Question 1

The nursing student is listing the phases of full-thickness wound healing to the nursing mentor.Which of the following phases she lists indicate she needs further education? (Select all that apply.)

Accepted Answer

Wound healing occurs in four stages.(1)Hemostasis: Blood vessels constrict; clotting factors activate coagulation to stop bleeding.Clot formation seals disrupted vessels so blood loss is controlled and acts as a temporary bacterial barrier.Growth factors are released,which attract cells needed to begin tissue repair.(2)Inflammatory phase: Vasodilation occurs,allowing plasma and blood cells to leak into the wound,noted as edema,erythema,and exudate.Leukocytes (WBCs)arrive in the wound to begin cleanup.Macrophages appear and regulate the wound repair.(3)Proliferation/rebuilding phase: New capillaries are created,restoring the delivery of oxygen and nutrients to the wound bed.At the same time new granulation tissue is formed.Collagen is synthesized and begins to provide strength and structural integrity to a wound.Contraction reduces the size of the wound.Epithelial resurfacing (the construction of new epidermis)begins to cover the wound.(4)Maturation/remodeling phase: Collagen is remodeled to become stronger and provide tensile strength to the wound.Outer appearance in an uncomplicated wound will be that of a well-healed scar.Healing by primary intention occurs when the wound edges of a clean surgical incision remain close together.Wounds left open and allowed to heal by scar formation are classified as healing by secondary intention.

Question 2

The nurse is assessing a wound that is healing by secondary intention.Which of the following assessments are important to address? (Select all that apply.)

Accepted Answer

When assessing a wound that is healing by secondary intention (e.g.,pressure ulcer or contaminated surgical or traumatic wound),it is important to assess the anatomical location of the wound,the wound dimensions,undermining,the extent of tissue loss,the tissue type,the presence of exudate,the wound edges,and the periwound skin.

Question 3

1. A ______ __________ wound is a loss of the epidermis and superficial dermal layers and heals by regeneration.

Accepted Answer

The answer of 1. A ______ __________ wound is a...

Question 4

The nurse is preparing to use high-pressure pulsatile lavage to irrigate a necrotic wound.Which of the following statements indicate a need for further education on this type of irrigation? (Select all that apply.)

Accepted Answer

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds.Pressure settings should be set per provider order (usually between 4 and 15 psi)and should not be used on skin grafts,exposed blood vessels,muscle,tendon,or bone.Use with caution if the patient has coagulation disorder or is on anticoagulants.

Question 5

2. A _____ ______wound is a total loss of epidermis and dermis and in some cases is as deep as the muscle layer or bone; it heals by scar formation.

Accepted Answer

The answer of 2. A _____ ______wound is a total...

Question 6

The nurse is caring for a patient who has a Jackson-Pratt drain in place on postoperative day 1.The NAP reports there is no drainage and the patient is complaining of pain at the site.What should the nurse do first?

Accepted Answer

It is important to compare amount and characteristics of drainage with what is expected to determine patency of tubing and functioning of the drainage evacuator.You would expect some drainage on postoperative day 1,so the nurse should inspect for drainage around the tubing,which may indicate lack of vacuum or obstruction of the drainage system and then notify the healthcare provider if there is an obstruction.The nurse should reestablish a seal and see if there is drainage that comes out.Rating the patient's pain and giving pain medications would be done after the drain is managed.

Quiz 24: Wound Care and Irrigation

The nursing student is listing the phases of full-thickness wound healing to the nursing mentor.Which of the following phases she lists indicate she needs further education? (Select all that apply.)

The nurse is assessing a wound that is healing by secondary intention.Which of the following assessments are important to address? (Select all that apply.)

1. A ____ wound is a loss of the epidermis and superficial dermal layers and heals by regeneration.

The nurse is preparing to use high-pressure pulsatile lavage to irrigate a necrotic wound.Which of the following statements indicate a need for further education on this type of irrigation? (Select all that apply.)

2. A _ __wound is a total loss of epidermis and dermis and in some cases is as deep as the muscle layer or bone; it heals by scar formation.

The nurse is caring for a patient who has a Jackson-Pratt drain in place on postoperative day 1.The NAP reports there is no drainage and the patient is complaining of pain at the site.What should the nurse do first?