Deck 38: Wound Care and Irrigations

Question 1

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

A) The wound edges are separated
B) No drainage or erythema is present
C) The patient is anxious about their removal
D) A cosmetically aesthetic result would not be achieved

Answer 1

The wound edges are separated

Question 2

When is healing by primary intention expected?

A) When the wound is left open and is allowed to heal
B) When a surgical wound is left open for 3 to 5 days
C) When connective tissue development is evident
D) When the edges of a clean incision remain close together

Answer 2

When the edges of a clean incision remain close together

Question 3

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

A) Snip both ends of the sutures
B) Apply tension on the suture line to remove the sutures
C) Pull the exposed surface of the suture through the tissue below the epidermis
D) Apply Steri-Strips if any separation greater than the width of two stitches is present

Answer 3

Apply Steri-Strips if any separation greater than the width of two stitches is present

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?

A) Use irrigation pressures of less than 4 psi
B) Cleanse in a direction from most contaminated to least contaminated
C) Irrigate so that the solution flows from least contaminated to most
D) Irrigate with clean irrigation solution only

Question 5

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

A) The incision line should be cleansed last
B) She should start at one end of the incision line and swab the entire length
C) She should start at the center of the incision line and swab toward one end
D) She should work in a circular motion around the incision line

Question 6

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

A) Place a safety pin on the part of the drain outside the body
B) Replace the cap immediately after emptying
C) Pin the drainage tubing to the patient's gown
D) Place the Hemovac on a flat surface

Question 7

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

A) Graft sites
B) Wounds with exposed blood vessels
C) Necrotic tissue
D) Wounds with exposed muscle or tendons

Question 8

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

A) Reduction in the size of the wound
B) Duplication of epithelial cells
C) Synthesis of collagen at the site
D) An increase in blood flow to the wound and arrival of white blood cells

Question 9

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

A) Alginates
B) Hydrogel
C) Hydrocolloid
D) Transparent film

Question 10

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

A) Decrease scar formation
B) Remove debris from the wound
C) Improve circulation from the wound
D) Decrease irritation from wound drainage

Question 11

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

A) Make normal saline with 8 tsp of salt and 1 gallon of distilled water
B) Use normal saline for 1 week and then discard it
C) Not apply topical anesthetics before wound care
D) Call the physician's office to have someone come to the home and complete the wound care

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?

A) Change the dressing so she can assess the wound
B) Administer an analgesic 30 to 45 minutes before a dressing change
C) Culture the wound if wound exudate is present
D) Administer an analgesic 30 minutes after a dressing change

Question 13

What should the nurse do when removing intermittent sutures?

A) Snip both sides of the suture before removing
B) Snip the suture as close to the knot as possible
C) Snip the suture as close to the skin as possible
D) Pull up the knot to apply as much tension as possible

Question 14

What is an appropriate technique for the nurse to implement for drainage evacuation?

A) Replace the Hemovac drain fully expanded
B) Attach the drainage tubing to the patient's gown
C) Tilt the evacuator of the Hemovac away from the plug
D) Complete the dressing change before the drainage evacuation

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?

A) Decreases the amount of angiogenesis
B) Reduces mechanical stretch of tissue
C) Should not need to be changed for 48 hours
D) Helps create a dry environment

Question 16

When should a nurse consider culturing a wound?

A) When the tissue is clean and dry
B) When exudate is not present
C) When the patient is afebrile
D) When the surrounding area shows inflammation

Question 17

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

A) Skin serves as a sensory organ for pain
B) Skin serves as a sensory organ for touch
C) Skin serves as a sensory organ for temperature
D) Skin has an acid pH
E) None of above

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?

A) Try to reinsert the abdominal contents
B) Cover the wound with a dry sterile dressing
C) Notify the surgeon when he makes rounds
D) Cover the wound with a moist saline dressing

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?

A) A dry sterile dressing
B) A Jackson-Pratt (JP) drain
C) A Hemovac drain
D) No drain placement

Question 20

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

A) Placing the patient in supine position
B) Placing the syringe directly into the wound
C) Using sterile technique for a chronic wound
D) Selecting a soft catheter for deep wounds with small openings

Question 21

A full-thickness wound (total loss of skin layers as well as some deeper tissues)heals by ____ formation.

Question 22

Healing by ________ 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 23

___________________ is a failure of wound healing,with total separation of the layers of the wound and protrusion of the internal organs through the wound.

Question 24

___________ is black,brown,or tan tissue in the wound that should be removed before wound healing can begin.

Question 25

Negative-pressure-wound therapy (NPWT)supports wound healing by which of the following? (Select all that apply.)

A) Optimizing blood flow
B) Removing wound fluid
C) Maintaining a moist environment.
D) Applying positive pressure to the wound

Question 26

Wounds that have been approved for treatment using NPWT include which of the following? (Select all that apply.)

A) Pressure ulcers
B) Diabetic ulcers
C) Traumatic wounds
D) Venous stasis ulcers
E) None of above

Question 27

__________________is a mechanical wound care treatment that uses controlled negative pressure to assist and accelerate wound healing.The most common commercial brand is called Wound (V.A.C.).

Question 28

Intact ________ is the body's first line of defense against invasion by infectious microorganisms.

Question 29

Physiologically,wound healing occurs in the same way for all patients,with some tissues (including the vascular tissues)regenerating quickly and others regenerating slowly or not at all.The latter group includes which of the following cells? (Select all that apply.)

A) Liver cells
B) Skin cells
C) Renal tubules
D) Central nervous system neurons

Question 30

The _____________ is composed of newly formed collagen,and the nurse can usually feel it along a healing wound.It is usually present directly under the suture line between days 5 and 9.

Question 31

Healing by _____________ intention occurs when the edges of a clean surgical incision remain close together.

Question 32

In a full-thickness wound,the phases include which of the following? (Select all that apply.)

A) Hemostasis
B) Inflammation
C) Proliferation
D) Maturation
E) None of above

Question 33

_____________ uses the mechanical force (either high or low)of a stream of solution to remove debris,bacteria,and necrotic tissue from a wound.

Question 34

___________ are threads of wire or other materials used to sew body tissues together.

Question 35

Wounds that are left open and are allowed to heal by scar formation are classified as healing by _________ intention.

Question 36

___________ are stainless steel wires used to hold body tissues together.

Question 37

The nurse is caring for a patient who has had major abdominal surgery.She is concerned about the possibility of dehiscence.She realizes that factors that contribute to surgical wound dehiscence include which of the following? (Select all that apply.)

A) Age
B) Malnutrition/obesity
C) Gender
D) Use of steroids

Question 38

Viable tissue is normally red to pink and moist in appearance.This type of tissue is called ____________ tissue and indicates a wound that is moving toward healing.

Question 39

A failure of wound healing in which the surgical wound breaks,separates,and opens to the fascial level is known as ______________.

Question 40

A partial-thickness wound (loss of tissue limited to epidermis and partial dermis)heals by the process of ______________.

Question 41

The Jackson-Pratt (JP)drain relies on the presence of a vacuum to withdraw drainage and is considered a __________ drainage system.

Question 42

A Penrose drain is considered an __________ drain system because it removes drainage from the wound and deposits it onto the skin surface.