Flashcards in Diabetic Patient Deck (35)
The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _____ dressing.
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.
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.
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.
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
The nurse would consider a dry dressing appropriate for a wound that requires which of the following?
c. Absorption of heavy exudate
d. Healing by second intention
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.
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.
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.
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.
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.
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.
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.
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.
What should the nurse anticipate might happen to a patient if bleeding cannot be controlled?
a. Skin dryness
c. Hypovolemic shock
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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.
c. every 8 hours.
d. every 48 hours.
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.
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.
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.
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
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.
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
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.
Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.)
b. Surgical incisions
c. Infected wounds
d. Deep pressure ulcers
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.
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
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.
Negative-pressure wound therapy (NPWT) would be contraindicated in which of the following? (Select all that apply.)
a. Dehisced wounds
b. Pressure ulcers
d. Necrotic tissue with eschar
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.
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.
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.
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, B, D