Ch48- EAQ

A patient who has an acute wound because of trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation? 1 Educating the patient about wound care 2 Positioning the patient in different angles 3 Encouraging the patient to drink 6 to 8 liters of water 4 Applying a sterile dressing as per the health care provider's prescription

4

In a supine position, which site has the least risk of a pressure injury? 1 Ischium 2 Elbow 3 Occipital bone 4 Medial knee

4

When cleaning a wound, which action is incorrect? 1 Using two separate swabs to clean the affected site 2 Irrigating from the least to most contaminated area 3 Applying noncytotoxic solutions using gentle friction 4 Cleaning from the surrounding skin to the site of incision

4

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch? 1 A local skin infection requiring antibiotics 2 Sensitive skin that requires special bed linen 3 A stage 3 pressure injury needing the appropriate dressing 4 Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4

Which characteristic would be indicative of abnormal healing of a primary wound? 1 Slough tissue in the wound base 2 A fruity, earthy, or putrid odor 3 A dry or moist granulation tissue bed 4 Drainage for more than 3 days after closure

4

While assessing a patient who has a pressure injury, the nurse finds black wound tissue. In which stage is this pressure injury? 1 Stage 1 2 Stage 2 3 Stage 3 4 Unstageable

4

A patient is admitted with a stage 2 pressure injury. Which characteristic of a pressure injury is the nurse likely to find during a wound assessment? 1 It has a reddish-pink wound bed without slough. 2 The subcutaneous fat is visible. 3 It may include undermining and tunneling. 4 The wound extends to muscles and bones.

1

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a C-section. Which nursing action indicates a need for further learning? 1 Choosing a dressing that keeps the periwound moist 2 Applying a dressing that controls exudates from the wound 3 Cleaning the periwound and wound without applying pressure 4 Using sterile normal saline and a sterile gauze to clean the surgical wound

1

Which stage of pressure injury is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? 1 1 2 2 3 3 4 4

1

On assessing your patient's sacral pressure injury, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. Which stage would be applied to this patient's pressure injury? 1 Stage 2 2 Stage 4 3 Unstageable 4 Suspected deep tissue damage

3

The nurse understands that a protein deficiency can adversely affect wound healing. Which parameter should be measured to determine this deficiency in the patient? Select all that apply. One, some, or all responses may be correct. 1 Serum albumin 2 Serum transferrin 3 Serum prealbumin 4 Hemoglobin levels 5 Serum creatinine levels

1,2,3

Which statement is true regarding the hemostasis phase of blood clotting? Select all that apply. One, some, or all responses may be correct. 1 Clots form a fibrin matrix. 2 Blood vessels constrict, and platelets gather. 3 Blood loss is controlled, establishing bacterial control. 4 Epithelial cells migrate from a wound's edges to resurface. 5 Collagen fibers go through remodeling before assuming a normal appearance.

1,2,3

Which finding is characteristic of a stage 3 pressure injury? Select all that apply. One, some, or all responses may be correct. 1 It has full-thickness skin loss. 2 The subcutaneous fat may be visible. 3 The wound may present as an open, serum-filled blister. 4 There may be a reddish-pink wound bed without slough. 5 Neither the bone, tendon, nor muscle is exposed.

1,2,5

Which vitamin should be provided to a patient to promote wound healing? Select all that apply. One, some, or all responses may be correct. 1 A 2 B 3 C 4 D 5 E

1,3

A patient presents to the emergency department with severe injuries. The nurse notices that the wound on the abdomen is so deep that the liver has been eviscerated. Which prompt action does the nurse take in such a case? Select all that apply. One, some, or all responses may be correct. 1 Assess the patient for symptoms of shock. 2 Administer oral antibiotics to prevent infection. 3 Contact the surgical team for emergency surgery. 4 Place sterile gauze soaked in saline over the wound. 5 Keep the wound open to examine the extent of injury.

1,3,4

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which change in the wound might have led the nurse to this conclusion? Select all that apply. One, some, or all responses may be correct. 1 The wound is filled with granulation tissue. 2 There is localized redness, edema, warmth, and throbbing. 3 The wound contracts to reduce the area that requires healing. 4 There is vasodilation of the surrounding capillaries and exudation of serum. 5 There is reepithelialization of the wound surface.

1,3,5

Which characteristic differentiates a friction injury from a shear injury? Select all that apply. One, some, or all responses may be correct. 1 Type of force 2 Location of the injury 3 Involvement of tissue 4 Condition of the patient 5 Presentation of the injury

1,3,5

Arrange the phases involved in the process of a full-thickness wound repair in the correct order. 1. Hemostasis 2. Remodeling 3. Proliferative 4. Inflammatory

1->4->3->2

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development? 1 Gaskin's Nursing Assessment of Skin Color (GNASC) tool 2 Braden Scale 3 Bates-Jensen Wound Assessment Tool (BWAT) 4 Wound, Ostomy, and Continence Nurses Society (WOCN) scale

2

A patient who has a stage 3 pressure injury develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. Which condition would the nurse suspect is occurring in the patient? 1 Bruising 2 Infection 3 Internal bleeding 4 Blanchable erythema

2

A patient with an abdominal wound from a motor vehicle accident comes into the emergency department with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. Which rationale explains this nursing action? 1 Pain reduction 2 Infection prevention 3 Pressure injury prevention 4 Periwound edema prevention

2

Which nutrient supports healing by promoting wound closure? 1 Protein 2 Vitamin A 3 Vitamin C 4 Zinc

2

Which statement regarding the skin is true? 1 The stratum corneum prevents entrance of topical medications. 2 The dermis and the inner layer of the skin provide tensile strength. 3 The basal layer of the epidermis is responsible for collagen formation. 4 The three layers of the skin are the epidermis, dermis, and endodermis.

2

Which type of wound drainage is shown in the image? 1 Serous 2 Purulent 3 Sanguineous 4 Serosanguineous

2

A senior nurse is teaching a group of nursing students to assess skin changes related to development of pressure injuries. Which information should the students keep in mind when assessing dark-skinned patients? Select all that apply. One, some, or all responses may be correct. 1 Darker skin is more vulnerable to tans and sunburns. 2 Blanching is not a conclusive sign in these patients. 3 Differentiate skin color changes with reference to baseline skin tone. 4 Mongolian spots may not be present in dark-skinned patients because of sun exposure. 5 Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

2,3,5

A patient with limited mobility develops a stage 3 sacral pressure injury. Which nursing intervention is appropriate for reducing the risk of wound infection in this patient? Select all that apply. One, some, or all responses may be correct. 1 Obtaining a wound culture as needed 2 Irrigating and cleansing the wound with saline twice a day 3 Repositioning the patient at least every 90 minutes 4 Packing the open wound with antibiotic solution-moistened gauze 5 Requesting a prescription for a prophylactic antibiotic

2,4

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply. One, some, or all responses may be correct. 1 Skin tag 2 Bedsore 3 Skin wound 4 Pressure sore 5 Pressure ulcer 6 Decubitus ulcer

2,4,5,6

Chronologically arrange the steps for using a syringe and needle to collect a sample for a wound culture. 1. Applying suction to the 10-mL mark 2. Removing skin flora with a disinfectant solution 3. Moving the needle back and forward at different angles for two to four explorations 4. Using a 10-mL disposable syringe with a 22-gauge needle

2->4->1->3

The nurse notices an increased amount of red-colored fluid from the drain in a postoperative patient who had undergone abdominal surgery 2 days ago. The nurse inspects the incision site and notices some swelling and warmth over the incision. The patient is otherwise afebrile and has stable vital signs. Which condition are these findings indicative of? 1 Infection 2 Evisceration 3 Hemorrhage 4 Full-thickness repair

3

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure injuries. Which nursing action indicates a need for further learning? 1 Teaching the patient to shift his or her weight every 15 minutes 2 Encouraging the patient to sleep in a supine position 3 Encouraging the patient to sit on a donut-shaped cushion 4 Encouraging the patient to place the ischial areas on an air-filled pillow

3

Which blood cells are known as garbage cells? 1 Neutrophils 2 Erythrocytes 3 Macrophages 4 T-lymphocytes

3

Which nutrient is an antioxidant that promotes wound healing? 1 Zinc 2 Protein 3 Vitamin C 4 Vitamin A

3

Which role does vitamin A play in wound healing? 1 Quickens fibroplasia 2 Acts as an antioxidant 3 Promotes wound closure 4 Acts as immune function

3

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? 1 Low-air-loss surface 2 Nonpowered surface 3 Lateral rotation surface 4 Air-fluidized bed

3

he registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning? 1 Cleaning a wound with normal saline 2 Using a different method of specimen collection for each type of organism 3 Collecting wound culture samples from old drainage 4 Using a 10-mL disposable syringe with a 22-gauge needle

3

The nurse is attending to a patient who is bedridden after a prolonged illness. The patient has darkly pigmented skin, which makes it difficult for the nurse to detect pressure injuries. Which characteristic will alert the nurse to the possibility the patient may develop pressure injuries? Select all that apply. One, some, or all responses may be correct. 1 The skin appears flabby. 2 Localized areas of skin may appear red. 3 The color remains unchanged when pressure is applied. 4 The circumscribed area of intact skin may be warm to touch. 5 Inflammation may be detected when compared with the surrounding skin.

3,4,5