gauze pads are not placed in the wound bed.

39. A pt. w/a large infected wound needs negative-pressure wound therapy (NPWT) and asks the wound care nurse how the technique works. Which statement by the nurse is most accurate.

1. A 58/yo woman who s on immunosuppressive drugs for arthritis. 2. A 34/yo man who has had diabetes mellitus since the age of 12. 3. A 42/yo woman who has been using steroids for asthma. 6. A 20/yo man who is receiving radiation near the wound. The following conditions, medications, or treatments interfere w/wound healing: immunosuppressive drugs, diabetes, steroids, and irradiation.

39. A wound care nurse is reviewing the charts of a group of pt.s to be seen in the clinic. Which pt.s are most at risk for wound-healing problems?

Remove and reapply the abdominal binder. If the binder is placed either too high or too tight, a pt. can exp. sob, which would require you to release the binder and reapply it.

39. After the nurse applies an abdominal binder to a pt., the pt. begins to experience shallow, rapid respirations. What is the first appropriate nursing action?

4. Select proper size so it extends onto periwound skin at least 2.4 cm (1 inch). 3. Remove paper backing from adhesive side of wafer and place over wound. 5. Mold wafer to affected body part. 1. Hold dressing in place for 30 to 60 seconds. 2. Secure with nonallergenic tape.

39. Place the Following steps for application of a hydrocolloid dressing in the correct order:

Hydrogel A hydrogel dressing is soothing and is the most appropriate one for a pt. with burns.

39. The nurse is caring for a pt. w/a painful burn wound. The wound care would be most appropriate if the nurse applied which type of dressing?

Necrotic tissue is seen in the removed packed gauze. To adequately debride a wound, the packing needs to be dry on removal. The dressing was too wet when it was placed in the wound initially.

39. The nurse is removing a moist-to-dry dressing from a packed wound 6 hours after it was placed in the wound. Which observation indicates that the packing technique was incorrect?

You should remove on layer of gauze at a time to be sure that you don't pull on any underlying drain. A surgical wound often has a drain in place. Gauze dressings should be removed one layer at a time to prevent accidentally pulling and removing the drain. The removal of a sterile dressing requires only clean gloves. Saline is not needed to moisten gauze unless drainage in the dressing sticks to the wound.

39. You are mentoring a student nurse on a surgical floor. You observe the student removing a dry gauze dressing from a pt. who had an abdominal laparotomy 24 hr ago. The student applies a pair of clean gloves, uses the dominant hand to remove all of the gauze dressings at one time, and places them in a plastic trash bag. What would be your best reaction to this technique?

Washing with soap and water. Soap and water are essential for visibly dirty hands according to the Centers for Disease Control and Prevention.

7. A health care worker has visible dirt on his hands. Which method of hand hygiene is most appropriate?

1. Blocks the portal of entry for microorganisms. 2. Blocks the portal of exit. Gloves form a barrier that prevents entrance of microorganisms on the nurse's hands into the urinary device and protects the nurse from exit of microorganisms in the urine.

7. A nurse applies clean gloves when collecting a urine specimen. How does this technique break the chain of infection?

Contact Microorganisms causing pneumonia exist in droplets of mucus and do not remain suspended in air; therefore they can be spread by direct contact w/secretions, especially by unclean hands.

7. A nurse enters the room of a pt. who has been diagnosed with pneumonia. The nurse instructs the pt. to cover the mouth when coughing. This reduces transmission of infection by:

3. Discard the gown after using it. 4. Perform hand hygiene. Gowns are used once and discarded bc of the chance of being contaminated. Hand hygiene should always be performed before and after going into a room.

7. A nurse goes in and out of a pt.'s room and only needs a gown when coming into contact w/the pt. What should the nurse do on leaving the room?

Explain the reason for isolation and answer the pt.'s questions. Explaining the reason for isolation and answering questions relieve pt.'s anxiety.

7. A pt. is isolated for pulmonary tuberculosis. The nurse notes that the pt. seems angry but knows that this is a normal response to isolation. The best intervention is to:

Using soap and water when performing hand hygiene. Soap and water flush spores from hands more efficiently.

7. C. difficile organisms can be passed easily from pt. to pt. An infection prevention practice used to reduce possible transmission includes:

Contact w/ health care workers' hands. Health care worker's hand are the greatest source of microorganisms.

7. The most likely means of transmitting infection between pt. is:

Droplet A mask provides a barrier when the pt. has droplet precautions.

7. The use of a mask when the nurse is closer than 3 feet to a pt. involves which type of precautions?

1. The need for social interaction. 2. The type of isolation required. 3. The pt.'s cultural background. 4. Education of family and friends regarding the isolation. 5. Organization of care to minimize trips in and out of the isolation room. All of the first five factors relate to pt./family needs, the type of isolation devices needed, and organizing nursing care. Item 6 does not impact the delivery of nursing while on isolation precautions.

7. When a pt. is to be placed on isolation precautions, there are many factors to consider regarding his or her care.

Using plenty of lather w/friction. Lathering the hands w/the cleaning agent using friction is the best method to remove dirt and transient bacteria.

7. Which aspect of handwashing is most effective to loosen dirt and transient bacteria?

Asking another nurse to change the dressing. When a nurse is sick and needs to get close to an open wound of a pt. whose immune system is not functioning well, it is appropriate to ask someone else to change the dressing rather than put the pt. at risk. This is the best answer and the only one that keeps the sick nurse away from the pt.

8. A nurse has a cold and needs to change a dressing on a pt. who is immunocompromised. Which action by the nurse would be most appropriate?

Grab only the inside of the glove with the ungloved hand. The inside of the glove becomes unsterile when it comes in contact with the ungloved hand.

8. A nurse is preparing to change a dressing using sterile gloves. It is most important to remember which concept when putting them on?

When pouring a solution on the sterile field, the label of the solution bottle is facing the floor. The label of the bottle should be facing the student's palm so it does not become distorted or ruined if fluid runs down the bottle.

8. A nurse is supervision a nursing student setting up for a sterile dressing change. Which action by the nursing student would require intervention from the nurse?

Putting a pair of synthetic gloves on before donning the latex sterile gloves. The pair of synthetic gloves affords some protection from the latex. All other options offer no protection.

8. A nurse with a latex allergy needs to perform a sterile procedure and finds that the only sterile gloves available are latex. Which action by the nurse would be most effective in solving the problem?

Obtaining a nonlatex catheter for the procedure. Individuals with spina bifida are at risk for latex allergy; thus the nures should use a nonlatex catherter and nonlatex gloves. Individuals with spina bifida who have a latex sensitivity may also be allergic to bananas, avocados, kiwi fruit, and tomatoes, but not eggs.

8. A teenager with spina bifida is to have a urinary catheter inserted. Which action is most important before performing this procedure?

The first flap of the sterile package is opened toward the nurse. Opening the first flap toward the nurse would require the nurse to reach over the sterile field to completely open the pack. The flap should open away from the nurse.

8. In setting up a sterile field, which of the listed actions would require intervention?

S 1. Urinary catheterization S 3. Tracheal suctioning S 4. Lumbar puncture Procedures listed invade sterile body cavities.

8. Place an S next to the procedures requiring sterile (aseptic) technique.

1. An autoclave Provides steam under pressure, the most effective means of sterilizing instruments and packaged dressings.

8. Sterilization of surgical instruments and surgical dressings is accomplished by using:

Holding or moving the object below the waist. The area below the waist is more likely out of direct vision and can become contaminated easier by contact with a nonsterile surface.

8. When opening a sterile pack, which action compromises the sterility of the contents?

"position" The NAP can be most effective by helping the pt. assume and maintain the position that the nurse needs to perform the procedure.

8. When performing a sterile procedure at the bedside, the NAP can help by assisting the nurse to __________ the pt.