Question 1

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

Accepted Answer

Assess healing ridge and skin integrity of 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.
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 2

When is healing by primary intention expected?

Accepted Answer

Healing by primary intention occurs when the edges of a clean surgical incision remain close together.The wound heals quickly,and tissue loss is minimal or absent.The skin cells quickly regenerate,and the capillary walls stretch across under the suture line to form a smooth surface as they join.
Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention.Connective tissue development is evident during healing by secondary intention.Healing by tertiary 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 3

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

Accepted Answer

Apply Steri-Strips 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 suture; there will be no way to remove the part of the suture situated below the surface.Grasp 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 exposed surface of any suture into tissue below epidermis.The exposed surface of any suture is considered contaminated.

Question 4

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?

Accepted Answer

When one is irrigating,all the solution flows from the least contaminated to the most contaminated area.The pressure needed to irrigate wounds is between 4 and 15 psi.Irrigating solutions are sterile.

Question 5

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

Accepted Answer

The center is the most important part of the suture line; therefore,using a sterile swab or gauze,clean the suture line by starting at the center of the suture line and working toward one end.With another sterile swab or gauze,start at the center of the incision and work toward the other end.All other cleansing involves moving from one end to the other on each side of the incision.Work in straight lines,moving away from the suture line with each successive stroke.

Question 6

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

Accepted Answer

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

Question 7

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

Accepted Answer

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds.The amount of irrigant is wound size dependent.Pressure settings on the device need to remain between 4 and 15 psi.Do not use this type of irrigation with graft sites or exposed blood vessels,muscle,tendon,or bone.

Question 8

Which of the following occurs during the inflammatory stage of wound healing in a full-thickness wound?

Accepted Answer

Vasodilatation occurs,allowing plasma and blood cells to leak into the wound,noted as edema,erythema,and exudate.Leukocytes (white blood cells)arrive in the wound to begin wound cleanup.Macrophages,a type of white blood cell,appear and begin to regulate wound repair.The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound.
It is during the proliferative stage,not the inflammatory stage,that contraction causes a reduction in the size of the wound,duplication of epithelial cells occurs,and collagen is synthesized.

Question 9

For the absorption of heavy exudate from a wound,a nurse selects which of the following dressings?

Accepted Answer

Alginates are used for absorption of heavy to moderate wound exudate.Hydrogels are used for dry wounds to wounds with minimal exudate.Hydrocolloids are used to absorb minimal to moderate exudate.Transparent film has no absorption quality.

Question 10

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

Accepted Answer

Wound irrigations promote wound healing by removing debris from a wound surface,decreasing bacterial counts,and loosening and removing eschar.The primary purposes of wound irrigation do not include decreasing scar formation,improving circulation,or decreasing irritation.

Question 11

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

Accepted Answer

Teach patient and caregiver how to make normal saline,especially if cost is an issue.They can make normal saline by using 8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month.The saline solution should be allowed to reach room temperature before use.
Commonly used topical anesthetic solutions include 2% and 4% lidocaine jelly that inactivates exposed wound pain receptors.Some patients need to receive wound care management in an outpatient wound care clinic.Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies.

Question 12

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?

Accepted Answer

To promote patient comfort,administer an analgesic as ordered,usually 30 to 45 minutes before changing the dressing.However,you will need to assess to determine the best time for analgesic administration before wound care.Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal.The presence of wound exudate is an expected stage of epithelial cell growth.

Question 13

What should the nurse do when removing intermittent sutures?

Accepted Answer

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

Question 14

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 tubing and insertion site.Check evacuator for reestablishment of vacuum,patency of drainage tubing,and absence of stress on tubing.The Hemovac needs to be flattened (compressed)to create a vacuum.Tilt evacuator in direction of plug.Drainage evacuation may be done at times other than dressing change times.

Question 15

The nurse is caring for a patient with a large stasis ulcer.She has just changed the wound dressing and is using a negative-pressure-wound system.What does the nurse understand about the functioning of this system?

Accepted Answer

The dressing is changed on a scheduled basis,usually no earlier than 48 hours.Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels),and that it stimulates the production of new blood vessels via mechanical stretch of the tissue.The dressing placed into the wound maintains a moist environment to facilitate healing.A suction device is placed over the dressing,and the dressing,suction,and wound area are covered with a transparent dressing,which provides the airtight seal necessary for negative-pressure-wound therapy (NPWT).

Question 16

When should a nurse consider culturing a wound?

Accepted Answer

Consider culturing a wound if it has a foul,purulent odor; inflammation surrounds the wound; a nondraining wound begins to drain; or patient is febrile.

Question 17

How does the skin defend the body? (Select all that apply.)

Accepted Answer

The skin defends the body in other ways by serving as a sensory organ for pain,touch,and temperature,and it has an acid pH,which is often called the "acid mantle."

Question 18

The nurse answers the patient's call light to find the patient agitated and stating that she "felt something pop." The nurse finds that the patient's abdominal surgical wound has eviscerated.What should the nurse do?

Accepted Answer

This is a surgical emergency,and the nurse needs to cover the wound with a moist saline dressing,immediately notify the surgeon,and prepare the patient for emergency surgery.

Question 19

The physician reports that he is expecting that the patient's wound will have an output of close to 500 mL per day.The nurse anticipates the 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,while the Hemovac drain accommodates more drainage,usually up to 500 mL in 24 hours.

Question 20

When performing wound irrigation,a nurse uses appropriate technique when:

Accepted Answer

If the patient has a deep wound with a narrow opening,attach a soft catheter to the syringe to permit the fluid to enter the wound.Position the patient comfortably to permit gravitational flow of irrigating solution through wound and into collection receptacle.Hold syringe tip 2.5 cm (1 inch)above upper end of wound and over area being cleansed; this prevents syringe contamination.Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds)or clean technique (some chronic wounds).

Quiz 38: Wound Care and Irrigations