Deck 27: Dressings, Bandages, and Binders
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Deck 27: Dressings, Bandages, and Binders
1
The nurse is assisting a patient with putting on an abdominal binder.In which position does the nurse place the patient?
A) Semi-Fowler's
B) Supine
C) Prone
D) High-Fowler's
A) Semi-Fowler's
B) Supine
C) Prone
D) High-Fowler's
Supine
2
The nurse assesses the patient's transparent film dressing and observes white opaque exudate and reddened and edematous wound edges.Which is the priority intervention for the nurse to implement?
A) Record the observation in the patient's record.
B) Remove the white exudate carefully.
C) Obtain an order for a wound culture.
D) Apply a light absorbent dressing.
A) Record the observation in the patient's record.
B) Remove the white exudate carefully.
C) Obtain an order for a wound culture.
D) Apply a light absorbent dressing.
Obtain an order for a wound culture.
3
The nurse is preparing to change a moist-to-dry dressing on a patient.After correctly identifying the patient, what is the next most appropriate step for the nurse to perform?
A) Assess patient/family's knowledge of the purpose of the dressing change.
B) Assess the dressing for the presence of drainage.
C) Ask the patient to rate his or her wound pain.
D) Review the order for the type of dressing.
A) Assess patient/family's knowledge of the purpose of the dressing change.
B) Assess the dressing for the presence of drainage.
C) Ask the patient to rate his or her wound pain.
D) Review the order for the type of dressing.
Ask the patient to rate his or her wound pain.
4
The nurse delegates applying a binder over the patient's abdominal incision to nursing assistive personnel (NAP).Which does the nurse include in the NAP's instructions?
A) Start the binder right under the axilla.
B) Place the patient in a semi-Fowler's position.
C) Secure the binder with metal fasteners.
D) Remove the old dressing and apply a binder.
A) Start the binder right under the axilla.
B) Place the patient in a semi-Fowler's position.
C) Secure the binder with metal fasteners.
D) Remove the old dressing and apply a binder.
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5
The nurse needs to apply a dry sterile dressing.Which should the nurse implement first?
A) Inspect the appearance of the wound.
B) Remove excess moisture from the wound.
C) Cleanse with sterile saline solution.
D) Prepare the sterile field for supplies.
A) Inspect the appearance of the wound.
B) Remove excess moisture from the wound.
C) Cleanse with sterile saline solution.
D) Prepare the sterile field for supplies.
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6
The wound care nurse prepares wound care supplies.Which patient assessment datum cues the nurse to provide Montgomery straps to promote wound healing?
A) Heavy exudate
B) Deep laceration
C) Femoral dressing
D) Wound dehiscence
A) Heavy exudate
B) Deep laceration
C) Femoral dressing
D) Wound dehiscence
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7
The wound care nurse prepares to dress the wounds of four patients.Which wound should receive a transparent film dressing?
A) A clean, superficial laceration
B) A deep leg ulcer with infection
C) A puncture wound with bleeding
D) A large laceration over the eyebrow
A) A clean, superficial laceration
B) A deep leg ulcer with infection
C) A puncture wound with bleeding
D) A large laceration over the eyebrow
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8
The nurse is caring for a patient who requires a moist-to-dry dressing.Which action by the nurse is appropriate during the procedure?
A) Applies a dry absorbent outer dressing.
B) Packs flat gauze into the wound bed.
C) Soaks the wound packing with antiseptic.
D) Moistens the old dressing before removal.
A) Applies a dry absorbent outer dressing.
B) Packs flat gauze into the wound bed.
C) Soaks the wound packing with antiseptic.
D) Moistens the old dressing before removal.
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9
The nurse assigns patient care to nursing assistive personnel (NAP).Which wound care tasks should the nurse assign to this staff member?
A) Apply the hydrocolloid dressing.
B) Assess dimensions of the wound.
C) Report visible drainage on the dressing.
D) Change the first postoperative dressing.
A) Apply the hydrocolloid dressing.
B) Assess dimensions of the wound.
C) Report visible drainage on the dressing.
D) Change the first postoperative dressing.
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10
The nurse dresses the surgical incision on the patient's elbow.Which method of securing the bandage should the nurse use with this patient?
A) Spiral
B) Circular
C) Recurrent
D) Figure-eight
A) Spiral
B) Circular
C) Recurrent
D) Figure-eight
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11
The nurse is caring for a patient with a history of chronic respiratory problems who has an abdominal binder in place.Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome?
A) The skin around the binder is dry without redness or edema.
B) The patient experiences difficulty moving around in bed.
C) The patient's pain level has changed from 8 to 6 on a scale of 1-10.
D) The respiratory rate has decreased from 17 to 15 breaths per minute.
A) The skin around the binder is dry without redness or edema.
B) The patient experiences difficulty moving around in bed.
C) The patient's pain level has changed from 8 to 6 on a scale of 1-10.
D) The respiratory rate has decreased from 17 to 15 breaths per minute.
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12
The nurse is preparing to dress an open, shallow wound with a moderate amount of drainage.Nursing care is correct if the nurse chooses which dressing material?
A) Alginate nonwoven
B) Adhesive transparent dressing
C) Hydrocolloid adhesive
D) Foam nonadherent pad
A) Alginate nonwoven
B) Adhesive transparent dressing
C) Hydrocolloid adhesive
D) Foam nonadherent pad
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13
The nurse removes the patient's hydrocolloid dressing and observes minimal clear, watery drainage.Which action should the nurse take at this time?
A) Evaluate for leukocytosis.
B) Change to foam dressing.
C) Collaborate with the health care provider.
D) Document serous drainage.
A) Evaluate for leukocytosis.
B) Change to foam dressing.
C) Collaborate with the health care provider.
D) Document serous drainage.
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14
The patient started bleeding profusely from a surgical wound on the thigh.Nursing care is appropriate if the nurse takes which action to care for this patient?
A) Assesses the wound for sinus tracts and tunneling.
B) Applies roller gauze over the gauze pads on the extremity using a figure-eight pattern.
C) Obtains sterile gauze and sterile gloves.
D) Has nursing assistive personnel (NAP) apply the pressure dressing.
A) Assesses the wound for sinus tracts and tunneling.
B) Applies roller gauze over the gauze pads on the extremity using a figure-eight pattern.
C) Obtains sterile gauze and sterile gloves.
D) Has nursing assistive personnel (NAP) apply the pressure dressing.
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15
The nurse plans care for the patient's wound that requires a moist-to-dry dressing.Which should the nurse use for an expected patient outcome several hours after applying a new dressing?
A) The patient states that the dressing feels cold.
B) The dressing is dry and intact.
C) The dressing has bright red drainage.
D) The patient states that the pain level is 8 on a scale of 1-10.
A) The patient states that the dressing feels cold.
B) The dressing is dry and intact.
C) The dressing has bright red drainage.
D) The patient states that the pain level is 8 on a scale of 1-10.
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16
The nurse applies a circumferential gauze dressing to a patient's amputated leg.Which method should the nurse use to decrease edema in the extremity?
A) Montgomery straps
B) An adhesive tape wrap
C) A figure-eight wrap
D) A circular turns dressing
A) Montgomery straps
B) An adhesive tape wrap
C) A figure-eight wrap
D) A circular turns dressing
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17
The nurse prepares to change the patient's dressing over a surgical incision without drainage but palpates a ridge along the suture line.Which dressing should the nurse apply to this wound?
A) Foam pad
B) Wet-to-dry
C) Transparent film
D) Dry sterile gauze
A) Foam pad
B) Wet-to-dry
C) Transparent film
D) Dry sterile gauze
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18
The nurse inspects a patient's surgical incision and notes dehiscence several inches long.Which is the most important intervention for the nurse to implement?
A) Call for assistance.
B) Place a sterile moist dressing on the wound.
C) Apply direct pressure over the wound dressing.
D) Apply a pressure dressing over the open area.
A) Call for assistance.
B) Place a sterile moist dressing on the wound.
C) Apply direct pressure over the wound dressing.
D) Apply a pressure dressing over the open area.
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19
The nurse prepares to perform a dressing change on an ulcerated area.Which principle does the nurse apply while performing a dressing change?
A) The dead space found in an ulcer should be packed tightly.
B) The wound should be débrided using multiple dry gauze pads.
C) The dressing should absorb exudate without damaging the wound bed.
D) The wound bed should be dried to stimulate granular tissue.
A) The dead space found in an ulcer should be packed tightly.
B) The wound should be débrided using multiple dry gauze pads.
C) The dressing should absorb exudate without damaging the wound bed.
D) The wound bed should be dried to stimulate granular tissue.
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20
The nurse is applying a gauze bandage to hold a dressing on a patient's wrist since the patient is allergic to tape.Which technique would be most appropriate for the nurse to use?
A) Montgomery straps
B) A 7.6-cm (3-inch) bandage wrapped proximal to distal
C) A 2-inch bandage using the spiral wrap technique
D) A loosely wrapped elastic bandage using a recurrent turn
A) Montgomery straps
B) A 7.6-cm (3-inch) bandage wrapped proximal to distal
C) A 2-inch bandage using the spiral wrap technique
D) A loosely wrapped elastic bandage using a recurrent turn
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21
The nurse has applied a transparent dressing to facilitate débridement of the pressure ulcer.How often should the nurse change that dressing?
A) Every 6 days
B) Every day
C) Every 3-4 days
D) Every 12 hours
A) Every 6 days
B) Every day
C) Every 3-4 days
D) Every 12 hours
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22
A _______ is a fungal or bacteria-embedded slimy matrix of proteins and sugars that adhere to the surface of a wound bed.
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23
The nurse is caring for a patient with a pressure injury.The nurse would expect which of the following outcomes if the patient's wound is healing? (Select all that apply.)
A) Pain intensity is reduced during dressing changes.
B) The depth of wound is reduced.
C) The amount of exudate increases.
D) The amount of necrotic tissue decreases.
A) Pain intensity is reduced during dressing changes.
B) The depth of wound is reduced.
C) The amount of exudate increases.
D) The amount of necrotic tissue decreases.
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24
A ______dressing is contraindicated in ischemic wounds with dry eschar and third-degree burns or wounds that tunnel.
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25
The nurse is working with a student nurse to provide care to a patient with a pressure injury.The student nurse describes characteristics of an ideal dressing.Which of the following statements indicate the student needs more education? (Select all that apply.)
A) The dressing should keep the wound bed dry.
B) The dressing can be removed without causing trauma.
C) The dressing should conform to the body to allow for movement.
D) Cost should not be a consideration.
E) Should be easy for the patient to change after discharge.
A) The dressing should keep the wound bed dry.
B) The dressing can be removed without causing trauma.
C) The dressing should conform to the body to allow for movement.
D) Cost should not be a consideration.
E) Should be easy for the patient to change after discharge.
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26
A highly absorbent nonwoven material that forms a gel when exposed to wound drainage is called a(n) __________ dressing.
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