Nursing skill Quiz 1
Transparent dressing (tegaderm)
-stage 1-2 -Prevents skin breakdown and prevents entrance of moisture and bacteria but allows oxygen and moisture vapor permeability.
A (measurement in inch or inches) margin at each edge of an opened drape is considered un-sterile, since the edges are in contact with un-sterile surfaces.
1 inch
Provide meds before dressing
1/2 hour
1. What is the maximum temperature of the water in a hot water bottle for an adult?
125 F
AIDET
Acknowledge, Introduce, Duration, Explain, Thank
Which of the following group of clients are standard precautions used for?
All hospitalized clients regardless of their diagnosis or possible infection status
What factors does the nurse consider when selecting a dressing for a wound?
All of the above
Therapeutic Applications
Circulation, Mobility, Sensation, Skin Temp, pulses, capillary refill, any bleeding conditions. Record
Select the four characteristics of drainage that should be noted when a dressing is changed.
Color, odor, consistency, amount
Abdominal binders are used primarily for what purposes?
Comfort, Immobilize wound, apply pressure and support, secure dressing, promote healing, prevent injury, warmth, muscle control.
As you are removing the wrapping from a sterile bowl, an edge of the wrapper touches the sterile field you have just set up. You would continue with the procedure because the wrapper is sterile.
False
Heat is often applied to prevent swelling?
False
It is permissible to reserve one corner of a sterile field for disposal of nonsterile items.
False
It is safe to fold and pin a heating pad to keep it in place?
False
Your patient has a large volume of sanguineous drainage requiring every 2 hour dressing changes. What are some concerns for this patient?
Fluid loss Infection Compromised skin integrity from frequent dressing changes
Where is the best site to obtain a wound culture?
From granulation tissue.
A client is admitted into the hospital for Tuberculosis and placed in isolation. In what sequence should the nurse remove the protective barriers when leaving the isolation room?
Gloves, wash hands, goggles, gown, mask, and then wash hands.
What is granulation tissue and what would it indicate to the nurse?
Granulation tissue is healing tissue that indicates to the nurse the wound was healing.
How is MRSA is primarily transmitted?
Hands
What is the most effective way to prevent the spread of infection?
Handwashing
Secondary intention healing
Healing from the inside out edges cant meet, must granulate
After giving an injection, what should be done with the needle?
Leave uncapped or safety capped and discard in a designated receptacle.
What is rebound phenomenon and why is it important?
Maximum therapeutic effect occurs in 20-30 minutes. Some patients cannot feel or report too hot or too cold.
Asepsis
Medical clean absence of almost all organisms
Risk factors of healing
Obesity, Age, Blood Flow, and Tobacco
Serosanguineous
Pale, red, watery: mixture of clear and red fluid
Systemic effects of heat
Peripheral vasodialation -> Fainting or Drop in BP
What are the four purposes for dressings?
Provide moist wound healing, prevent injury, absorb drainage, and wound debridement
You are almost finished with changing a sterile dressing on your client. As you are about to place the final 4x4 gauze dressing on the wound your nose itches and as a matter of reflex you touch your nose with your gloved hand. What do you do now?
Remove sterile gloves and don new sterile gloves
Greater risk of infection healing
Secondary intension
Which statement below is true regarding objects used in a sterile field?
Should never be left unattended after opening.
Which of the following are physiologic effects of cold applications?
Slows bacterial growth,Lowers cellular metabolism,Vasoconstriction,Decreases capillary permeability,Reduces inflammatory response,Reduces bleeding
What is the purpose of the spiral-reverse turn method of bandaging?
To wrap a part that is cylindrical in shape such as a forearm or lower leg
Prior to performing a sterile procedure, the nurse should explain the procedure and how the patient can cooperate.
True
The assessments performed with a patient that has a wound includes location of wound, type of wound, presence of infection and lab data such as WBC.
True
The physician orders a damp to damp dressing change. The reason for this is to keep the wound clean to promote healing.
True
Primary intention healing
Two edges seamed together
The physician inserts a Hemovac drain due to excessive drainage from a surgical wound. How do you clean a wound with a drain?
Use a new swab or gauze for each swipe. Clean around the drain after cleansing the rest of the wound
Mrs. Williams has a large abdominal wound that requires frequent dressing changes. A drainage tube is present to aid in removal of wound exudate. How can the nurse control infection during the care of this client ?
Use gown and gloves and other PPE as indicated Keep dressing dry, intact and use sterile technique with wound and drainage tube care Use leak proof container to dispose of soiled dressings
Thermal tolerance
Various areas of the body differ in their response to heat and cold.
Local effects of cold
Vasoconstriction decreased capillary permeability decreased cellular metabolism slowed bacterial growth decreased inflammation local anesthetic effect for sprains, fractures, swelling
Systemic effects of cold
Vasoconstriction BP can increase because shunted to internal organs Shivering -> body`s attempts to warm itself
Local effects of heat
Vasodialation, Increases in Capillary permeability, cellular metabolism, blood flow, and inflammation. Sedative effect Promotes soft tissue healing and used for joints or low back pain
What are four physiologic effects of heat applications?
Vasodilation, increased inflammation, sedative effect, increased capillary permeability
Sanguineous
bloody
Serous
clear, watery plasma
Purulent
containing pus
Rebound phenomenon
maximum therapeutic effect achieved and opposite effect begins 20-30 minutes
Aquathermia pad
tube containing water, with electronic controls.
Hydrocolloid dressing
used for clean stage 2 or shallow stage 3 pressure ulcers
