Deck 40: Wound Care and Irrigations

Question 1

The nurse is changing a surgical dressing and is cleansing the wound.She knows that:

A)the incision line should be cleansed last.
B)she should start at one end of the incision line and swab the entire length.
C)she should start at the center of the incision line and swab toward one end.
D)she should work in a circular motion around the incision line.

Answer 1

she should start at the center of the incision line and swab toward one end.

Question 2

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing.Which of the following can be appropriately delegated to the nurse assistant?

A)Performing a sterile dressing change
B)Observing for any drainage on the dressing
C)Performing wound assessment during the dressing change
D)Notifying the physician of drainage present on the dressing

Answer 2

Observing for any drainage on the dressing

Question 3

What should the nurse do when performing suture or staple removal?

A)Snip both ends of the sutures.
B)Apply tension to the suture line to remove the sutures.
C)Pull the exposed surface of the suture through the tissue below the epidermis.
D)Apply Steri-Strip if any separation greater than the width of two stitches is present.

Answer 3

Apply Steri-Strip if any separation greater than the width of two stitches is present.

Question 4

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

A)Decrease scar formation.
B)Remove debris from the wound.
C)Improve circulation from the wound.
D)Decrease irritation from wound drainage.

Question 5

What is an appropriate technique for the nurse to implement for drainage evacuation?

A)Replace the Hemovac drain fully expanded.
B)Attach the drainage tubing to the patient's gown.
C)Tilt the evacuator of the Hemovac away from the plug.
D)Complete the dressing change before the drainage evacuation.

Question 6

The nurse is caring for a patient who has a dressing over a surgical wound created the night before.The dressing has never been changed.How should the nurse proceed?

A)Change the dressing so she can assess the wound.
B)Administer an analgesic 30 to 45 minutes before a dressing change.
C)Culture the wound if wound exudate is present.
D)Administer an analgesic 30 minutes after a dressing change.

Question 7

Which of the following approaches is correct technique when wound irrigation is performed?

A)Placing the patient in supine position
B)Placing the syringe directly into the wound
C)Using sterile technique for a chronic wound
D)Selecting a soft catheter for deep wounds with small openings

Question 8

The nurse is educating a patient about his role in wound healing.Which of the following factors,if modified by the patient,can support adequate oxygenation at the tissue level?

A)Age
B)Smoking
C)Underlying cardiopulmonary conditions
D)Hemoglobin

Question 9

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?

A)Place a safety pin on the part of the drain outside the body.
B)Replace the cap immediately after emptying.
C)Pin the drainage tubing to the patient's gown.
D)Place the Hemovac on a flat surface.

Question 10

How does the skin defend the body?

A)Skin serves as a sensory organ for pain.
B)Skin serves as a sensory organ for touch.
C)Skin serves as a sensory organ for temperature.
D)Skin has an acid pH.

Question 11

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

A)The wound edges are separated.
B)No drainage or erythema is present.
C)The patient is anxious about their removal.
D)A cosmetically aesthetic result would not be achieved.

Question 12

The nurse is explaining healing of a full-thickness wound to a patient.Which of the following phases should the nurse include in the explanation?

A)Hemostasis
B)Inflammation
C)Proliferation
D)Maturation

Question 13

When teaching about wound care in the home environment,the nurse instructs the patient and caregiver to:

A)make normal saline with 8 teaspoons of salt and 1 gallon of distilled water.
B)use normal saline for 1 week and then discard it.
C)not apply topical anesthetics before wound care.
D)call the physician's office to have someone come to the home and complete the wound care.

Question 14

The nurse should consider culturing a wound when which one of the following situations occurs?

A)The tissue is clean and dry.
B)Exudate is not present.
C)The patient is afebrile.
D)The surrounding area shows inflammation.

Question 15

The physician expects that the patient's wound will have an output of close to 500 mL/day.The nurse anticipates placement of which of the following?

A)Dry sterile dressing
B)Jackson-Pratt (JP)drain
C)Hemovac drain
D)No drain

Question 16

Healing by primary intention is expected to occur with which of the following situations?

A)The wound is left open and is allowed to heal.
B)A surgical wound is left open for 3 to 5 days.
C)Connective tissue development is evident.
D)The edges of a clean incision remain close together.

Question 17

What should the nurse do when removing intermittent sutures?

A)Snip both sides of the suture before removing.
B)Snip the suture as close to the knot as possible.
C)Snip the suture as close to the skin as possible.
D)Pull up the knot to apply as much tension as possible.

Question 18

The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock.How should the nurse proceed?

A)Use irrigation pressures of less than 4 psi.
B)Cleanse in a direction from most contaminated to least contaminated.
C)Irrigate so that the solution flows from least contaminated to most contaminated.
D)Irrigate with clean irrigation solution only.

Question 19

The nurse is explaining wound healing to a patient.Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

A)A reduction in the size of the wound is noted.
B)The epithelial cells duplicate.
C)Synthesis of collagen occurs at the site.
D)Blood flow to the wound and arrival of white blood cells are increased.

Question 20

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

A)Graft sites
B)Wounds with exposed blood vessels
C)Necrotic tissue
D)Wounds with exposed muscle or tendons

Question 21

The _____________ is composed of newly formed collagen,and the nurse can usually feel it along a healing wound.It is usually present directly under the suture line between days 5 and 9.

Question 22

The Jackson-Pratt (JP)drain relies on the presence of a vacuum to withdraw drainage and is considered a __________ drainage system.

Question 23

Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

Question 24

You are explaining negative-pressure wound therapy (NPWT)to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing?

A)NPWT optimizes blood flow.
B)NPWT will remove wound fluid.
C)NPWT will maintain a moist environment.
D)NPWT will apply positive pressure to the wound.

Question 25

_____________ uses the mechanical force (high or low)of a stream of solution to remove debris,bacteria,and necrotic tissue from a wound.

Question 26

Wounds that have been approved for treatment using negative-pressure wound therapy (NPWT)include which of the following?

A)Pressure ulcers
B)Diabetic ulcers
C)Traumatic wounds
D)Venous stasis ulcers

Question 27

___________ is black,brown,or tan tissue in the wound that should be removed before wound healing can begin.

Question 28

___________ are threads of wire or other materials used to sew body tissues together.

Question 29

The nurse is caring for a patient who has had major abdominal surgery and is concerned about the possibility of dehiscence.During the assessment,the nurse assesses for which of the following contributing factors?

A)Age
B)Malnutrition/obesity
C)Gender
D)Use of steroids