Deck 25: Wound Care and Dressings

Question 1

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
When cleansing the skin under a drain site,you use a __________ motion,moving from the __________ of the drain site to the __________ of the wound.

Answer 1

Circular,edge,periphery.

Question 2

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
Mrs.Smith has a Hemovac suction in place.Briefly describe how to reestablish the closed drainage system after emptying the suction.

Answer 2

Pour out drainage.Compress Hemovac by pushing top and bottom together.Reinsert plug,keeping pump tightly compressed.

Question 3

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
While setting up the sterile field,state four guidelines that need to be followed to maintain sterility.
a._________________
b._________________
c._________________
d._________________

Answer 3

a.Never turn your back on a sterile field.
b.Avoid talking,coughing,sneezing,or reaching across a sterile field.
c.Keep sterile objects above waist level.
d.Do not spill solutions on the sterile field.
e.Open all sterile packages away from the sterile field to prevent crossover and contamination.

Question 4

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
Briefly describe how to place the contents of a commercially prepared package on the sterile field.

Question 5

Describe how an electrical stimulation is used in wound care therapy.

Question 6

You are ambulating a client down the hall 7 days after surgery when he suddenly coughs and dehiscence occurs.Your first action is to

A)Place him in a supine position.
B)Call the doctor.
C)Obtain vital signs.
D)Cover the wound with a sterile dressing.

Question 7

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
When placing the sterile 4*4 gauze pads on Mrs.Smith's incision,you did not cover the incision as you intended.You should

A)Remove the gauze pads and replace them with new pads.
B)Adjust the pads to cover the incision.
C)Place an additional pad over the exposed section of the incision.
D)Leave the gauze pads in place and apply an ABD over them.

Question 8

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
If Mrs.Smith's wound becomes infected,healing takes place by __________ healing.

Question 9

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
When putting on sterile gloves,the most important concept to remember is to keep both gloves in __________ of you and above your __________.

Question 10

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
Several days later the physician asks you to remove Mrs.Smith's staples.The most appropriate action to accomplish this is to place the staple-removing device

A)On one side of staple,depress device,and lift off staple.
B)On both ends of staple,one side at a time,depress device,and lift off staple.
C)Under center of staple,press down on handle to clip staple.
D)Under center of staple,lift staple,then depress device.

Question 11

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
List three goals of wound care.
a.____________
b.____________
c.____________

Question 12

List three of the four wound care protocols that need to be completed each time a dressing is changed for an open wound.
a.___________
b.___________
c.___________

Question 13

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
Commercially prepared sterile packages can be opened and used as a sterile field.

Question 14

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
You are asked to apply an abdominal binder to Mrs.Smith.You position the binder so it is at the top of the __________ and under her hips at the level of the __________.

Question 15

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
In addition to the obvious obesity factor,list three factors that might have affected wound healing in Mrs.Smith's condition.
a.____________
b.____________
c.____________

Question 16

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
The most important principle for maintaining sterility is not to __________ the sterile field.

Question 17

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
You are preparing to complete a dressing change for Mrs.Smith.Place in sequence from 1 to 10 the activities you perform.(An activity may be performed more than one time. )
__________ a.Remove old dressing.
__________ b.Don sterile gloves.
__________ c.Prepare a sterile field.
__________ d.Obtain a wound culture specimen.
__________ e.Don clean gloves.
__________ f.Wash your hands.
__________ g.Cleanse the wound.
__________ h.Apply sterile dressing.
__________ i.Discard clean gloves.
__________ j.Discard sterile gloves.

Question 18

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
Which hand,dominant,or nondominant,is usually placed in a sterile glove first?

Question 19

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
While preparing for your clinical experience,you remember that healing takes place in the following three major phases.
a.___________
b.___________
c.___________

Question 20

Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery. She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience.
When cleaning Mrs.Smith's wound,you start at the __________ area and work to the __________ area.

Question 21

List the four mechanical factors that contribute to the development of pressure ulcers.
a._________________
b._________________
c._________________
d._________________

Question 22

Before surgery,clients are assessed to determine risk factors associated with surgical site infections (SSIs).List 2 risk factors.

Question 23

Complete the nurses' notes for a wet-to-moist dressing change.Your assessment includes the following data: The incision was healing by secondary intention with the bottom edge starting to close.The exudate was greenish yellow and purulent in nature.Normal saline was used for the dressing change.The discarded dressing was dry and covered with a large amount of exudate.

Question 24

Circle T if the statement is true or F if the statement is false.

A)When putting on sterile gloves,the second glove may be pulled on by grasping the edge of the folded cuff with the sterile gloved hand.
B)When opening sterile wrappers,open the first edge toward you.
C)When placing medicine cups on a sterile tray,they should be placed near the center of the field.
D)The label on the medicine bottle is kept in the uppermost position when pouring.
E)Pull the tape away from the incision site when removing soiled dressings.
F)Cleanse the wound site by starting at the outer edge and working toward the incision.
G)Montgomery straps should be used for most abdominal wounds.
H)The Hemovac or Jackson-Pratt suction provides drainage for a wound only when it is compressed.
I)When removing sutures,the straight tip of the scissors is placed away from the knot under the suture.
J)The staple remover is placed under the staple near the edge for staple removal.
K)When removing sterile gloves from the wrapper,it is important to remember that the inside of the wrapper must remain sterile.
L)The major goal for a wet-to-damp dressing is to maintain a moist environment.

Question 25

Clients with which one of the following conditions would not be a candidate for electrical stimulation wound therapy?

A)Traumatic wounds
B)Wound flap
C)Recipient site of burn graft
D)Diabetic ulcers

Question 26

When applying a transparent dressing to a pressure ulcer,the most important principle is to keep it .

Question 27

The client has a score of 12 on the Norton Scale for assessing the risk for developing a pressure ulcer.What does this indicate?

A)No risk for ulcer development.
B)High risk for ulcer development.
C)Some risk for ulcer development.
D)Highly unlikely an ulcer will develop.

Question 28

Which of the following interventions is most beneficial in preventing formation of a pressure ulcer?

A)Keep skin dry by applying benzoin or alcohol around reddened areas.
B)Ensure fluid intake of at least 2000 mL each day.
C)Elevate head of bed to prevent pressure on coccyx and heels.
D)Change chux under client each shift.

Question 29

To obtain the ankle-brachial index (ABI),divide the __________ by the __________.

Question 30

Clients using the Warm-Up Therapy system will be required to keep it in place for how long?

Question 31

Negative pressure wound therapy will not be used for which one of the following clients? Clients with

A)Traumatic wounds.
B)Necrotic tissue and eschar.
C)Pressure ulcers.
D)Dehised wounds.

Question 32

List four areas of the body most vulnerable to the formation of pressure ulcers.
a._________________
b._________________
c._________________
d._________________

Question 33

Which wound assessment findings indicate the vacuum assisted closure V.A.C can be implemented in treatment of the wound?

Question 34

Electrical stimulation treatments last

A)30 minutes
B)60 minutes
C)8 hours
D)24 hours