Deck 38: Wound Care and Irrigations

Question 1

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.

Answer 1

she should start at the center of the incision line and swab toward one end.

Question 2

The nurse is explaining wound healing to a patient.Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

A)A reduction in the size of the wound is noted.
B)The epithelial cells duplicate.
C)Synthesis of collagen occurs at the site.
D)Blood flow to the wound and arrival of white blood cells are increased.

Answer 2

Blood flow to the wound and arrival of white blood cells are increased.

Question 3

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 3

When the edges of a clean incision remain close together

Question 4

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 5

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

A)Snip both ends of the sutures.
B)Apply tension to 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.

Question 6

Which situation noticed during evaluation would determine that the staples or 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.

Question 7

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 8

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 9

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 placement of which of the following?

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

Question 10

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 contaminated.
D)Irrigate with clean irrigation solution only.

Question 11

For 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 12

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 13

Which of the following approaches is correct technique when wound irrigation is performed?

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 14

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 15

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 16

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 can the nurse tell the patient about the functioning of this system?

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

Question 17

The nurse is educating a patient about his role in wound healing.Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level?

A)Age
B)Smoking
C)Underlying cardiopulmonary conditions
D)Hemoglobin

Question 18

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 19

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

A)make normal saline with 8 teaspoons 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 20

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 21

You are explaining wound healing to your patient.You are trying to explain the healing process in a full-thickness wound.Which of the following phases should you include in your explanation? (Select all that apply.)

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

Question 22

You are irrigating a wound and are trying to make sure you get the wound adequately cleansed.Which of the following should you avoid?

A)Inserting the tip of a soft catheter into a deep wound
B)Using a 19-gauge angiocatheter
C)Pushing the tip inside a deep wound that has a small opening
D)Using a large syringe

Question 23

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 24

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

Question 25

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

Question 26

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 27

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing.Which of the following can be appropriately delegated to the nurse assistant?

A)Performing a sterile dressing change
B)Observing for any drainage on the dressing
C)Performing wound assessment during the dressing change
D)Notifying the physician of drainage present on the dressing

Question 28

The nurse is caring for a patient who has had major abdominal surgery.She is concerned about the possibility of dehiscence.During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply.)

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

Question 29

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

Question 30

You are explaining negative-pressure wound therapy (NPWT) to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

A)NPWT optimizes blood flow.
B)NPWT will remove wound fluid.
C)NPWT will maintain a moist environment.
D)NPWT will apply positive pressure to the wound.

Question 31

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

Question 32

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 33

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

Question 34

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 35

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