Chapter 38: Providing Wound Care and Treating Pressure Ulcers – Flashcards
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The nurse clarifies that the first stage of wound healing is:
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inflammation. (Inflammation is the first stage of wound healing, followed by the proliferation, maturation, and reconstruction stages)
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The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by _____ intention.
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first (A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first, or primary, intention. Wounds that are not closed heal by either second (secondary) or third (tertiary) intention.)
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The nurse gives an example of a wound that heals by second (secondary) intention as a:
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laceration with edges that do not approximate. (A secondary intention healing occurs when there is a jagged wound whose edges do not approximate.)
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When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurses most helpful response would be that swelling indicates that:
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vessels have dilated and allowed plasma to leak into the wound site. (As part of the healing process, histamines and prostaglandins have caused small vessels to dilate and leak plasma and electrolytes into the wound site causing swelling, which causes the wound to become reddened and swollen as the phagocytosis cleans up the microorganisms.)
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. The nurse warns the patient that one of the patients habits has caused the reduction of functional hemoglobin, which limits the hemoglobins oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit:
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smoking cigarettes. (Smoking reduces the functional hemoglobin which, in turn, reduces the amount of oxygen carried to the cells of the body.)
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A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by _____ blood pressure.
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restlessness, rising pulse, and falling
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The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
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increased serosanguineous drainage from the wound.
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A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, I think something just let go. The initial intervention by the nurse should be to:
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assist the patient in a supine position.
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A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:
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uses one alcohol wipe to clean both the spout and the plug.
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The nurse chooses a nonadherent dressing to apply to a wound because the nonadherent dressing:
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allows drainage to seep through the barrier and be absorbed on the other side.
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. Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use:
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Montgomery straps.
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A nurse caring for a patient with a stage I pressure ulcer would most appropriately select a(n) _____ dressing.
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thin film (Thin film dressings are used on stage I ulcers to protect them from shearing forces and to keep them moist.)
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A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a(n):
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hematoma. (A hematoma is a pooling of blood under unbroken skin. An abrasion is a scraping away of skin tissue. A laceration is a torn, ragged, or mangled wound, and a an avulsion refers to something being torn away)
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The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:
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in a circular motion around the wound circling to the outside. (A circular motion around the wound toward the outside keeps the wound area cleanest)
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A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?
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From each of the four sides toward the wound (The tape should be removed by pulling it off toward the wound. This helps prevent disruption of the wound.)
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A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
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occlude air and promote breakdown of necrotic tissue. (Hydrocolloid dressings are air-occlusive dressings used on noninfected wounds that provide a moist environment for wound healing. They can be left in place for up to 7 days.)
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The nurse changing a wet-to-damp normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurses most beneficial intervention would be to:
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add normal saline to loosen it. (If the dressing sticks to the wound, normal saline should be added to loosen it. Pulling loose a stuck dressing damages new tissue. Leaving it in place does not promote a clean wound. Povidone-iodine must be ordered.)
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A nurse performing a right eye irrigation will position the patient:
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supine with the head tilted toward the right eye. (The patient should be positioned supine with the head tilted toward the affected eye. This position allows the irrigation solution to drain away from the eye and not contaminate the other eye.)
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A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:
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pull outward. (The handles should be squeezed together all the way. This depresses the center of the staple and allows it to be lifted outward from the skin.)
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The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:
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drawing the wound edges together by negative pressure. (A vacuum-assisted dressing that is accomplished by a special dressing and vacuum device applies negative pressure to the wound, which increases blood flow, increases oxygenation, and improves the delivery of nutrients to the wound.)
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The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the:
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heel. (Debridement is not recommended for treatment of a pressure ulcer on the heel because of the small amount of tissue available at that site.)
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The nurse places Dakins solution in a wound to accomplish chemical ___________.
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debridement (Dakins solution is placed in a wound to destroy the necrotic tissue so that granulation tissue can form to heal the wound (debridement).)
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The nurse assesses the large raised scar on the African-American patient. The nurse documents the lesion as a ___________.
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keloid (Keloids are large raised permanent scars resulting from colloid overgrowth that are seen most frequently on darkly pigmented skin.)
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The nurse explains to the patient that the foot will be submerged in warm water for a maximum of ______ minutes.
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20 Twenty (Warm soaks that involve submerging the limb should only last for 15 to 20 minutes.)
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The nurse is concerned about an HIV immunocompromised patients ability to heal because of the lack of: (Select all that apply.)
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B) adequate fibroblast function. C) synthesis of collagen. E) adequate phagocytosis.
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The nurse recognizes that of the drugs a patient is currently taking, several contribute to delayed healing, such as: (Select all that apply.)
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B) antineoplastic drugs. D) heparin. E) steroids.
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The nurse reminds the 85-year-old patient that his healing will be slower because of age- related changes such as: (Select all that apply.)
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B) atherosclerosis. C) diminished lung function. D) slow metabolism.
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e nurse irrigating an infected wound of the hand would: (Prioritize the steps. Separate the letters by a comma and a space as follows: A, B, C, D, E, F, G.)
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A. Open sterile irrigation basin and solution. C. Pour irrigating solution in basin. G. Place pad under the infected hand. B. Don sterile gloves to apply dressing. D. Irrigate keeping the syringe tip 1 inch from the wound surface. F. Pat wound dry and redress. E. Document procedure.
