Chapter 22
What amount of pressure would the nurse administer when placing a vacuum-assist closure (VAC) device to a patient's wound? 1 5 to 200 mm Hg 2 201 to 300 mm Hg 3 301 to 400 mm Hg 4 401 to 500 mm Hg
ANS: 1
Which inference could the nurse make from a postappendectomy incision site that has bright red gauze? 1. Sutures have ruptured. 2. Normal wound healing is occurring. 3. Sutures have become infected. 4. Serum is oozing from the sutures.
ANS: 1
Which intervention is essential for the nurse to implement to prevent a problem with skin integrity for an elderly patient who needs dressing changes three times a day? 1. Reinforcing the bandage with paper tape 2. Vigorously scrubbing the skin on the wound 3. Applying bandages extra tightly over the wound 4. Using tape with a heavy adhesive to secure dressing
ANS: 1
Which measure should the student nurse take immediately on completion of a wet-to-dry dressing change? 1 Document the patient's therapy and progress. 2 Charge for supplies used during the dressing change. 3 Notify the charge nurse that the dressing has been changed. 4 Inform the health care provider of the condition of the wound.
ANS: 1
A student nurse is caring for a patient with a wound that is not healing. Which factors in the patient's health history could negatively affect the healing process? Select all that apply. 1. History of heart disease 2. Diabetic for 10 years 3. Smokes a pack of cigarettes daily 4. Eats three well-balanced meals per day 5. Physically active with no history of illnesses
ANS: 1, 2, 3
Which information is essential to be documented in the chart after a dressing change? Select all that apply. 1 Patient's response 2 Patient's medication 3 Status of the wound 4 Level of consciousness 5 Location of the wound 6 Type of dressing applied
ANS: 1, 3, 5, 6
A bandage is applied to the left upper arm of a patient. Further assessment upon the patient's arm distal to the bandage reveals that it is cool to touch, the pulse is diminished, and the arm appears slightly blue. Which intervention should the nurse perform immediately? 1. Tighten the bandage. 2. Readjust the bandage immediately. 3. Place the arm in a sling for support. 4. Perform passive range-of-motion exercises.
ANS: 2
The nurse is caring for a patient who has undergone an appendectomy. The nurse observes that the patient has difficulty coughing. Which suggestion given by the nurse would help the patient to cough effectively during this recovery period? 1 "Gargle with warm saline every 2 to 3 hours." 2 "Use a pillow to support the incisional site while coughing." 3 "Place a pillow below your neck and elevate the head of the bed." 4 "Perform deep breathing exercises after each coughing episode."
ANS: 2
Which action will decrease tissue trauma to the skin surrounding a wound? 1 Removing the bandage slowly Correct2 Using the thumb to retract skin away from the tape 3 Applying petroleum jelly on the skin around the wound 4 Soaking the skin with alcohol before removing the bandage
ANS: 2
Which factor would cause a keloid on the patient's skin at the site of injury? 1 Shortening of muscle tissue 2 Overgrowth of collagen 3 Impaired blood flow 4 Reduction in skin capillaries
ANS: 2
A postsurgery patient with an abdominal incision has been complaining of discomfort because of coughing. Which technique should the nurse instruct a patient to use when coughing? 1. Instruct the patient to lay supine, take a deep breath, and cough forcibly. 2. Ask the patient to lean forward, place head to the knees, and cough softly. 3. Tell the patient to place the palms of the hands or a pillow over the incision and cough. 4. Have the patient assume the prone position and use the mattress to cushion the wound.
ANS: 3
In classifying wounds, which classification results from the presence of gastrointestinal (GI) products? 1. Dirty 2. Clean 3. Contaminated 4. Clean-contaminated
ANS: 3
The nurse is caring for a diabetic patient who has injuries due to an accident. The nurse finds that the patient has delayed wound healing. What food does the nurse suggest to the patient to promote faster wound healing? 1 Apples 2 Peaches 3 Oranges 4 Watermelon
ANS: 3
Which approach is the most appropriate way to cleanse the wound and surrounding area for a sterile dry dressing change? 1. Use a sterile swab to soak up any drainage; then apply a clean dressing. 2. Using an aseptic swab, start on the side of the wound closest to you and apply one stroke per swab. 3. Using an aseptic swab, start from the incision outward, applying one stroke per swab; then allow to air-dry. 4. Using an aseptic swab, start at the top of the incision, using the same swab until dirty; then get a clean swab.
ANS: 3
Which datum indicates that a patient's wound is infected? 1 Edges closely approximated 2 No edema or tenderness noted 3 Foul odorous purulent drainage 4 Absence of exudate or discharge
ANS: 3
Which dietary tray would be ordered for a patient to provide adequate nutrition that will promote wound healing? 1 Baked potato, peach cobbler, and milk 2 Fried chicken, baked French fries, and chocolate milk 3 Baked fish, legumes, spinach, strawberries, and decaffeinated tea 4 Hot ham and cheese sandwich, baked French fries, peaches, and milk
ANS: 3
Which method should be used to remove a bandage when the gauze becomes stuck to the wound bed? 1. Allow the patient to remove the gauze. 2. Quickly pull the gauze from the wound. 3. Moisten the gauze with sterile normal saline. 4. Have the patient moisten the gauze in the shower.
ANS: 3
After a wound irrigation, which intervention should the nurse do to ensure that a transparent dressing will adhere to the wound? 1 Reinforce dressing with paper and silk tape. 2 Seal all four edges with paper tape. 3 Secure dressing with a binder to prevent sliding. 4 Dry skin thoroughly before applying dressing.
ANS: 4
For removing staples from a surgical incision, which intervention is most appropriate? 1. Remove all the staples. If the edges pull apart, apply Steri-Strips. 2. Remove every other staple; then wait several days to remove the rest. 3. Remove the middle staples first; then proceed to the outer edges and apply the dressing. 4. Remove every other staple first and replace with Steri-Strips while ensuring that the incision remains closed.
ANS: 4
If a patient with an abdominal incision and discomfort begins to cough, which intervention is the most appropriate? 1. Roll the patient to the left side. 2. Offer the patient a drink of water. 3. Sit the patient up in a semi-Fowler's position. 4. Apply a pillow to the incision with slight pressure.
ANS: 4
The nurse has received an order to irrigate a patient's wound using an antiseptic solution. Which action should the nurse take to reduce the risk of contamination? 1 Place the tip of the syringe against the area needing to being cleaned. 2 Instill the solution with force to remove any debris quickly from the wound. 3 Direct the solution from unhealthy tissue toward healthy tissue within the wound. 4 Have the solution flow from the least contaminated to the most contaminated area.
ANS: 4
The nurse is assessing a patient with a gangrenous leg. While collecting the patient's medical history, the nurse finds that the patient had developed the gangrene after lower-limb surgery. Which class of surgical wound does the nurse expect the patient has? 1 Class I 2 Class II 3 Class III Correct4 Class IV
ANS: 4
Which nursing action will improve comfort for a patient with a large wound who cries during sterile dressing changes because of severe pain? 1 Allowing the patient to perform the dressing change 2 Removing the dressing carefully to avoid discomfort 3 Letting the patient soak the dressing off in a bathtub of warm water 4 Medicating the patient 30 minutes before the dressing is to be changed
ANS: 4
Which wetting agent solution would the nurse use while dressing a patient's wounds when a deodorizing effect is required? 1. Acetic acid 2. Povidone-iodine 3. Lactated Ringer's 4. Sodium hypochlorite
ANS: 4
While inspecting a patient's wound, the nurse observes that the skin around the wound has softened and is broken. Which finding does this indicate about the wound? 1. It was covered with a dry dressing. 2. It was covered with a gauze dressing. 3. It was exposed to air for a long time. 4. It was covered with an occlusive dressing.
ANS: 4
