Deck 31: Performing Wound and Pressure Injury Care

Question 1

Which task could the nurse safely assign to the assistive personnel (AP)?

A) Changing the postoperative dressing on a clean wound
B) Irrigating the client's wound
C) Establishing and monitoring a sitz bath
D) Performing a damp-to-damp dressing change

Answer 1

C
Explanation:1. Due to the need for aseptic technique and assessment skills, changing a postoperative dressing cannot be delegated to the AP.
2. Due to the need for aseptic technique and assessment skills, irrigating a wound cannot be delegated to the AP.
3. Administering a sitz bath can be established and monitored by the AP after the wound has been assessed and the safety of the client has been ensured.
4. Due to the need for aseptic technique and assessment skills, performing damp-to-damp dressing changes cannot be delegated to the AP.

Question 2

A client has a clean moist wound. Which dressing should the nurse anticipate using for this client?

A) Collagen
B) Hydrogel
C) Hydrocolloid
D) Clear absorbent acrylic

Answer 2

A
Explanation:1. A collagen dressing is used for clean moist wounds.
2. Hydrogel is used for pressure injuries, skin tears, and partial-thickness wounds.
3. Hydrocolloid is used for stages 2 through 4 pressure injuries, autolytic debridement, and partial-thickness wounds.
4. Clear absorbent acrylic is used for pressure injuries, skin tears, venous stasis injuries, surgical wounds, and wounds being chemically debrided.

Question 3

The assistive personnel (AP) notes purulent drainage seeping around a client's wound dressing. Which action should the nurse take?

A) Assess the wound and drainage.
B) Ask the AP to measure the wound.
C) Direct the AP to change the dressing.
D) Suggest the AP use a different type of dressing material.

Answer 3

A
Explanation:1. The nurse should assess the wound and drainage.
2. The AP is not trained to measure wounds.
3. The AP is not trained to change dressings.
4. The AP is not trained to change dressings.

Question 4

A client had staples removed from a surgical wound. Which should the nurse include when documenting the procedure?

A) Type of surgery
B) Number of staples removed
C) Device used to remove the staples
D) Length of time the staples were intact