Deck 26: Wound Care

Question 1

A quadriplegic patient who was admitted for pneumonia was found to have a stage III pressure ulcer. A nurse explains to the patient's mother that she will know that the pressure ulcer is in the reconstruction phase of healing when

A) A scab has formed over the wound.
B) Pink or red tissue can be seen in the wound.
C) The wound becomes warm to the touch.
D) A healing ridge has developed beneath the wound.

Answer 1

Pink or red tissue can be seen in the wound.

Question 2

After assessing a patient with a stage II pressure ulcer, a nurse verifies that the patient is on a diet that will enhance healing. This patient's diet is

A) High carbohydrate, low calorie.
B) High protein, high calorie.
C) Low protein, high calorie.
D) Low carbohydrate, high calorie.

Answer 2

High protein, high calorie.

Question 3

During an initial assessment, a nurse finds that a patient's bone is visible in the pressure ulcer. The nurse notifies the physician that the pressure ulcer appears to be at stage

A) I.
B) II.
C) III.
D) IV.

Answer 3

IV.

Question 4

Upon answering a patient's call light, a nurse finds that the patient's wound has eviscerated. The nurse's first action is to

A) Prepare to do a dressing change with sterile Kerlix gauze.
B) Call the physician and collect sterile towels and saline.
C) Cover the wound with sterile dressings soaked in saline.
D) Obtain samples of purulent drainage and send them to the laboratory.

Question 5

While assessing a patient's surgical incision, a nurse notes that it is dry, clean, and intact, with edges approximated. The incision is healing by

A) First intention.
B) Second intention.
C) Third intention.
D) Tertiary intention.

Question 6

During a morning assessment, a nurse notices a change in a patient's wound. Which of the following samples of documentation would indicate a possible infection?

A) "Dressing dry and intact, small amount of serosanguineous drainage."
B) "Incision line well-approximated, moderate amount of drainage noted."
C) "Incision intact, small amount of pink granulation along incision line, no drainage."
D) "Incision intact, moderate amount of purulent drainage, foul odor."

Question 7

In explaining to a patient who is being dismissed from the hospital that he has a clean-contaminated wound, the nurse states:

A) "Although the wound is an incision, it was grossly contaminated during surgery, so it is important to notify your physician if the drainage increases."
B) "Your incision seems to be developing a purulent drainage. Make sure that you notify your doctor if you notice that the drainage develops a foul smell."
C) "Your drainage cultured a high number of microorganisms, but since we've seen no evidence of infection and you are taking an antibiotic, you probably don't need to worry about it."
D) "Surgical wounds are exposed to normal flora that resides on the skin. It is important to observe it for signs of infection, such as drainage that turns yellow or green."

Question 8

A nurse is providing care for a patient who has just had surgery. The nurse understands that the patient's wound will need to be closely monitored for infection because it falls under the classification of

A) Open wounds.
B) Closed wounds.
C) Contusion wounds.
D) Laceration wounds.

Question 9

When assessing a patient's wound, a nurse suspects that the wound most likely has been infected with Clostridia because

A) A crackling sensation can be felt when palpating around the wound.
B) The area surrounding the wound is bright red and draining serosanguineous material.
C) The drainage from the wound has changed from serous to purulent.
D) The wound is not as well approximated as it appeared to be yesterday.

Question 10

The first step that a nurse must take to contribute to the development of a care plan for a patient with a pressure ulcer is to

A) Determine the location of the ulcer.
B) Measure the length of the ulcer.
C) Gather all of the available data.
D) Assess the color of the drainage.

Question 11

When reassessing a patient's wound, a nurse notes redness and swelling, but no drainage. This is indicative of a phase of healing called the

A) Reconstruction phase.
B) Remodeling phase.
C) Inflammatory phase.
D) Maturation phase.

Question 12

A nurse checks a patient's Jackson-Pratt (JP) drain following surgery. The nurse explains to the patient that a closed drain speeds healing and facilitates wound drainage by

A) Gravity.
B) Absorption.
C) Penetration.
D) Suction.

Question 13

Prevention of a wound infection requires diligent care from a nurse. The first and most important step for the nurse to take when emptying the patient's Jackson-Pratt drain is to

A) Don sterile gloves.
B) Wash his or her hands.
C) Wipe the drain spout with alcohol.
D) Assess the contents of the drain.

Question 14

A patient's wound is showing signs of delayed healing. A nurse determines that the patient's diet may be the culprit and instructs the patient to eat more

A) Protein.
B) Vitamin B.
C) Vitamin D.
D) Fiber.

Question 15

A nurse notes an increase in serosanguineous drainage from a patient's incision. The most appropriate action for the nurse to take is to

A) Notify the physician of increasing amounts of clear drainage.
B) Draw a circle around the drainage and write the date, time, and initials on the dressing.
C) Change the dressing to decrease the patient's risk for infection.
D) Immediately call the laboratory and order a white blood cell (WBC) count.

Question 16

A patient who was involved in a motor vehicle accident is admitted to the hospital. The patient was thrown from the vehicle, and the nurse finds several areas where the patient's skin appears to have been scraped away, most likely as a result of hitting the pavement. These types of injuries are termed

A) Lacerations.
B) Contusions.
C) Punctures.
D) Abrasions.

Question 17

A nurse charts that a patient has a contusion that is approximately 3 inches in diameter on the right thigh. The nurse understands that a contusion is

A) A scrape or a scratch.
B) A discoloration of the skin.
C) An object embedded in the skin.
D) A cut or tear in the skin.

Question 18

When irrigating a patient's wound with a syringe, a nurse directs the flow of solution from the superior area to the inferior area of the wound. The rationale for this action is to

A) Slow the irrigation of the wound, thus eliminating patient discomfort.
B) Assist the nurse in proceeding in an organized manner.
C) Direct the flow of solution from the least contaminated area to the most contaminated area.
D) Use gravity in increasing the force of the irrigation.

Question 19

A nurse determines that the best way to clean a long incision that is sutured or stapled closed with approximated edges is to

A) Use antiseptic swabs and clean from the inferior end of the incision to the superior end.
B) Use antiseptic swabs and clean around the wound in a circular manner.
C) Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end of the incision to the inferior end.
D) Use one cotton ball to make a circular sweep and then dispose of the cotton ball.

Question 20

A patient's wound, which has a slight amount of drainage, will benefit from a dressing that provides a moist environment. Which type of dressing will the nurse apply?

A) Hydrofiber
B) Hydrocolloid
C) Gauze
D) Abdominal dressing pads (ABD)

Question 21

About 3 weeks after being admitted to the hospital, a patient's wounds begin to fill in with a red and semitransparent material. The nurse identifies this as

A) Granulation tissue.
B) Phagocytosis.
C) Hemostasis.
D) Keloids.

Question 22

A postoperative patient's wound is producing drainage that is slightly pink. A nurse would identify this type of drainage as

A) Serous.
B) Sanguineous.
C) Serosanguineous.
D) Purulent.

Question 23

A nurse explains to a patient that his stage 1 pressure ulcer will heal better if it is kept slightly moist by using a ____________________ dressing.

Question 24

Which of the following interventions would a nurse include in the plan of care for an incontinent patient with a stage II sacral pressure ulcer with no activity restrictions?

A) Repositioning the patient every 2 hours
B) Getting the patient up in a chair for meals and prn
C) Assessing the patient's incontinence pads every shift
D) Massaging the area around the decubitus bid
E) Elevating the patient's heels while he or she is in bed

Question 25

A nurse notes that there is a large amount of sanguineous drainage on a patient's dressing. There are no physician orders for a dressing change, so the nurse will

A) Circle the drainage on the dressing and record the time of assessment.
B) Continue to monitor the dressing.
C) Carefully clean around the wound.
D) Reinforce the dressing with additional dressings.

Question 26

A nurse provides conscientious care to an obese patient who is at risk for development of pressure ulcers. This care should include which of the following?

A) Turning the patient from side position to prone position every 2 hours
B) Keeping linens free of wrinkles
C) Offering the patient liquids and a nutritious diet
D) Keeping the patient's skin clean and moist
E) Assessing the patient's skin every 2 hours for indications of breakdown

Question 27

If ____________________ has occurred, a nurse should immediately cover exposed organs with sterile dressings soaked in normal saline. The nurse should never attempt to replace the organs into the abdominal cavity.

Question 28

A nurse gathers the necessary equipment and supplies in preparation for the removal of a patient's sutures. Place the following steps for suture removal in the correct order (1-7).(Enter the number of each step in the proper sequence, do not use commas).
1. Pull the suture smoothly and firmly with the nondominant hand.
2. Remove the remaining sutures, unless otherwise ordered.
3. Cut the suture next to the skin, adjacent to the knot.
4. Using the forceps, grasp the knot of the suture with the nondominant hand and lift the suture away from the skin.
5. Remove every other suture and observe the wound edges for any signs of separation.
6. Open the peel pack containing the suture removal set.
7. Using the notched scissors from the removal kit in the dominant hand, slide the notched blade under the suture.

Question 29

A patient is scheduled for the surgical removal of dead tissue associated with the condition gas gangrene. A nurse identifies this process as ____________________.

Question 30

A patient with a chronic heart valve problem is experiencing edema caused by deoxygenated blood in the veins of the lower extremities. A nurse should monitor the patient closely for the development of a

A) Sinus tract.
B) Stasis ulcer.
C) Pressure ulcer.
D) Contusion.

Question 31

A patient complains about what appears to be a tunnel-like infection under the skin with a small opening that is draining thick, yellow pus. The nurse identifies this type of wound as a

A) Pressure ulcer.
B) Stasis ulcer.
C) Contusion.
D) Sinus tract.

Question 32

Which of the following patients are at the greatest risk for development of pressure ulcers and, therefore, must be carefully monitored by a nurse?

A) A 32-year-old quadriplegic
B) A 59-year-old with a 1-day postoperative appendectomy
C) A 66-year-old with diabetes mellitus
D) A 40-year-old with bilateral leg casts
E) An 80-year-old with thin and inelastic skin

Question 33

A nurse is supervising a student applying a transparent dressing. The nurse intervenes when the student

A) Cuts the dressing to overlap the wound with a 1-inch margin.
B) Removes the surface film from the top of the dressing.
C) Stretches the dressing tightly against the wound.
D) Writes the date, time, and his or her initials on the edge of the dressing.

Question 34

A nurse breaks open a pressure ulcer and finds a dry, leathery, tan layer of dead tissue that prevents the identification of the ulcer's stage. The nurse identifies this thin layer as ____________________.

Question 35

A patient's open wound is healing by third intention. The nurse charts:

A) "Wound intact and draining a moderate amount of serosanguineous fluid."
B) "Wound approximately 2 '' $\times$ 3'', granulation tissue visible, draining serous fluid."
C) "Wound 4'' in diameter, open with jagged edges, draining sanguineous fluid."
D) "Wound 6'' long with well-approximated edges, reddened around incision, no drainage."

Question 36

A patient, 3 days postoperative, tells the nurse that her wound is a little more painful today than it was yesterday. Which of the following would be important information to document about the patient's wound?

A) Skin turgor
B) Color of drainage
C) Length of wound
D) Odor of drainage
E) Closed or open

Question 37

During a postoperative assessment, a nurse determines that the patient could be hemorrhaging. Place the following nursing actions in the appropriate order (1-4).(Enter the number of each step in the proper sequence, do not use commas).
1. Take the vital signs every 15 minutes.
2. Administer intravenous (IV) fluids as ordered by a physician.
3. Administer oxygen via mask or nasal cannula.
4. Position the patient in low Fowler position with knees flexed.

Question 38

A nurse has many responsibilities related to the application of wound dressings. When performing wound care on a patient with an abdominal wound that is healing by second intention, a nurse should do which of the following?

A) Exhibit a sterile conscience.
B) Keep the wound and dressing dry.
C) Assess for dark pink or red granulation tissue.
D) Measure the length, width, or diameter of the wound.
E) Assess for a threat of dehiscence.

Question 39

A patient has wet-to-damp dressings ordered for a wound. A nurse will

A) Apply the dressings twice a day.
B) Moisten the dressings with sterile water.
C) Change the dressings frequently to prevent drying out.
D) Apply the dressings using clean technique.

Question 40

Nine days after abdominal surgery, a nurse notices a complete separation of the outer layers of the patient's wound. The nurse identifies this rare and extremely serious condition as

A) Evisceration.
B) Sinus tract.
C) Phagocytosis.
D) Dehiscence.