Wound Care Flashcards

1
Q

The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting out watery effluent. The nurse recognizes that this is indicative of which location?

a. Descending colon
b. Sigmoid colon
c. Ileal portion of the small intestine
d. transverse colon

A

ANS: C
An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

The nurse is caring for a patient who has an ostomy. The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool. The nurse recognizes that this is indicative of which location?

a. Descending colon
b. Ileal portion of the small intestine
c. Sigmoid colon
d. Transverse or ascending colon

A

ANS: D
If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes that the stoma is red and moist. Which action should the nurse take?

a. Notify the physician immediately.
b. Apply pressure.
c. Note the condition of the stoma in her notes.
d. Change the appliance pouch.

A

ANS: C
The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient HER. If it is gray, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

In caring for a patient who had a fecal surgical diversion, which nursing intervention is essential?

a. Place a pouch over the newly created stoma.
b. Place a dressing over the stoma.
c. Wait several days before placing a pouch.
d. Prepare several pouches in advance.

A

ANS: A
Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient clean and dry, will protect the skin from drainage, and will provide a barrier against odor. Dressings would obstruct the opening and would become saturated with fecal material. Preparing multiple pouches in advance would be counterproductive; in the immediate postoperative period, the stoma may be edematous and the abdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise the pouching system to meet the changing size of the stoma and the changes in body contours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When planning care for a patient who has a colostomy, which intervention is important for the nurse to perform when pouching the colostomy ?

a. Leave an intact skin barrier in place for 3 to 7 days.
b. Use soap and water to cleanse the peristomal skin.
c. Empty the pouch when it is two-thirds full.
d. Use tape to secure pouches that have minor leaks.

A

ANS: A
Observe the existing skin barrier and pouch for leakage and length of time in place. The pouch should be changed every 3 to 7 days, not daily. To minimize skin irritation, avoid unnecessary changing of the entire pouching system, but if the effluent is leaking under the wafer, change it, because skin damage from the effluent will cause more skin trauma than will be caused by early removal of the wafer. Cleanse the peristomal skin gently with warm tap water using a washcloth; do not scrub the skin. Pat the skin dry. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion. Pouches must be emptied when they are one-third to one-half full, because the weight of the pouch may disrupt the seal of the adhesive on the skin. If the ostomy pouch is leaking, change it. Taping or patching it to contain effluent leaves the skin exposed to chemical or enzymatic irritation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When providing care for a patient with a colostomy or an ileostomy, the nurse recognizes that which is an expected assessment finding?

a. A moist, reddish-pink stoma
b. A dry, purplish stoma
c. Erythema on the skin around the stoma
d. No drainage noted from the stoma when washed

A

ANS: A
Normal findings in a patient with a postoperative ostomy that is healing include a stoma that is moist and reddish-pink, skin that is intact and free of irritation, and sutures that are intact. The stoma is edematous initially and shrinks over the next 4 to 6 weeks. A necrotic stoma is manifested by a purple or black color and a dry instead of moist texture. The stoma is functioning normally when the stoma drains a moderate amount of liquid or soft stool and flatus in the pouch. Flatus indicates the return of peristalsis after surgery. Flatus is noted by bulging of the pouch. (Flatus may not be observable if the pouch has a gas filter.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple stomas. Given the uniqueness of infants, which action is essential for the nurse to take?

a. Apply an ostomy pouch using standard sealants.
b. Use a pouch that can accommodate increased amounts of flatus.
c. Use multiple pouches (one for each stoma).
d. Be aware that the stoma size will remain the same as the baby grows.

A

ANS: B
Because babies swallow large amounts of air while sucking, it is normal to expect flatus. Make sure that the pouch can accommodate increased amounts of flatus after feeding, or be prepared to release flatus frequently. The skin of a preterm infant is not fully developed and is more absorbent than the skin of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm infant use. Neonates may have multiple stomas on their tiny abdomens that are the result of corrective bowel surgeries. Select a cut-to-fit pouch that allows multiple stoma openings in the skin barrier yet still fits on the neonate’s abdomen. Usually, a baby triples its birth weight in the first year. As a baby grows in size, so does the stoma.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

In caring for a patient who has a pouching for a noncontinent urinary diversion, which nursing intervention is essential?

a. Empty the pouch when it is one-third to one-half full.
b. Remove the ureteral stents after 2 days.
c. Pouch the stoma with the patient sitting up.
d. Dispose of used pouches in the toilet.

A

ANS: A
Empty pouches when they are one-third to one-half full so that the weight of the pouch does not disrupt the seal. A surgeon places the stents; these will be removed during the hospital stay or at the first postoperative visit with the surgeon. Place the patient in a semi-reclining position. If possible, provide the patient a mirror for observation. Properly dispose of used pouches and soiled equipment according to facility policy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When assessing the patient with a noncontinent urinary diversion, the nurse finds that the urine has mucous shreds. Which action should the nurse take?

a. Culture any drainage.
b. Instruct the patient to consume less water.
c. Note the characteristics of the urine in her notes.
d. Cleanse the stoma with soap and water.

A

ANS: C
Mucous shreds are normal when urine flows through an intestinal segment. Obtain a urine specimen for culture and sensitivity to test for possible infection when ordered by the physician if urine output is less than 30 mL/hr, or if the urine has a foul odor. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

The nurse has removed the patient’s old urostomy pouch and is attempting to measure the stoma opening for placement of a new pouch. Which action should the nurse take next?

a. Place the patient in a prone position.
b. Cleanse the peristomal skin with warm soap and water.
c. Remove any stents that are in place.
d. Place rolled gauze at the stoma opening.

A

ANS: D
Wick the stoma continuously during pouch measurement and change. Place a rolled gauze wick at the stomal opening. Using a wick at the stoma opening prevents the peristomal skin from becoming wet with urine during a pouching-change procedure. Position the patient in a semi-reclining position. Avoid soap when cleansing the area. In the immediate postoperative period, urinary stents extend out from the stoma. A surgeon places the stents to prevent stenosis of the ureters at the site where the ureters are attached to the conduit. The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

A patient who has a urostomy is being discharged to home. Which instruction will the nurse to provide to the patient?

a. Restrict fluid intake to reduce urine output.
b. Report any mucus in his urine.
c. Keep unused pouches in the refrigerator.
d. Shower without covering the pouch.

A

ANS: D
The patient may shower without covering the pouch. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Patients should avoid storing pouches in extremely hot or cold locations like the refrigerator. Teach patients that some mucus in the urine is expected, but that they should report to their physician any blood in the urine, excessively cloudy urine, chills, fever (101° F or higher), or back (flank) pain.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

The nurse is caring for a patient who has a urinary diversion. She notices that the patient has a temperature of 102° F and foul-smelling urine. What action should the nurse take?

a. Obtain a urine culture from the patient’s pouch.
b. Catheterize the patient to obtain a sterile urine specimen.
c. Notify the physician.
d. Realize that these are normal findings.

A

ANS: C
Common symptoms of a UTI include fever and foul-smelling odor. The Nurse will need to contact the physician immediately. The physician will order a catheterization so that a urine sample may be obtained. Although the nurse realizes the need for catheterization, it is an invasive procedure, and an invasive procedure requires a physician’s order. Obtaining a specimen of urine in a pouch does not result in an accurate finding because of the likely risk of contamination by microorganisms. Some mucus in the urine is expected.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch system. The nurse should take which action?

a. Place the patient in a semi-recumbent position.
b. Remove both pieces of the pouch system.
c. Remove the pouch and leave the barrier attached.
d. Use sterile gloves to remove the system.

A

ANS: C
Remove the pouch. If the patient uses a two-piece system, remove the pouch but leave the barrier attached to the skin. Position the patient sitting, if possible; gravity facilitates the flow of urine. Sterile gloves are used for the actual catheterization. Clean gloves are all that are necessary for removing the pouch.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

The nurse is caring for a patient who will have surgery in the morning to have a colostomy placed. The nurse is aware of the physical and emotional stresses that the patient will experience. These include which of the following? (Select all that apply.)

a. Body image changes
b. Fear of social rejection
c. Sexual function and intimacy issues
d. Loss of independence
e. Heightened immunity

A

ANS: A, B, C, D
In addition to the stresses of illness and surgical recovery, patients with ostomies face body image changes, fear of social rejection, concern about sexual function and intimacy, and the need for help with personal care. It is very important to provide an effective pouching system to facilitate the emotional adjustment to the ostomy. A supportive nurse makes the initial period of adjustment easier.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

The opening created into the abdominal wall for fecal or urinary elimination is known as a _______________.

A

ANS:
stoma
Certain diseases or conditions require surgical intervention to create an opening into the abdominal wall for fecal or urinary elimination. This opening is called a stoma and is constructed from a section of colon or small intestine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

The output from a urinary or fecal stoma is called the _______________.

A

ANS:
effluent
The output from the stoma is called the effluent.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A ______________ is an opening in the large intestine or colon for elimination of fecal material.

A

ANS:
colostomy
An opening in the large intestine or colon is a colostomy, and the fecal effluent will vary in consistency depending on where the opening in the colon is surgically created.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

An opening that is in the ileal portion of the small intestine is an ____________.

A

ANS:
ileostomy
An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

An ostomy that is created from a portion of the ileum to form a stoma through which urine can exit the body is called a(n) _____________.

A

ANS:
urostomy or ileal conduit
A urostomy or ileal conduit is created from a 6- to 8-inch portion of the intestine that is resected from the ileum. One end of the conduit is sutured closed, and the ureters are implanted through the mucosa. The other end is brought out of the abdominal wall, and a stoma is formed through which urine can exit the body.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

When is healing by primary intention expected?

a. When the wound is left open and is allowed to heal
b. When a surgical wound is left open for 3 to 5 days
c. When connective tissue development is evident
d. When the edges of a clean incision remain close together

A

ANS: D
Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed?

a. Change the dressing so she can assess the wound.
b. Administer an analgesic 30 to 45 minutes before a dressing change.
c. Culture the wound if wound exudate is present.
d. Administer an analgesic 30 minutes after a dressing change.

A

ANS: B
To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system?

a. Decreases the amount of angiogenesis
b. Reduces mechanical stretch of tissue
c. Dressing should not need to be changed for 48 hours
d. Helps create a dry environment

A

ANS: C
The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels), and that this stimulates the production of new blood vessels via mechanical stretch of the tissue. The dressing placed into the wound maintains a moist environment to facilitate healing. A suction device is placed over the dressing, and the dressing, suction, and wound area are covered with a transparent dressing, which provides the air-tight seal necessary for negative-pressure wound therapy (NPWT).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock. How should the nurse proceed?

a. Use irrigation pressures of less than 4 psi.
b. Cleanse in a direction from most contaminated to least contaminated.
c. Irrigate so that the solution flows from least contaminated to most contaminated.
d. Irrigate with clean irrigation solution only.

A

ANS: C
When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

The nurse is changing a surgical dressing and is cleansing the wound. She knows that:

a. the incision line should be cleansed last.
b. she should start at one end of the incision line and swab the entire length.
c. she should start at the center of the incision line and swab toward one end.
d. she should work in a circular motion around the incision line.

A

ANS: C
The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

The nurse answers the patient’s call light to find the patient agitated and stating that she “felt something pop.” The nurse finds that the patient’s abdominal surgical wound has eviscerated. What should the nurse do?

a. Try to reinsert the abdominal contents.
b. Cover the wound with a dry sterile dressing.
c. Notify the surgeon when he makes rounds.
d. Cover the wound with a moist saline dressing.

A

ANS: D
This is a surgical emergency, and the nurse needs to cover the wound with a moist saline dressing, immediately notify the surgeon, and prepare the patient for emergency surgery.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

The nurse prepares to irrigate the patient’s wound. What is the primary reason for this procedure?

a. Decrease scar formation.
b. Remove debris from the wound.
c. Improve circulation from the wound.
d. Decrease irritation from wound drainage.

A

ANS: B
Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. The primary purposes of wound irrigation do not include decreasing scar formation, improving circulation, or decreasing irritation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Which of the following approaches is correct technique when wound irrigation is performed?

a. Placing the patient in supine position
b. Placing the syringe directly into the wound
c. Using sterile technique for a chronic wound
d. Selecting a soft catheter for deep wounds with small openings

A

ANS: D
If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

a. Graft sites
b. Wounds with exposed blood vessels
c. Necrotic tissue
d. Wounds with exposed muscle or tendons

A

ANS: C
Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

When should a nurse consider culturing a wound?

a. When the tissue is clean and dry
b. When exudate is not present
c. When the patient is afebrile
d. When the surrounding area shows inflammation

A

ANS: D
Consider culturing a wound if it has a foul, purulent odor; inflammation surrounds the wound; a nondraining wound begins to drain; or the patient is febrile.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

When teaching about wound care in the home environment, the nurse instructs the patient and caregiver to:

a. make normal saline with 8 teaspoons of salt and .1 gallon of distilled water.
b. use normal saline for 1 week and then discard it.
c. not apply topical anesthetics before wound care.
d. call the physician’s office to have someone come to the home and complete the wound care.

A

ANS: A
Teach the patient and caregiver how to make normal saline, especially if cost is an issue. They can make normal saline by using 8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month. The saline solution should be allowed to reach room temperature before use. Commonly used topical anesthetic solutions include 2% and 4% lidocaine jelly, which inactivates exposed wound pain receptors. Some patients need to receive wound care management in an outpatient wound care clinic. Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

a. The wound edges are separated.
b. No drainage or erythema is present.
c. The patient is anxious about their removal.
d. A cosmetically aesthetic result would not be achieved.

A

ANS: A
Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges, normal color, and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, the wound has not healed properly. Notify the health care provider because sutures or staples may need to remain in place. Absence of drainage and erythema would indicate that sutures are ready for removal. Steps could be taken to relieve the patient’s anxiety, but suture removal is based on the condition of the wound. Timing of suture removal is based on adequate wound healing.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What should the nurse do when removing intermittent sutures?

a. Snip both sides of the suture before removing.
b. Snip the suture as close to the knot as possible.
c. Snip the suture as close to the skin as possible.
d. Pull up the knot to apply as much tension as possible.

A

ANS: C
Snip the suture as close to the skin as possible at the end distal to the knot. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knot of the suture with forceps, and gently pull up the knot while slipping the tip of the scissors under the suture near the skin.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What should the nurse do when performing suture or staple removal?

a. Snip both ends of the sutures.
b. Apply tension to the suture line to remove the sutures.
c. Pull the exposed surface of the suture through the tissue below the epidermis.
d. Apply Steri-Strips if any separation greater than the width of two stitches is present.

A

ANS: D
Apply Steri-Strips if any separation greater than two stitches or two staples in width is apparent, to maintain contact between wound edges. This supports the wound by distributing tension across the wound and eliminates closure technique scarring. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knotted end with forceps, and in one continuous smooth action, pull the suture through from the other side; this smoothly removes the suture without additional tension to the suture line. Tension on the suture line is not required. Never pull the exposed surface of any suture into tissue below the epidermis. The exposed surface of any suture is considered contaminated.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

The physician reports that he is expecting that the patient’s wound will have an output of close to 500 mL per day. The nurse anticipates placement of which of the following?

a. Dry sterile dressing
b. Jackson-Pratt (JP) drain
c. Hemovac drain
d. No drain

A

ANS: C
If drainage accumulates in the wound bed, wound healing is delayed. Drainage is removed by using a closed or an open drain system, even if the amount of drainage is small. A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range; the Hemovac drain accommodates more drainage, usually up to 500 mL in 24 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What is an appropriate technique for the nurse to implement for drainage evacuation?

a. Replace the Hemovac drain fully expanded.
b. Attach the drainage tubing to the patient’s gown.
c. Tilt the evacuator of the Hemovac away from the plug.
d. Complete the dressing change before the drainage evacuation.

A

ANS: B
Pinning drainage tubing to the patient’s gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?

a. Place a safety pin on the part of the drain outside the body.
b. Replace the cap immediately after emptying.
c. Pin the drainage tubing to the patient’s gown.
d. Place the Hemovac on a flat surface.

A

ANS: D
Place the evacuator on a flat surface with the open outlet facing upward; continue pressing downward until the bottom and the top are in contact; hold the surfaces together with one hand, quickly cleanse the opening and the plug with the other hand, and immediately replace the plug; and then secure the evacuator to the patient’s bed. Compression of the surface of the Hemovac creates a vacuum. Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation. Be sure the Penrose drain has a sterile safety pin in place. This pin prevents the drain from being pulled below the skin’s surface. Compress the bulb of a JP drain over the drainage container. Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container. Replacing the cap immediately prevents tension on the drainage tubing, but does not help to reestablish the vacuum.

37
Q

The nurse is explaining wound healing to a patient. Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

a. A reduction in the size of the wound is noted.
b. The epithelial cells duplicate.
c. Synthesis of collagen occurs at the site.
d. Blood flow to the wound and arrival of white blood cells are increased.

A

ANS: D
Vasodilatation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (white blood cells) arrive in the wound to begin wound cleanup. Macrophages, a type of white blood cell, appear and begin to regulate wound repair. The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound. It is during the proliferative stage, not the inflammatory stage, that contraction causes a reduction in the size of the wound, duplication of epithelial cells occurs, and collagen is synthesized.

38
Q

For absorption of heavy exudate from a wound, a nurse selects which of the following dressings?

a. Alginates
b. Hydrogel
c. Hydrocolloid
d. Transparent film

A

ANS: A
Alginates are used for absorption of heavy to moderate wound exudate. Hydrogels are used for dry wounds to wounds with minimal exudate. Hydrocolloids are used to absorb minimal to moderate exudate. Transparent film has no absorption quality.

39
Q

The nurse is educating a patient about his role in wound healing. Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level?

a. Age
b. Smoking
c. Underlying cardiopulmonary conditions
d. Hemoglobin

A

ANS: B
Factors that decrease oxygenation include decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions. Smoking is the only one of these factors that can be modified by the patient alone. Age causes vascular changes.

40
Q

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing. Which of the following can be appropriately delegated to the nurse assistant?

a. Performing a sterile dressing change
b. Observing for any drainage on the dressing
c. Performing wound assessment during the dressing change
d. Notifying the physician of drainage present on the dressing

A

ANS: B
Wound assessment and sterile dressing changes cannot be delegated to nursing assistive personnel (NAP). The nurse can direct the NAP to report any drainage from the wound that is present on the sheets or as strike-through from the dressing. The NAP should not be reporting this to a physician.

41
Q

You are irrigating a wound and are trying to make sure you get the wound adequately cleansed. Which of the following should you avoid?

a. Inserting the tip of a soft catheter into a deep wound
b. Using a 19-gauge angiocatheter
c. Pushing the tip inside a deep wound that has a small opening
d. Using a large syringe

A

ANS: C
Do not force a catheter into a wound because this will cause tissue damage. Using a 19-gauge angiocatheter and a 35-cc syringe is acceptable. If you need to irrigate a deep wound with a small opening, use a soft catheter and insert it 1.3 cm to avoid touching the fragile inner wall of the wound.

42
Q

How does the skin defend the body? (Select all that apply.)

a. Skin serves as a sensory organ for pain.
b. Skin serves as a sensory organ for touch.
c. Skin serves as a sensory organ for temperature.
d. Skin has an acid pH.

A

ANS: A, B, C, D
The skin defends the body by serving as a sensory organ for pain, touch, and temperature, and it has an acid pH, which is often called the “acid mantle.”

43
Q

Physiologically, wound healing occurs in the same way for all patients, with some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes which of the following cells? (Select all that apply.)

a. Liver cells
b. Skin cells
c. Renal tubules
d. Central nervous system neurons

A

ANS: A, C, D
Physiologically, wound healing occurs in the same way for all patients, with skin cells and some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes cells of the liver, renal tubules, and central nervous system neurons.

44
Q

You are explaining wound healing to your patient. You are trying to explain the healing process in a full-thickness wound. Which of the following phases should you include in your explanation? (Select all that apply.)

a. Hemostasis
b. Inflammation
c. Proliferation
d. Maturation

A

ANS: A, B, C, D

In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation.

45
Q

You are explaining negative-pressure wound therapy (NPWT) to a patient. Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

a. NPWT optimizes blood flow.
b. NPWT will remove wound fluid.
c. NPWT will maintain a moist environment.
d. NPWT will apply positive pressure to the wound.

A

ANS: A, B, C

NPWT supports wound healing by optimizing blood flow, removing wound fluid, and maintaining a moist environment.

46
Q

Wounds that have been approved for treatment using NPWT include which of the following? (Select all that apply.)

a. Pressure ulcers
b. Diabetic ulcers
c. Traumatic wounds
d. Venous stasis ulcers

A

ANS: A, B, C, D
Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT.

47
Q

The nurse is caring for a patient who has had major abdominal surgery. She is concerned about the possibility of dehiscence. During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply.)

a. Age
b. Malnutrition/obesity
c. Gender
d. Use of steroids

A

ANS: B, D

Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids.

48
Q

The _____________ is composed of newly formed collagen, and the nurse can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9.

A

ANS:
healing ridge
The healing ridge is composed of newly formed collagen, and you can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. Lack of a ridge is cause for concern, and you will need to begin interventions promptly to reduce mechanical strain on the wound.

49
Q

Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

A

ANS:
tertiary
Healing by tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed. Scarring is usually minimal.

50
Q

___________ is black, brown, or tan tissue in the wound that should be removed before wound healing can begin.

A

ANS:
Eschar
Black, brown, or tan tissue in the wound is eschar that should be removed before wound healing can begin.

51
Q

_____________ uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

A

ANS:
Irrigation
Irrigation uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

52
Q

A failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level is known as ______________.

A

ANS:
dehiscence
Dehiscence, a failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level. It occurs fairly early after surgery (5 to 8 days after surgery) in patients in whom the normal healing response lags.

53
Q

___________ are threads of wire or other materials used to sew body tissues together.

A

ANS:
Sutures
Sutures are threads of wire or other materials used to sew body tissues together.

54
Q

The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is considered a __________ drainage system.

A

ANS:
closed
A closed drainage system such as the JP drain (Figure 38-8) or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device.

55
Q

The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _____ dressing.

a. pressure
b. alginate
c. foam
d. hydrocolloid

A

ANS: A
Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate.

56
Q

The nurse is changing a dry, woven gauze dressing when she notices that the gauze has inadvertently stuck to the wound. What should the nurse do?

a. Pull the dressing off to aid in debridement.
b. Recover the dressing and leave in place.
c. Moisten the gauze to minimize trauma.
d. Ensure that the shiny side of the dry gauze dressing does not stick.

A

ANS: C
When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma. Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound.

57
Q

The nurse is caring for a patient who has a wound healing by primary intention that has little to no drainage. Which dressing is most appropriate for this type of wound?

a. Moist-to-dry dressing
b. Hydrocolloid dressing
c. Dry dressing
d. Hydrogel dressing

A

ANS: C
Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris. Hydrogel dressings (e.g., Curasol, IntraSite Gel, Vigilon) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues.

58
Q

The nurse would consider a dry dressing appropriate for a wound that requires which of the following?

a. Protection
b. Debridement
c. Absorption of heavy exudate
d. Healing by second intention

A

ANS: A
A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention.

59
Q

What should the nurse do for a patient who is having a wet-to-dry dressing applied?

a. Moisten the old inner dressing to remove it.
b. Pack the gauze in flat pieces into the wound.
c. Wet the new inner dressing with a cytotoxic solution.
d. Apply a secondary dressing over the inner wet packing.

A

ANS: D
The primary purpose of wet-to-dry dressings is to mechanically debride a wound. The moistened contact layer of the dressing (primary dressing) increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides the wound of tissue when the dressing is removed. The moistened gauze must be covered with a secondary dressing layer that is dry. It is incorrect technique and a common error by some clinicians to moisten the dried gauze before removing it. This defeats the purpose of using this type of dressing and reduces the amount of debris that the dressing will remove. Open or “fluff” the woven gauze that will be placed directly against the wound bed. Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions.

60
Q

Moist-to-dry dressings consist of gauze moistened with an appropriate solution. What should the nurse do when caring for a patient who has a pressure wound that requires debridement?

a. Saturate the primary dressing with saline or lactated Ringer’s solution.
b. Moisten the primary dressing with saline or lactated Ringer’s solution.
c. Moisten the primary dressing with acetic acid.
d. Moisten the primary dressing with povidone-iodine.

A

ANS: B
Moist-to-dry dressings consist of gauze moistened with an appropriate solution. Commonly used wetting agents include normal saline and lactated Ringer’s solution, which are isotonic solutions that aid in mechanical debridement. A dressing that is too wet causes tissue maceration and bacterial growth. It also does not dry out and therefore does not remove necrotic tissue when it is being removed from the wound. Acetic acid is effective against Pseudomonas aeruginosa but is toxic to fibroblasts in standard dilutions. Povidone-iodine is a rapid-acting antimicrobial agent for cleansing intact skin and is never used on a healthy granulating wound bed.

61
Q

The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

a. filling two thirds of the wound cavity.
b. leaving saline-soaked folded gauze squares in place.
c. putting the dressing in very tightly.
d. extending only to the upper edge of the wound.

A

ANS: D
Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface. If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed.

62
Q

What should the nurse do for a patient with a sudden severe hemorrhage?

a. Go for help.
b. Drape the patient.
c. Apply direct pressure.
d. Put on clean or sterile gloves.

A

ANS: C
Apply direct pressure immediately. Seek assistance after pressure is applied. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities.

63
Q

What should the nurse anticipate might happen to a patient if bleeding cannot be controlled?

a. Skin dryness
b. Bradycardia
c. Hypovolemic shock
d. Hypertension

A

ANS: C
Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shock. Hypertension is an increase in blood pressure.

64
Q

How should the nurse proceed when applying a pressure bandage?

a. Elevate the extremity or area of bleeding.
b. Wrap pressure-bandage gauze in a proximal-to-distal direction.
c. Apply pressure to diminish the pulse to the distal body part.
d. Wrap tape around the circumference of the site to secure the gauze padding.

A

ANS: A
As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity.

65
Q

Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond?

a. Initiate intravenous (IV) therapy.
b. Order blood for transfusions.
c. Remove and reapply any dressings.
d. Monitor vital signs every 15 minutes.

A

ANS: D
Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a provider’s order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.

66
Q

The patient is being sent home from the hospital after a cardiac catheterization. What should the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site?

a. Call the physician.
b. Call 9-1-1.
c. Apply pressure to the site.
d. Apply a new bandage.

A

ANS: C
Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site.

67
Q

The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon?

a. Pull the pipe out in the direction of entry.
b. Push the pipe through to the other side, then out.
c. Leave the pipe in place.
d. None of the above.

A

ANS: C
If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures.

68
Q

For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond?

a. Culture the wound.
b. Leave the current dressing in place.
c. Apply gauze over the top of the dressing.
d. Remove and stretch the film more tightly over the wound.

A

ANS: A
Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained.

69
Q

The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed?

a. Apply a film dressing after culturing the wound.
b. Apply a film dressing after cleansing the area.
c. Choose another type of dressing for this wound.
d. Keep the wound open to air.

A

ANS: C
If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, rather than transparent film dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and family that collection of wound fluid under the dressing is not “pus,” but rather is a result of normal interaction of body fluids with the dressing.

70
Q

In what type of wound is a foam dressing contraindicated?

a. Shallow stage II ulcer
b. Exudative stage II ulcer
c. Wound that has tunneling
d. Wound that is infected

A

ANS: C
Foam dressings are not appropriate when there is wound tunneling because the dressing expands, which can enlarge the tunnels. International pressure ulcer guidelines recommend foam for use on exudative stage II and shallow stage II pressure ulcers. Foam dressings are also used to dress infected wounds.

71
Q

When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as:

a. an expected occurrence.
b. a wound infection requiring a culture.
c. an adverse reaction to the hydrocolloid components.
d. excessive exudate requiring a different type of dressing.

A

ANS: A
Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odor. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound.

72
Q

What should the nurse remember to do when applying a hydrocolloid dressing?

a. Apply granules after applying the wafer.
b. Never use a secondary dressing.
c. Hold the dressing in place.
d. Use silk tape to hold the dressing in place.

A

ANS: C
Hold the dressing in place for 30 to 60 seconds after application. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case of a deep wound, hydrocolloid granules or paste is applied before the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic, paper tape around the edges of the hydrocolloid dressing.

73
Q

Which of the following is an appropriate procedure for the nurse to implement during the application of an absorption or alginate dressing?

a. Never cut the dressing to fit the wound.
b. Irrigate the wound gently to remove residual gel.
c. Fill the wound cavity entirely with the dressing material.
d. Never use a secondary dressing.

A

ANS: B
Cleanse the area gently with moist 4 × 4 sterile gauze pads, swabbing exudate away from the wound, or spray with a wound cleanser. Cleansing effectively removes any residual dressing gel without injuring newly formed delicate granulation tissue formed in the healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid.

74
Q

The nurse is caring for a patient who had a negative-pressure wound dressing. The nurse realizes that the system is working properly when the vacuum setting is set at which of the following levels?

a. –40 mm Hg
b. –210 mm Hg
c. –125 mm Hg
d. –25 mm Hg

A

ANS: C
The target negative pressures for wound healing range from –50 mm Hg to –175 mm Hg, but a setting of –125 mm Hg is most common.

75
Q

The nurse is caring for a patient who has a negative-pressure dressing. The nurse realizes that typically the dressing should be changed:

a. every shift.
b. daily.
c. every 8 hours.
d. every 48 hours.

A

ANS: D
You will typically change an entire NPWT dressing and wound filler every 48 hours or 3 times per week. The schedule for changing NPWT dressings varies and is based on the type and condition of the wound. An infected wound may need a dressing change every 24 hours, whereas a clean wound can be changed 3 times a week.

76
Q

The nurse is preparing to apply a gauze bandage to a dressing on the patient’s wrist. How should the nurse proceed?

a. Use a 3-inch bandage.
b. Use a 2-inch bandage.
c. Apply from the elbow toward the wrist.
d. Secure the bandage with a safety pin.

A

ANS: B
When applying a gauze or elastic bandage, you select a type of bandage and bandage width depending on the size and shape of the body part to be bandaged. For example, 3-inch bandages are used most commonly for the adult leg. A smaller, 2-inch bandage normally is used for the upper extremity. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage.

77
Q

Which of the following tasks might be delegated to nursing assistive personnel (NAP)?

a. Pressure dressing to an actively bleeding wound
b. Chronic wound that needs a nonsterile moist-to-dry dressing change
c. Hydrogel dressing change
d. Wound assessment during the dressing change

A

ANS: B
The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see facility policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated.

78
Q

Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.)

a. Maintains a moist environment
b. Prevents the spread of microorganisms
c. Increases patient comfort
d. Controls bleeding

A

ANS: A, B, C, D
Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding.

79
Q

Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.)

a. Burns
b. Surgical incisions
c. Infected wounds
d. Deep pressure ulcers

A

ANS: A, C, D
Healing by secondary intention occurs when a wound is left open. Healing results in the formation of granulation tissue from the bottom of the wound and eventual epithelialization from the sides of the wound to close the defect. During the process of epithelialization, epithelial cells migrate and proliferate from the wound edges to cover the wound surface. Burns, infected wounds, and deep pressure ulcers heal in this manner.

80
Q

Hydrocolloid dressings are used for which of the following? (Select all that apply.)

a. Maintaining a moist wound environment
b. Autolytic debriding of necrotic wounds
c. Absorption of moderately draining wounds
d. Protecting from friction

A

ANS: A, B, C
Hydrocolloid dressings comprise elastometric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction.

81
Q

Negative-pressure wound therapy (NPWT) would be contraindicated in which of the following? (Select all that apply.)

a. Dehisced wounds
b. Pressure ulcers
c. Malignancies
d. Necrotic tissue with eschar

A

ANS: C, D
NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together. It is commonly used for acute, chronic, traumatic, and dehisced wounds; pressure ulcers; and partial-thickness burns and as a bolster for skin grafts. Contraindications for NPWT for chronic wounds are exposed vital organs, inadequately debrided wounds, untreated osteomyelitis or sepsis near a wound, untreated coagulopathy, necrotic tissue with eschar, and malignancy within a wound.

82
Q

In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.)

a. Remove the binder and assess the skin and wound every 8 hours.
b. Evaluate the patient’s ability to breathe deeply and cough effectively every 4 hours.
c. Evaluate the patient’s pulmonary function every 8 hours.
d. Remove the binder at least daily.

A

ANS: A, B
Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patient’s ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function.

83
Q

The nurse is demonstrating a dressing change to a nursing student. What key safety features should she emphasize during the process? (Select all that apply.)

a. Knowing the type of wound
b. Knowing the expected amount of drainage
c. Knowing the patient’s blood type
d. Knowing whether drainage tubes are present

A

ANS: A, B, D
It is important to:
1. Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used.
2. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing.
3. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing.
Knowing the patient’s blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done.

84
Q

A __________ dressing comes in direct contact with the wound bed.

A

ANS:
primary
A primary dressing comes in direct contact with the wound bed.

85
Q

_____________ dressings cover or hold primary dressings in place.

A

ANS:
Secondary
Secondary dressings cover or hold primary dressings in place.

86
Q

___________ healing takes place when tissue is cleanly cut and the margins are reapproximated.

A

ANS:
Primary
Primary healing takes place when tissue is cleanly cut and the margins are reapproximated.

87
Q

_______________ dressings are used for wounds that require debridement.

A

ANS:
Moist-to-dry
Moist-to-dry dressings are used for wounds that require debridement.

88
Q

A _______________ is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters.

A

ANS:
transparent dressing
A transparent dressing is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing. These dressings manage superficial, minimally draining wounds and often are used for protection over high-friction areas and over IV catheters.

89
Q

_______________ is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.

A

ANS:
Negative-pressure wound therapy (NPWT)
NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.