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Wound Care Post test info

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Answer
Identify which of the following wounds would heal by secondary intention. (Select all that apply.) A. A pressure injury B. A surgical incision closed with staples C. An open surgical wound requiring packing D. A full-thickness burn   show
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show D. A peripheral vascular venous stasis injury E. A pressure injury  
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A wound that has healed by primary intention will have more scar formation than a wound that has healed by secondary intention. A. True B. False   show
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show B. Evisceration  
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What should the nurse's next action be after applying sterile gloves? A. Reinforce the dressing. B. Notify the health care provider. C. Apply sterile gauze saturated with sterile normal saline. D. Gently replace the intestinal protrusion and apply Ste   show
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Which of the following may primarily contribute to the development of dehiscence and evisceration, rather than fistula formation? (Select all that apply.) A. Radiation B. Obesity C. Cancer D. Malnutrition   show
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Identify the patients who may be at risk for impaired wound healing. (Select all that apply.) A. An obese patient who had abdominal surgery B. An elderly patient who has peripheral vascular disease and a foot injury C. A malnourished patient with AIDS   show
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show A. An 80-year-old underweight alcoholic with an infected toe  
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show A. True  
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123456 Location 1 Select label... 2 Select label... 3 Select label... 4 Select label... 5 Select label... 6 Select label...   show
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An elderly patient with chronic obstructive pulmonary disease (COPD) and pneumonia was admitted to the hospital. The patient reports a 40-year history of smoking. He is able to ambulate independently for short distances such as to the bathroom and does s   show
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It is a very busy day on the nursing unit. The nurse has several patient admissions and discharges. One of the patients under the nurse's care has a chronic pressure injury of the coccyx. Regarding this patient's care, what can the nurse delegate to the n   show
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show B. "It helps us identify people who are at risk for pressure injuries and intervene appropriately."  
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A poorly nourished patient is at risk for delayed wound healing. Which of the following indicate a poor nutritional status? (Select all that apply.) A. Body weight decreased by 17% B. Lymphocyte count less than 2500 per mm3 C. Serum albumin less than 3   show
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Injury Description 1. Blister on the elbow 2. Crater-type wound on the heel 3. Persistent redness over the greater trochanter 4. Crater-type wound with the bone visible   show
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show 1. True  
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A patient is being maintained on bed rest. Which of the following are appropriate expected outcomes regarding the prevention of skin breakdown for this patient? A. Patient's position is changed at least every 2 hours. B. Patient's skin remains intact an   show
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show A. Granulation tissue is present in wound base. B. Drainage from pressure injury site decreases D. Surrounding skin remains intact  
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Risk Factor Assessment Intervention 1. The patient is bedridden. ______ __________Implement turning schedule; provide pressure reduction surface. 2. The patient is incontinent. Moisture __________ ____________ 3. The patient needs help moving. ______   show
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show A. Surrounding skin is pink and intact, with injury decreasing in size. C. Signs and symptoms of infection are absent; foul odor and/or purulent drainage are absent; patient afebrile. D. Injury is approximately 3 cm (1.2 in.) diameter and 2 cm (0.8 in.)  
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show A. The patient's age C. The patient's nutritional status  
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The nurse makes an ongoing assessment of the patient’s skin. A(n) ________ sign of pressure-related injury is skin that does not blanch when firmly pressed.   show
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show B. necrotic  
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show D. 30- degree  
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The nurse knows to avoid ________ reddened areas because this may cause skin breakdown.   show
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Every time the nurse enters the room, the patient has slid to the bottom of the bed. This is an example of ________.   show
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In attempting to move himself up in bed, the patient has rubbed an area of skin on his elbows. This is an example of ________.   show
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show IMPEDE - A> steroid therapy >C. malnutrition >D. smoking >G. diabetes PROMOTE- B. young age E. moist wound environment F. absence of inffection H. normal weight  
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show False  
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show True  
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show - 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  
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show Inadequate nutrition delays wound healing and increases risk of infection.  
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show A 30-year-old woman who had an episiotomy with childbirth.  
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The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient’s 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   show
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show The nurse should be alert for an increase in serosanguineous drainage from the wound  
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show Is at greater risk for infection.  
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A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 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 nurse understands the pa   show
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show B. heels C. sacrum D. Lateral malleoli E. Trochanters F. Ischial tuberosities  
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show A. Malnutrition C. Decreased sensory perception/mobility D. Anemia E. Excessive sweating  
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Identify prevention strategies for pressure injuries (select all). A. Reposition pt atleast q4h; use a documented schedule. B. When the pt is in the side lyig position in bed, use the 30 degree lateral position. C. Place pt on a pressure reducing supp   show
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show B. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water.  
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show Stage 2  
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The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? A. To reduce the need for frequent dressing changes. B. To provide suction to remove and collect drainage from your wound to help it heal.   show
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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? A. I should empty the drain when it is one-half to two-thirds full. B. If drainage suddenly stops, it   show
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show A. When there is a change in color, amount, or odor of drainage.  
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show D. empties the Hemovac drain, replaces the plug, and records the amount of drainage.  
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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?   show
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Which of the following is inapproporaite to delegate to nursing assistive personnel (NAP)? A. Emptying a closed drainage container B. Measuring the amount of drainage C. Assessment of wound drainage. D. Reporting the amount on the patient's intake an   show
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The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse's best action?   show
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show A. To promote hemostasis C. Wound debridement' D. To prevent contamination  
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Which of the following patients would be expected to benefit from a damp to dry dressing? Select all   show
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show B. Packs wound tightly C. Leaves contact or primary dressing dripping moist.  
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A patient with a wound vaccum assisted closure (wound VAC) continues to complain of pain. What measures may be taken? A. Switch to the white poly vinyl alcohol (PVA) soft foam B. Decrease the pressure setting C. Administer pain medication D. Switch to   show
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show B. After the old dressing is removed and before cleansing the wound.  
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show A. Make sure that you have a margin of 1 to 1.5 in (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing.  
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A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response?   show
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show C. The nurse can check for air leaks by listening with a stethescope or by moving the hand around the edges of the wound while applying light pressure.  
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Which of the following is a correct sequence for changing a gauze dressing?   show
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