Deck 58: Wound Care

Question 1

A nurse is assessing the wound in the left arm of a client. The wound has torn, ragged edges. How should the nurse document the wound in the electronic medical record?

A) Incision
B) Abrasion
C) Laceration
D) Puncture

Answer 1

Laceration

Question 2

A nurse is assessing the wound in the right hip of a client following surgery. The wound has clean edges. How should the nurse document the wound in the electronic medical record?

A) Incision
B) Abrasion
C) Laceration
D) Puncture

Answer 2

Incision

Question 3

A nurse documents in the electronic medical record the discharge from a client's surgical wound as "slight serosanguineous drainage." What is meant by "serosanguineous drainage?"

A) Composed of pus only
B) Composed of blood only
C) Composed of clear serum
D) Composed of serum and blood

Answer 3

Composed of serum and blood

Question 4

What is the common cause of skin breakdown that occur as a result of clothing, bed linens, or client safety devices?

A) Shearing force
B) Immobility
C) Presence of external moisture
D) Sensory loss

Question 5

What stage pressure wound is characterized by a shallow crater/blister with a red/pink wound bed and no sloughing?

A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4

Question 6

A nurse documents a paralyzed client's right heel ulcer as a stage 3 pressure wound.
Which statement describes a stage 3 pressure wound?

A) Pressure-related alteration of intact skin
B) Loss of epidermis with damage into the dermis that appears as a shallow crater/blister with red/pink wound bed and no sloughing
C) Subcutaneous tissues involved and subcutaneous fat may be visible with no bone, tendon, or muscle exposed
D) Extensive damage to underlying structures, full-thickness tissue loss with exposed bones, tendons, or muscles

Question 7

What measurements are included as part of the Braden Scale? Select all that apply.

A) Pressure intensity
B) Sensory perception
C) Moisture level
D) Activity
E) Nutrition

Question 8

Which factors contribute to skin breakdown? Select all that apply.

A) Advanced age
B) High caloric intake
C) Immobility
D) Insufficient hydration
E) Moisture

Question 9

What nursing considerations should be kept in mind while recommending a dietary plan that promotes wound healing? Select all that apply.

A) Avoid a high-caloric diet.
B) Consume a high-protein diet.
C) Drink adequate fluids.
D) Consume citrus fruits.
E) Avoid frequent snacking.

Question 10

What nursing measures should be implemented to prevent skin breakdown for a client frequently incontinent of both urine and feces? Select all that apply.

A) Keep perianal skin cleansed and moisturized.
B) Keep areas of skin folds dry.
C) Apply antifungal powder to skin.
D) Apply powder or medicinal cream to skin.
E) Protect the affected skin with barrier ointments.

Question 11

What pressure-reducing technique will have the greatest effect on decreasing the client's risk for skin breakdown?

A) Use of a chair cushion
B) Application of elbow protectors
C) Use of a turning sheet
D) Reposition the client at least every 2 hours

Question 12

The nurse is taking care of a client who is paralyzed from the waist down. What intervention will support the client's ability to minimize the risk of skin breakdown?

A) Logrolling the client
B) Elevating heels off bed
C) Elevating head of bed no more than 30 degrees
D) Using of trapeze over bed

Question 13

A client diagnosed with a neck laceration develops a draining sinus tract. Which dressing is appropriate for this client?

A) Transparent dressing
B) Sterile padding
C) Dry sterile dressing
D) Gel-foam packing

Question 14

The nurse is taking care of a client who is at high risk for skin breakdown. The nurse wants to prevent skin breakdown caused by friction. Which dressing is appropriate for this client?

A) Transparent dressing
B) Sterile padding
C) Dry sterile dressing
D) Gel-foam packing

Question 15

A nurse is required to apply a dressing to a shallow to moderate depth wound with minimal drainage. Which dressing should the nurse apply to this client?

A) Wet to dry dressing
B) Dry sterile dressing
C) Wet to wet dressing
D) Hydrocolloid dressing

Question 16

A client who had a wound on her left thigh developed a scar following healing. What is the most likely cause of this client's deep scarring?

A) Third-intention healing
B) Electrical stimulation
C) First-intention healing
D) Antiseptic application

Question 17

A fireman suffered second-degree burns at the scene of a house fire. What process will be responsible for the client's wound healing?

A) First-intention
B) Second-intention
C) Third-intention
D) Fourth-intention

Question 18

By what process does a surgical incision heal?

A) First-intention
B) Second-intention
C) Third-intention
D) Fourth-intention

Question 19

A client had a colon resection that required a large abdominal incision. What is the
Purpose of a dry sterile dressing for this client?

A) Absorbs drainage from the surgical wound
B) Prevents development of a pressure WOUND
C) Protects the wound from contamination
D) Prevents skin breakdown owing to friction

Question 20

What are specific precautions for a wet-to-dry dressing? Select all that apply.

A) Dry the surrounding skin before applying the dressing.
B) Do not loosen the dressing with normal saline.
C) Keep a 1-in margin of dressing on all sides of wound.
D) Use a new gauze pad for each cleansing motion.
E) Remove the dressing only after it has dried

Question 21

A nurse is performing sterile wound irrigation on a client. Which precautions should the nurse take after opening the irrigation solution? Select all that apply.

A) Pour solution with the bottle label facing into the palm.
B) Place bottle cover on the table with the inside facing downward.
C) Pour the irrigation solution with an ungloved hand.
D) Discard a small amount of the solution before use.
E) Date and initial the opened solution bottle.

Question 22

A nurse is changing the dry sterile dressing of a client after a colectomy. Which precautions should the nurse take when performing this procedure? Select all that apply.

A) Prepare strips of tape before beginning the procedure.
B) Cleanse wound with alcohol or soap.
C) Cleanse the wound from center to outside.
D) Keep the wound as dry as possible.
E) Wear sterile gloves for the dressing change

Question 23

Which system is used to drain a post-mastectomy wound?

A) EnzySurge
B) Hemovac
C) VariCare
D) Fibracol

Question 24

Why is a vacuum-assisted closure machine used? Select all that apply.

A) Applies controlled localized positive pressure to a wound site
B) Increases the growth of granulation tissue
C) Decreases healing time of the client's wound
D) Particularly useful for stage III pressure wounds
E) Used to facilitate healing of stage IV pressure wounds

Question 25

What is the correct time frame for removal of sutures and staples after surgery?

A) 1 to 4 days
B) 4 to 7 days
C) 7 to 10 days
D) 10 to 14 days