Nightingale BSN 205, Week 8, ISB: Tissue Integrity (Wound Care)
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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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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| Which of the following patients has the least risk for developing a wound infection? | show 🗑
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| show | Inadequate nutrition delays wound healing and increases risk of infection.
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| show | The patient is demonstrating signs of a postoperative wound infection.
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| The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? | show 🗑
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| 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: | show 🗑
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| show | Wound dehiscence
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| show | Heels. Sacrum. Lateral male oil. Trochanters. Ischial tuberosities.
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| show | Malnutrition. Decreased sensory perception/mobility. Anemia. Excessive sweating.
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| Identify prevention strategies for pressure injuries. (Select all that apply.) | show 🗑
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| show | She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water.
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| 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? | show 🗑
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| The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? | 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? | show 🗑
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| When should wound drainage be cultured? | show 🗑
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| show | 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 inappropriate to delegate to nursing assistive personnel (NAP)? | 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 | To promote hemostasis. Wound Debridement. To prevent contamination.
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| show | 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.
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| show | Packs wound tightly. Leaves contact or primary dressing dripping moist.
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| show | Switch to the white polyvinyl alcohol (PVA) soft foam. Decrease the pressure setting. Administer pain medication
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| show | After the old dressing is removed and before cleansing the wound
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| A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? | show 🗑
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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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| How can the nurse determine that negative pressure is being achieved with a wound V.A.C.? | show 🗑
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| Which of the following is a correct sequence for changing a gauze dressing? | show 🗑
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