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ISB:Tissue Integrity
Nightingale BSN 205, Week 8, ISB: Tissue Integrity (Wound Care)
| Question | Answer |
|---|---|
| A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. | False. |
| Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms | True |
| Which of the following may indicate internal hemorrhage? (Select all that apply.) | Distention or swelling of the affected body part. A decreased blood pressure and increased pulse. A change in the type and amount of drainage from a surgical drain. |
| Which of the following patients has the least risk for developing a wound infection? | A 30-year-old woman who had an episiotomy with childbirth |
| When teaching a patient about wound healing, what should the nurse tell the patient? | Inadequate nutrition delays wound healing and increases risk of infection. |
| The nurse is caring for a patient who had knee replacement surgery 5 days ago. Knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? | The patient is demonstrating signs of a postoperative wound infection. |
| The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? | The nurse should be alert for an increase in serosanguineous drainage from the wound. |
| The nurse reports that a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient: | Is at greater risk for infection. |
| A postoperative diabetic patient had an exploratory laparotomy 5 days ago. The patient’s history indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Based on this information, the patient should be observed for: | Wound dehiscence |
| Which of the following are common sites for the development of pressure injuries? (Select all that apply.) | Heels. Sacrum. Lateral male oil. Trochanters. Ischial tuberosities. |
| Identify contributing factors to pressure injury formation. (Select all that apply) | Malnutrition. Decreased sensory perception/mobility. Anemia. Excessive sweating. |
| Identify prevention strategies for pressure injuries. (Select all that apply.) | When the patient is in the side-lying position in bed, use the 30-degree lateral position. Place patient on a pressure-reducing support surface. Oral supplements should be instituted if the patient is found to be undernourished. |
| The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? | She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. |
| A family member calls regarding their mother who has developed a “bedsore” on her right heel. Describes the injury as “a blister that has now popped and you can see redness.” Based on this description, at what stage would classify this pressure injury? | Stage 2. |
| The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? | To provide suction to remove and collect drainage from your wound to help it heal." |
| A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? | "If drainage suddenly stops, it means the drain is ready to be removed." |
| When should wound drainage be cultured? | When there is a change in color, amount, or odor of drainage. |
| The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient: | empties the Hemovac drain, replaces the plug, and records the amount of drainage. |
| Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this? | Because drainage can be irritating to the skin and may cause skin breakdown. |
| Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? | Assessment of wound drainage. |
| The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse’s best action | Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site. |
| Which of the following are functions of dressings? (Select all that apply.) | To promote hemostasis. Wound Debridement. To prevent contamination. |
| Which of the following patients would be expected to benefit from a damp-to-dry dressing? (Select all that apply.) | A 24-year-old patient with an open and infected wound from a spider bite. A 30-year-old after large cyst removal with necrotic tissue present in crater-type wound. |
| The nurse is observing the patient's wife perform the damp-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) | Packs wound tightly. Leaves contact or primary dressing dripping moist. |
| A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to complain of pain. What measures may be taken? (Select all that apply.) | Switch to the white polyvinyl alcohol (PVA) soft foam. Decrease the pressure setting. Administer pain medication |
| During a sterile dressing change, when are the gloves changed? | After the old dressing is removed and before cleansing the wound |
| A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? | Correct! "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing." |
| A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? | "Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes. |
| How can the nurse determine that negative pressure is being achieved with a wound V.A.C.? | The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure. |
| Which of the following is a correct sequence for changing a gauze dressing? | Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing |
Created by:
alishalynne93
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