Deck 40: Wound Care Management and Dressings

Question 1

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.

Answer 1

Hold the dressing in place.

Question 2

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

A) primary
B) secondary
C) tertiary
D) multi-layer

Answer 2

primary

Question 3

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 odour.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.

Answer 3

an expected occurrence.

Question 4

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) Apply direct pressure to the insertion site of the pipe.

Question 5

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.

Question 6

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.

Question 7

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.

Question 8

In what type of wound is a foam dressing contraindicated?

A) Shallow stage 2 pressure injury
B) Exudative stage 2 pressure injury
C) Wound that has tunnelling
D) Wound that is infected

Question 9

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

A) pressure
B) alginate
C) foam
D) hydrocolloid

Question 10

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.

Question 11

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

Question 12

The nurse is changing a dry,woven gauze dressing when it is observed 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.

Question 13

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.

Question 14

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.

Question 15

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

Question 16

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.

Question 17

Which of the following tasks might be delegated to unregulated care providers (UCP)?

A) Pressure dressing to an actively bleeding wound
B) Chronic wound that needs a nonsterile dry dressing change
C) Hydrogel dressing change
D) Wound assessment during the dressing change

Question 18

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 occurs 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.

Question 19

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 7.5-cm (3-inch)bandage.
B) Use a 5-cm (2-inch)bandage.
C) Apply from the elbow toward the wrist.
D) Secure the bandage with a safety pin.

Question 20

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

Question 21

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

A) Primary
B) Secondary
C) Tertiary
D) Multi-layer

Question 22

The nurse is demonstrating a dressing change to a nursing student.What key safety features should be emphasized 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

Question 23

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

Question 24

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

Question 25

Which of the following may dry gauze come impregnated with? (Select all that apply.)

A) Zinc oxide paste
B) Iodinated agents
C) Petrolatum
D) Crystalline sodium chloride
E) None of the above

Question 26

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.

Question 27

_____________ dressings cover or hold primary dressings in place.

A) Primary
B) Secondary
C) Tertiary
D) Multi-layer

Question 28

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
E) None of the above

Question 29

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

A) gauze dressing
B) transparent film
C) hydrocolloid
D) hydrofibre gel