Question 1

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

Accepted Answer

The Jackson-Pratt (JP) drain is a closed drainage system that uses a vacuum to collect bodily fluids from surgical sites.

Question 2

The nurse is aware that pressure injuries can occur (Select all that apply.)

Accepted Answer

Pressure injuries can occur from any position that causes soft tissue compression (A), due to lack of blood flow or ischemia (B), and can develop in as little as 90 minutes (D). They are not limited to bed-bound patients (C).

Question 3

The removal of devitalized tissue in a wound is known as ______________.

Accepted Answer

Debridement is the removal of devitalized tissue in a wound.

Question 4

Patients are at risk for developing pressure injuries on which areas of the body? (Select all that apply.)

Accepted Answer

Pressure injuries can develop on any area of the body where prolonged pressure is applied, especially over bony prominences or areas with less tissue padding. The coccyx, nares (especially in patients with nasal tubes), ears, and genitalia can all be susceptible to pressure injuries under certain conditions.

Question 5

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

Accepted Answer

Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges,normal color,and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples.If wound edges are separated or signs of infection are present,the wound has not healed properly.Notify the health care provider because sutures or staples may need to remain in place.Absence of drainage and erythema would indicate that sutures are ready for removal.Steps could be taken to relieve the patient's anxiety,but suture removal is based on the condition of the wound.Timing of suture removal is based on adequate wound healing.

Question 6

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

Accepted Answer

Pinning drainage tubing to the patient's gown will prevent tension or pulling on the tubing and the insertion site.Check the evacuator for reestablishment of the vacuum,patency of drainage tubing,and absence of stress on the tubing.The Hemovac needs to be flattened (compressed)to create a vacuum.Tilt the evacuator in the direction of the plug.Drainage evacuation may be done at times other than dressing change times.

Question 7

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?

Accepted Answer

During the inflammatory stage of wound healing, blood flow to the wound and arrival of white blood cells are increased. This helps to remove debris, foreign particles, and microorganisms while also promoting the formation of a fibrin clot to stop bleeding. The other options are not accurate descriptions of the inflammatory stage.

Question 8

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

Accepted Answer

Eschar is dead tissue that is black, brown, or tan and needs to be removed for proper wound healing.

Question 9

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

Accepted Answer

Irrigation involves using a stream of solution to mechanically clean a wound by removing debris, bacteria, and necrotic tissue.

Question 10

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?

Accepted Answer

If drainage accumulates in the wound bed,wound healing is delayed.Drainage is removed by using a closed or an open drain system,even if the amount of drainage is small.A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range;the Hemovac drain accommodates more drainage,usually up to 500 mL in 24 hours.

Question 11

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 an unregulated care provider?

Accepted Answer

Unregulated care providers can observe and report findings such as drainage on a dressing, but they cannot perform sterile procedures, assess wounds, or notify physicians directly.

Question 12

When skin layers adhere to the linens and deeper tissue layer move downward,________ damage occurs.

Accepted Answer

Shear damage occurs when skin layers stick to a surface like linens while deeper tissues move in the opposite direction, causing tissue distortion and damage.

Question 13

The healing ridge is composed of newly formed collagen,and the nurse can usually feel it along a healing wound.The nurse knows it is usually present directly under the suture line on days

Accepted Answer

The healing ridge, indicating collagen formation and wound healing, typically becomes palpable under the suture line around days 5 to 9 post-surgery.

Question 14

What should the nurse do to re-establish the vacuum of the Hemovac system after emptying?

Accepted Answer

Place the evacuator on a flat surface with the open outlet facing upward;continue pressing downward until the bottom and the top are in contact;hold the surfaces together with one hand,quickly cleanse the opening and the plug with the other hand,and immediately replace the plug;and then secure the evacuator to the patient's bed.Compression of the surface of the Hemovac creates a vacuum.Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation.Be sure the Penrose drain has a sterile safety pin in place.This pin prevents the drain from being pulled below the skin's surface.Compress the bulb of a JP drain over the drainage container.Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container.Replacing the cap immediately prevents tension on the drainage tubing,but does not help to reestablish the vacuum.

Question 15

What should the nurse do when removing intermittent sutures?

Accepted Answer

Snip the suture as close to the skin as possible at the end distal to the knot.Never snip both ends of the suture;there will be no way to remove the part of the suture situated below the surface.Grasp the knot of the suture with forceps,and gently pull up the knot while slipping the tip of the scissors under the suture near the skin.

Question 16

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?

Accepted Answer

Factors that decrease oxygenation include decreased hemoglobin level,smoking,and underlying cardiopulmonary conditions.Smoking is the only one of these factors that can be modified by the patient alone.Age causes vascular changes.

Question 17

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.

Accepted Answer

Tertiary intention healing occurs when wounds are left open for a period to allow for reduction of edema or infection before being closed surgically.

Question 18

A _______________ is a localized injury to the skin or underlying tissue,usually over a bony prominence,as a result of pressure,or pressure in combination with shear or friction.

Accepted Answer

The answer of A _______________ is a localized injury to...

Question 19

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

Accepted Answer

Apply Steri-Strip if any separation greater than two stitches or two staples in width is apparent,to maintain contact between wound edges.This supports the wound by distributing tension across the wound and eliminates closure technique scarring.Never snip both ends of the suture;there will be no way to remove the part of the suture situated below the surface.Grasp the knotted end with forceps,and in one continuous smooth action,pull the suture through from the other side;this smoothly removes the suture without additional tension to the suture line.Tension on the suture line is not required.Never pull the exposed surface of any suture into tissue below the epidermis.The exposed surface of any suture is considered contaminated.

Question 20

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

Accepted Answer

Sutures are threads of wire or other materials used to sew body tissues together, commonly used in medical procedures to close wounds.

Quiz 39: Prevention and Care of Skin Breakdown

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