Deck 10: Complex Wound Management

Question 1

The nurse manager has noted an increase in wound infections in a postoperative unit.What instruction to the unit staff is the most important?

A)Wear gloves at all times.
B)Administer antibiotics as prescribed.
C)Assess patients for infection risk upon admission.
D)Follow hand hygiene protocols.

Answer 1

Follow hand hygiene protocols.

Question 2

A male patient tells the nurse that he has "excruciating pain" in his perineal region that started a few days after having an indwelling urinary catheter removed.Upon inspection,the nurse sees a dime-sized reddened area on the patient's perineum below the scrotal sac.What nursing intervention is priority?

A)Have the wound further evaluated for possible Fournier's gangrene.
B)Apply ice to the region.
C)Give the patient prn acetaminophen.
D)Place a scrotal support on the patient.

Answer 2

Have the wound further evaluated for possible Fournier's gangrene.

Question 3

A nurse documents a stage 1 pressure ulcer on a patient's lateral malleolus.What assessment findings would indicate that this ulcer has progressed to stage II? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)The subcutaneous fat layer is exposed.
B)A fluid-filled blister is present.
C)A shallow open ulcer is present.
D)There is an area of boggy purple skin on the bony prominence.
E)There is an area of skin that does not turn white with pressure.

Answer 3

A fluid-filled blister is present.
A shallow open ulcer is present.

Question 4

The nurse measures a patient's wound diameter and notes that it has reduced in size.The nurse evaluates this information to indicate the wound has entered which phase?

A)Remodeling
B)Inflammatory
C)Maturation
D)Proliferative

Question 5

The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection.Which nursing intervention is indicated?

A)Draw peak and trough concentrations as indicated.
B)Give the medication over a 2-hour period.
C)Hold the medication if the patient experiences nausea.
D)Monitor for increase in creatinine clearance.

Question 6

There is dead tissue throughout the patient's nonhealing abdominal wound.The nurse prepares for which intervention needed to encourage this wound to heal?

A)Diet analysis for protein adequacy
B)Keeping the wound covered to increase oxygen to the wound bed
C)Debridement of devitalized tissue
D)Introduction of air into the wound for drying

Question 7

A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound.The nurse anticipates providing which care for this patient's wound?

A)Irrigating the wound twice daily before applying dry dressing
B)Caring for a split thickness skin graft
C)Applying wet-to-dry dressings
D)Caring for a suture line created by surgical closure of the wound

Question 8

A patient is admitted for a repair of an abdominal aortic aneurysm.Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)?

A)Diagnosis of type 2 diabetes mellitus
B)Daily use of nonsteroidal anti-inflammatory drugs (NSAIDs)for arthritis symptoms
C)Diagnosis of peripheral vascular disease
D)History of radiation therapy to treat colon cancer

Question 9

The nurse is assessing a wound using the technique shown in this picture.How would the nurse document this assessment?

A)The wound is macerated.
B)The wound is tunneled.
C)The wound is deep.
D)The wound is filled with exudate.

Question 10

A patient has a wound that extends into the subcutaneous fatty tissue.The nurse plans care for this wound with the knowledge that it has penetrated to which skin level?

A)Epidermis
B)Hypodermis
C)Dermis
D)Cartilage

Question 11

The patient's colectomy incision is red and the skin around the sutures is taut and shiny.What nursing intervention is indicated?

A)Assess for the presence of drainage or odor.
B)Clean this healing wound and redress as ordered.
C)Collaborate with the healthcare provider regarding suture removal.
D)Instruct the patient to use additional splinting for deep breathing and coughing.

Question 12

The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line.How would the nurse dress this wound?

A)Hydrocolloid dressing
B)Wet-to-dry dressing
C)Alginate dressing
D)Dry,sterile dressing

Question 13

Assessment of the patient's sternal surgical incision reveals that the skin between sutures is opened.There is a small amount of drainage present on the dressing.The nurse would anticipate caring for this wound as it heals in which manner?

A)Tertiary intention
B)Primary intention
C)Secondary intention
D)Recurrent surgical debridement

Question 14

A patient is to receive lavage treatments for a chronic ulcer on the left heel.Which explanation would the nurse provide for this treatment?

A)"This treatment is a form of autolytic debridement to remove dead tissue from your heel."
B)"Your foot will be submersed in a whirlpool tub for this treatment."
C)"This treatment will help cleanse the wound bed."
D)"This treatment will inject medications into the deep crevices of your wound."

Question 15

The wound care specialist has assessed a patient's pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement.The nurse would plan interventions associated with which stage pressure ulcer?

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

Question 16

During initial assessment,the nurse notes that the edges of a wound are hard to palpation.The nurse would continue assessment for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Infection
B)Necrosis
C)Osteomyelitis
D)Deep tissue injury
E)Maceration

Question 17

A patient with several burn scars tells the nurse that the scars are prone to injury and don't seem as tough as the rest of his skin.Which nursing response is indicated?

A)"Even when healed,the scar will only regain about 80% of the strength of normal skin."
B)"Your body is still making new blood vessels for the wound."
C)"Your body is trying to remove additional bacteria from the wound area."
D)"Your healing process hasn't been completed."

Question 18

A patient has a wound on his thigh that is swollen and red.The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters.Which other assessment findings would cause the nurse to alert the healthcare provider about possible necrotizing fasciitis (NF)? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Blood pressure is 140/90 mm Hg.
B)The patient reports recently taking steroids for a severe ear infection.
C)The patient works in an elementary school.
D)The patient reports pain as a 9 on the 1 to 10 pain scale.
E)The patient's body mass index is 31.

Question 19

A patient presents to the emergency department with a large leg wound.The nurse identifies which factors as increasing this patient's risk of complications with wound healing? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)The patient smokes eight cigarettes a day.
B)The patient has cardiac disease.
C)The patient has osteoarthritis in his knees.
D)The patient's average blood sugar measurements are over 200 mcg/dL.
E)The patient lost some blood during the injury but the loss was not excessive.

Question 20

The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges.Which nursing intervention is indicated?

A)Encourage the patient to ingest more fluids.
B)Assess for pain and warmth.
C)Cover the wound with a sterile dry dressing.
D)Dress the wound as prescribed.