Question 1

The nurse manager has noted an increase in wound infections in a postoperative unit.What instruction to the unit staff is the most important?

Accepted Answer

Following hand hygiene protocols is the most effective way to prevent infections in a healthcare setting, including wound infections in a postoperative unit. Hand hygiene is a fundamental practice for preventing the spread of infections according to the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

Question 2

A male patient tells the nurse that he has "excruciating pain" in his perineal region that started a few days after having an indwelling urinary catheter removed.Upon inspection,the nurse sees a dime-sized reddened area on the patient's perineum below the scrotal sac.What nursing intervention is priority?

Accepted Answer

The patient's symptoms of excruciating pain and a reddened area on the perineum are concerning for Fournier's gangrene, a rare but serious form of necrotizing fasciitis that affects the genital and perineal regions. Immediate evaluation and treatment by a healthcare provider is necessary for this potentially life-threatening condition. The other interventions listed may provide some temporary relief of symptoms, but they do not address the underlying problem and may potentially worsen the condition if it is Fournier's gangrene.

Question 3

A nurse documents a stage 1 pressure ulcer on a patient's lateral malleolus.What assessment findings would indicate that this ulcer has progressed to stage II? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Stage II pressure ulcers are characterized by partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. They may also present as intact or open/ruptured serum-filled blisters. Option A describes a stage III pressure ulcer where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Option D describes suspected deep tissue injury, and Option E describes non-blanchable erythema, which is characteristic of a stage I pressure ulcer.

Question 4

The nurse measures a patient's wound diameter and notes that it has reduced in size.The nurse evaluates this information to indicate the wound has entered which phase?

Accepted Answer

Wound healing consists of four phases: inflammatory, proliferative, remodeling, and maturation. The proliferative phase is characterized by the formation of new tissue and wound contraction. Reducing wound diameter is an indication that the wound is in the proliferative phase.

Question 5

The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection.Which nursing intervention is indicated?

Accepted Answer

Drawing peak and trough levels is necessary for monitoring the drug's therapeutic effectiveness and preventing toxicity.

Question 6

There is dead tissue throughout the patient's nonhealing abdominal wound.The nurse prepares for which intervention needed to encourage this wound to heal?

Accepted Answer

The presence of dead tissue in the wound bed impedes the healing process and needs to be removed through a process called debridement. This can be done through surgical, mechanical, or chemical means. Other interventions such as ensuring protein adequacy and providing oxygen to the wound bed may also be necessary, but they would not be effective until the devitalized tissue is removed. Introduction of air into the wound would not be appropriate as it can dry out the wound and delay healing.

Question 7

A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound.The nurse anticipates providing which care for this patient's wound?

Accepted Answer

Granulation tissue formation is a sign of wound healing, indicating that the wound is ready for further reconstructive procedures such as a split thickness skin graft. This step is common in the management of large wounds that cannot heal by primary intention.

Question 8

A patient is admitted for a repair of an abdominal aortic aneurysm.Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)?

Accepted Answer

A history of radiation therapy increases the risk of ECF formation due to tissue damage and weakened blood vessels. The other factors listed are not specifically associated with increased risk of ECF formation.

Question 9

The nurse is assessing a wound using the technique shown in this picture.How would the nurse document this assessment?

Accepted Answer

The answer of The nurse is assessing a wound using...

Question 10

A patient has a wound that extends into the subcutaneous fatty tissue.The nurse plans care for this wound with the knowledge that it has penetrated to which skin level?

Accepted Answer

The hypodermis is the layer of skin just below the dermis, composed primarily of adipose tissue. If a wound penetrates into the subcutaneous fatty tissue, it has penetrated through the dermis and into the hypodermis.

Question 11

The patient's colectomy incision is red and the skin around the sutures is taut and shiny.What nursing intervention is indicated?

Accepted Answer

Redness and taut, shiny skin around sutures can indicate infection or inflammation. Assessing for drainage or odor is a critical step in identifying potential infection or complications.

Question 12

The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line.How would the nurse dress this wound?

Accepted Answer

The wound has steri-strips across it and a small amount of dried blood over the incision line, indicating that the wound is healing well and does not require a dressing that promotes moisture, such as hydrocolloid or alginate. Wet-to-dry dressing is not recommended anymore as it is outdated and can cause trauma to the wound. A dry, sterile dressing would be appropriate to absorb any remaining blood and protect the wound from outside contaminants.

Question 13

Assessment of the patient's sternal surgical incision reveals that the skin between sutures is opened.There is a small amount of drainage present on the dressing.The nurse would anticipate caring for this wound as it heals in which manner?

Accepted Answer

The presence of an open wound with drainage indicates that healing will occur by secondary intention, as the wound will need to heal from the bottom up through the process of granulation tissue formation and epithelialization. Tertiary intention involves delayed closure of a wound, while primary intention involves the immediate closure of a wound. Recurrent surgical debridement would not be appropriate for a healing wound.

Question 14

A patient is to receive lavage treatments for a chronic ulcer on the left heel.Which explanation would the nurse provide for this treatment?

Accepted Answer

Lavage treatments are used to cleanse the wound bed, removing debris, exudate, and contaminants, which helps to promote healing by reducing the risk of infection and facilitating the natural healing processes.

Question 15

The wound care specialist has assessed a patient's pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement.The nurse would plan interventions associated with which stage pressure ulcer?

Accepted Answer

The answer of The wound care specialist has assessed a...

Question 16

During initial assessment,the nurse notes that the edges of a wound are hard to palpation.The nurse would continue assessment for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

The answer of During initial assessment,the nurse notes that the...

Question 17

A patient with several burn scars tells the nurse that the scars are prone to injury and don't seem as tough as the rest of his skin.Which nursing response is indicated?

Accepted Answer

Scar tissue does not have the same strength as normal skin, and even when fully healed, it only regains about 80% of the strength of normal skin. This is important information for the nurse to provide to the patient to help manage their expectations for the healing process and prevent further injury or damage to the scarred area. B, C, and D are not relevant or accurate responses to the patient's concerns.

Question 18

A patient has a wound on his thigh that is swollen and red.The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters.Which other assessment findings would cause the nurse to alert the healthcare provider about possible necrotizing fasciitis (NF)? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

The use of steroids can impair the immune system and increase the risk for infection, severe pain at the site of the wound is a common symptom of NF, and obesity is a risk factor for NF. A high blood pressure reading and the patient's occupation are not necessarily indicative of NF.

Question 19

A patient presents to the emergency department with a large leg wound.The nurse identifies which factors as increasing this patient's risk of complications with wound healing? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Smoking, cardiac disease, and uncontrolled diabetes all increase a patient's risk of complications with wound healing. Osteoarthritis and mild blood loss do not have as significant of an impact on wound healing.

Question 20

The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges.Which nursing intervention is indicated?

Accepted Answer

The increase in redness and swelling around the wound edges may indicate infection or inflammation. Assessing for pain and warmth can help determine if these symptoms are present, which are signs of infection.

Quiz 10: Complex Wound Management