Deck 26: Wound Care

Question 1

The home care nurse visits a client to assess an abdominal surgery site.The client is elderly, lives alone, and takes multiple medications for chronic illnesses.The nurse notes that the client's wound shows signs of delayed healing.Which factor does the nurse recognize as being least likely to be a contributing factor for the delayed healing?

A)The client has an agency deliver two cold meals and one hot meal daily.
B)The client admits to having difficulty managing dressing changes.
C)The client takes medication for heart and respiratory problems.
D)The client does not shower due to fear of falling while alone.

Answer 1

The client has an agency deliver two cold meals and one hot meal daily.

Question 2

A client arrives at a clinic with a wound received by an ax two days ago while cutting firewood.The client states that initial wound care was performed at home.The nurse assesses a deep open wound on the lower leg, which will need surgical closure.Which complication does the nurse recognize is a probability for this client?

A)Delayed healing because of the passage of time before surgery
B)The possibility of lower limb amputation due to muscle damage
C)A high risk for infection from Staphylococcus aureus contamination
D)A wound that will be treated by using a secondary intention closure

Answer 2

A high risk for infection from Staphylococcus aureus contamination

Question 3

The nurse is caring for a client immediately after surgery.During assessment the nurse notes sanguineous drainage on the client's dressing.Which action by the nurse is most correct?

A)Notify the physician about the possibility of hemorrhage.
B)Mark and initial the edges of the drainage, including the date and time.
C)Reinforce the dressing and monitor for additional bleed through.
D)Monitor vital signs for changes indicating excessive bleeding.

Answer 3

Mark and initial the edges of the drainage, including the date and time.

Question 4

The nurse is caring for a client who was involved in a motor vehicle accident.The client was thrown from the vehicle and has several areas where skin appears to have been scraped away.The nurse identifies the wounds as abrasions.Which statement is true about this type of wounds?

A)They are much like burns and take an extended period of time to heal.
B)They involve deep tissue and can cause muscle and bone infection.
C)They are generally superficial and will heal quickly if kept clean.
D)They will require systemic antibiotics for treatment of infection.

Question 5

The nurse is preparing to irrigate a client's wound with a syringe and sterile saline.Which action by the nurse demonstrates correct procedure?

A)The irrigation of the wound is performed slowly to eliminate client discomfort.
B)The nurse places the tip of the syringe against the skin to help debride the wound.
C)The solution flow is directed from the least contaminated to the most contaminated area.
D)The wound is irrigated with high pressure in order to force out pathogens.

Question 6

While assessing a client's surgical incision, the nurse notes that it is dry, clean, and intact, with edges approximated.The nurse is aware that which type of healing is taking place?

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

Question 7

The nurse is caring for a client with diabetes mellitus who has a non-healing wound on the bottom of the foot.Which assessment finding causes the nurse to conclude that the wound is likely infected with Clostridia?

A)A crackling sensation under the skin can be felt when palpating around the wound.
B)The area surrounding the wound is dark red, swollen, and draining yellow exudate.
C)The infected area around the wound appears to be expanding to surrounding tissue.
D)The wound drainage has a strong smell of rotten grapes and appears green in color.

Question 8

The nurse is caring for a client who is five days postoperative.The physician orders that every other staple be removed from the incision.The nurse notices that the staples appear to be far apart and after the first staple is removed, the incision begins to gap open.Which action will the nurse take?

A)Finish removing the staples as ordered.
B)Call the physician and report wound dehiscence.
C)Apply a sterile dressing and document the event.
D)Use adhesive strips to re-approximate the gaping edges.

Question 9

The nurse is providing care for multiple clients in an extended care facility.Which client does the nurse identify for being at the most risk for the development of pressure injuries?

A)An elderly client with daily urinary incontinence
B)A client who is immobile and underweight for age and height
C)An elderly client with diabetes mellitus who is immobile
D)A client who has limited mobility due to poor circulation

Question 10

The nurse assesses a client's wound.Which documentation will the nurse make to indicate a possible infection?

A)Dressing intact, with a small amount of serosanguineous drainage
B)Incision line well approximated, moderate amount of drainage noted
C)Incision intact, suture line is well approximated, and no drainage
D)Incision intact, moderate amount of purulent drainage, foul odor

Question 11

The nurse answers a client's emergency call light, which is activated from the client's bathroom.The nurse discovers pinkish-gray organs protruding from the bottom of an abdominal dressing.Which action does the nurse take first?

A)Get the client to bed and place in a semi-Fowler position with knees bent.
B)Call the physician and report the client has an incisional evisceration.
C)Cover the eviscerated organs with sterile dressings soaked in sterile saline.
D)Make the client NPO in anticipation of surgery to close the open suture line.

Question 12

The nurse is providing care for a client with a surgical wound exhibiting signs of delayed healing but no redness or drainage.The physician orders a culture of the wound.Which condition does the nurse understand the culture will reveal?

A)A necrotic wound
B)A colonized wound
C)An infected wound
D)A closed wound

Question 13

The nurse is providing discharge teaching to a client who had surgery to remove a growth on the tongue.The nurse understands that the surgery site is identified as a clean-contaminated wound.Which teaching will the nurse provide?

A)The wound is considered to have been grossly contaminated during surgery.
B)Due to the location of the wound, the presence of purulent drainage is expected.
C)Mouth wounds are known to heal quickly and usually without complications.
D)Because of the normal flora in the mouth, the wound is at risk for infection.

Question 14

The nurse is providing care for a client with a stage III pressure injury on the right trochanter area.The physician has ordered the use of hydrocolloid dressings.Which action will the nurse perform in the maintenance of the prescribed dressing?

A)Change the dressing daily to prevent infection from collected drainage.
B)Use warm compresses to keep the dressing flat and adhered to the skin.
C)Inspect the dressing for escaping drainage, wrinkling, and excessive exudate.
D)Document the application process and a description of the wound.

Question 15

The nurse is caring for a client admitted through the emergency department (ED)following an accident.The client's injuries include an open fracture of the leg and multiple bruises.Which terminology will the nurse use to document the client's wounds?

A)Closed leg injury with multiple cuts
B)Massive bruising with broken bones
C)Compound leg fracture with multiple contusions
D)Puncture leg wound with surface skin scrapes

Question 16

The nurse provides care to an obese client who is at risk for pressure injuries.The client's plan of care places the client on pressure injury prevention.Which actions should the nurse be implementing? Select all that apply.

A)Turning the client from side position to prone position every 2 hours
B)Maintaining a bed with clean, dry linens that are free of wrinkles
C)Encouraging an adequate fluid intake and a nutritious diet
D)Performing hygiene care as needed to keep skin clean and moist
E)Assessing the client's skin every 2 hours for indications of breakdown

Question 17

The nurse is caring for a client admitted with chronic venous insufficiency.The nurse assesses the client's lower extremities, which are edematous and discolored.Which additional finding should the nurse expect to find during assessment?

A)Sinus tract development on the ankles
B)Skin wounds known as stasis ulcers
C)Pressure injuries where the knees touch
D)Contusions from unsteady ambulation

Question 18

The nurse is preparing to clean a surgical wound that is closed with staples.Assessment reveals that the incision is clean, dry, well approximated, and without redness or tenderness.Which wound cleaning procedure will the nurse use?

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 using a wide circular motion.
C)Use forceps with a sterile antiseptic swab and move from the superior to the inferior end.
D)Use an antiseptic swab to cleanse the left side, right side, and then the center of the incision.

Question 19

The nurse is providing care for a client readmitted to the hospital following a modified mastectomy.The nurse notes that the primary surgical wound is inflamed, painful, and edematous.Under the client's arm, the nurse notices a small open area draining a moderate amount of green drainage.Which condition does the nurse identify?

A)Infection in a contaminated surgery wound
B)Skin breakdown caused from migrated drainage
C)Stasis ulcer from decreased arm movement
D)Sinus tract between infected and healthy tissue

Question 20

The nurse is providing care for a client after surgery for repair for a penetrating wound to the abdomen.Which characteristic of the wound will make the nurse most vigilant for signs of infection?

A)The object that entered the client's abdomen remained embedded until surgery.
B)The object was removed by first responders and the wound flushed for foreign bodies.
C)The object inflicted no injury on the client's internal organs or boney structures.
D)The object was smooth, nonporous metal, and a diameter of less than one inch.

Question 21

The nurse is caring for multiple clients.The nurse recognizes which clients as being at greatest risk for development of pressure injuries? Select all that apply.

A)A 32-year-old client who is quadriplegic
B)A 59-year-old one day postoperative
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 22

A client who is 3 days postoperative states a slight increase in pain level from the day before.Which additional assessment will the nurse make to determine the condition of the client's wound? Select all that apply.

A)Skin turgor
B)Color of drainage
C)Type of closure
D)Odor of drainage
E)Closed or open