Question 1

The nurse warns the patient that one of the patient's habits has caused the reduction of functional hemoglobin, which limits the hemoglobin's oxygen carrying ability. To improve this situation, the nurse suggests that the patient quit:

Accepted Answer

Smoking reduces the functional hemoglobin which, in turn, reduces the amount of oxygen carried to the cells of the body.

Question 2

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

Accepted Answer

If the dressing sticks to the wound, normal saline should be added to loosen it. Pulling loose a stuck dressing damages new tissue. Leaving it in place does not promote a clean wound. Povidone iodine must be ordered.

Question 3

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:

Accepted Answer

A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first, or primary, intention. Wounds that are not closed heal by either second (secondary) or third (tertiary) intention.

Question 4

The nurse clarifies that the first stage of wound healing is:

Accepted Answer

Inflammation is the first stage of wound healing, followed by the proliferation, maturation, and reconstruction stages.

Question 5

A nurse performing a right eye irrigation will position the patient:

Accepted Answer

The patient should be positioned supine with the head tilted toward the affected eye. This position allows the irrigation solution to drain away from the eye and not contaminate the other eye.

Question 6

A nurse caring for a patient with a Stage I pressure ulcer would most appropriately select:

Accepted Answer

Thin film dressings are used on Stage I ulcers to protect them from shearing forces and to keep them moist.

Question 7

A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?

Accepted Answer

The tape should be removed by pulling it off toward the wound. This helps prevent alteration of the wound.

Question 8

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

Accepted Answer

If hemorrhage occurs, it can lead to hypovolemic shock. Indicators of hemorrhage include restlessness, rising pulse, and falling blood pressure.

Question 9

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use:

Accepted Answer

Montgomery straps allow the dressing to be changed without constantly applying and removing tape.

Question 10

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

Accepted Answer

Hydrocolloid dressings are air occlusive dressings used on noninfected wounds that provide a moist environment for wound healing. They can be left in place for up to 7 days.

Question 11

A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a(n):

Accepted Answer

A hematoma is a pooling of blood under unbroken skin. An abrasion is a scraping away of skin tissue. A laceration is a torn, ragged, or mangled wound, and a contusion is a bruise.

Question 12

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

Accepted Answer

A vacuum-assisted dressing that is accomplished by a special dressing and vacuum device applies negative pressure to the wound, which increases blood flow, increases oxygenation, and improves the delivery of nutrients to the wound.

Question 13

A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, "I think something just let go." The initial intervention by the nurse should be to:

Accepted Answer

The patient is likely experiencing wound dehiscence and should immediately be assisted into a supine position. This eliminates the force of gravity from putting additional stress on the suture line and possibly causing evisceration.

Question 14

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

Accepted Answer

Increase in the serosanguineous drainage from the surgical wound is a common sign of impending dehiscence.

Question 15

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

Accepted Answer

Separate alcohol swabs should be used to clean the spout and the plug.

Question 16

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

Accepted Answer

A circular motion around the wound toward the outside keeps the wound area cleanest.

Question 17

A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:

Accepted Answer

The handles should be squeezed together all the way. This depresses the center of the staple and allows it to be lifted outward from the skin.

Question 18

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

Accepted Answer

As part of the healing process, histamines and prostaglandins have caused small vessels to dilate and leak plasma and electrolytes into the wound site causing swelling, which causes the wound to become reddened and swollen as the phagocytosis cleans up the microorganisms.

Question 19

The nurse gives an example of a wound that heals by second (secondary) intention as a:

Accepted Answer

A secondary intention healing occurs when there is a jagged wound whose edges do not approximate.

Question 20

The nurse chooses a nonadherent dressing to apply to a wound because the nonadherent dressing:

Accepted Answer

Telfa dressings have a shiny, nonadherent surface; the shiny side is applied to the wound to prevent the dressing from sticking to the skin. The drainage seeps through the barrier and is absorbed on the other side. It does require some sort of adhesive or binder to keep the pad in place.

Quiz 38: Providing Wound Care and Treating Pressure Ulcers