Deck 60: Caring for the Patient With Wounds

Question 1

The nurse is caring for a frail, elderly patient who has a chronic pressure ulcer on the ankle. The nurse plans care to reverse which factors that impair healing in the wound?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Repeated prolonged insults to the tissue
B) Patient's lack of concern about the wound
C) An inadequate blood supply in the tissue
D) Newly diagnosed urinary tract infection that may have been present for some time
E) Recent laceration on the other leg

Answer 1

Repeated prolonged insults to the tissue
An inadequate blood supply in the tissue
Newly diagnosed urinary tract infection that may have been present for some time

Question 2

The nurse would increase surveillance and prevention for pressure ulcer development in which at-risk patients?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) A 70-year-old patient who has been living at home and has limited ability to obtain groceries
B) A 68-year-old patient whose assessment reveals a low body mass index
C) A 50-year-old patient who has developed urinary incontinence after hospitalization for cholecystectomy.
D) A 35-year-old patient who has diabetic neuropathy
E) A 29-year-old patient hospitalized for treatment of pregnancy-induced hypertension

Answer 2

A 70-year-old patient who has been living at home and has limited ability to obtain groceries
A 68-year-old patient whose assessment reveals a low body mass index
A 50-year-old patient who has developed urinary incontinence after hospitalization for cholecystectomy.
A 35-year-old patient who has diabetic neuropathy

Question 3

The nurse is caring for a patient with a large open wound. While changing the dressing, the nurse notes purulent drainage. What additional assessments are necessary for this patient?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Wound odor
B) Blood urea nitrogen (BUN)
C) Fever
D) Wound bleeding
E) White blood cell count

Answer 3

Wound odor
Fever
White blood cell count

Question 4

A patient injured in an accident has a large open leg wound that will require hospitalization for several days. The patient states he has just completed a course of steroid therapy. The nurse will include additional monitoring for which condition in the plan of care?

A) Delayed wound healing
B) Increased risk of thromboembolism
C) Increased tendency to bleed excessively
D) Increased pain at the wound site

Question 5

A nurse assesses that the periwound area of a patient's large abdominal wound is macerated. What change in nursing management will be required because of the maceration?

A) Apply a petroleum-based product to the periwound area.
B) Keep the moist dressing off the periwound area.
C) No new measures are necessary, as this is a normal finding.
D) Apply a separate moist dressing to the periwound area.

Question 6

Wound breakdown after healing continues to be an issue with burn victims. Research into which topic would offer the most comprehensive interventions to help diminish this problem?

A) Techniques to reduce wound infection
B) Techniques to increase tensile strength
C) Methods to increase family participation in wound care
D) Methods to increase patient compliance with exercise routines

Question 7

The nurse who is current on wound care research would consider which product to be antimicrobial when used in wound dressings?

A) Normal saline
B) Tap water
C) Topical gold
D) Topical silver

Question 8

The nurse would assess that granulation tissue is developing in a wound when noting which characteristics?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Beefy red color
B) Blue-gray tinge to the wound bed
C) Small, round nodules in the wound bed
D) Pearly-appearing wound margins
E) Moist tissue

Question 9

A patient has a large scar on the leg from a laceration. What information would the nurse provide about these scars?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) "This scar tissue is just as strong as any other skin on your body."
B) "You need to protect this scar from trauma for about 3 or 4 months."
C) "Do not expose the scar to intense sunlight."
D) "It may take up to 2 years for this area to get as strong as it is going to."
E) "Once the scar is present, epithelialization will begin."

Question 10

A nurse who works in a diabetes clinic is providing education regarding foot care to a group of patients and families. The nurse would make which statements to explain why these patients are at risk for foot ulcers?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) "You may not be able to feel injury to your feet."
B) "Changes in your blood vessels decrease circulation to your feet."
C) "Diabetes makes you clumsier."
D) "Your body responds to infection more slowly than do those without diabetes."
E) "Swelling associated with diabetes tends to make shoes and socks fit more tightly."

Question 11

The nurse is caring for a patient with a deep wound that has tunneling. Following the dressing change, what factors are essential for the nurse to document?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Amount of irrigation poured into the tunnel
B) Type of drainage coming from the wound
C) Size and shape of the tunnel
D) Direction and number of tunnels
E) Length of dressing needed to pack wound

Question 12

The nurse caring for a patient with an extensive wound would expect angiogenesis to begin during which phase of healing?

A) Remodeling
B) Inflammatory phase
C) Maturation
D) Proliferation

Question 13

The nurse routinely uses a tracing graph of transparent film to assess the dimensions of wounds. What rationales would the nurse offer for this decision?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Using this film helps to document the shape of the wound.
B) Placement of this film helps to prevent infection from iatrogenic causes.
C) Having a visual representation of the wound offers a psychological boost to the patient.
D) These films help keep the wound dry.
E) These tracings show the progress of the wound surface contracture.

Question 14

The nurse is caring for an 84-year-old patient who was just admitted with a large sacral ulcer. When assessing the wound, the nurse notes small areas of both black and white tissue in the wound bed. Which dressing protocol would the nurse expect to follow with this wound?

A) Wet-to-dry with normal saline every 6 hours
B) Dry dressing twice per day
C) Wet-to-wet with Dankins solution once per day
D) Petroleum-based antiseptic dressing once per day

Question 15

The nurse is developing unit assessment protocols for the risk of pressure ulcer development. What factors would the nurse include in this document?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Presence of moisture
B) Potential for friction and shear
C) Adequacy of nutrition
D) Mobility status
E) Presence of confusion

Question 16

The nurse is caring for a patient with a large wound on the right hip. What nursing measure is the most essential for the patient?

A) Keep the patient on continuous bed rest.
B) Encourage the patient to sit up in a chair as much as possible through the day.
C) Turn the patient from side to side every 2 hours.
D) Keep the patient's weight off the right side.

Question 17

A patient with a severe laceration was malnourished before the injury. Which nursing interventions are indicated?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Encourage intake of vitamin C-containing foods.
B) Ensure that the patient consumes probiotic-enhanced dairy products.
C) Administer appropriate medications with a canned nutritional drink.
D) Restrict fluids that contain sodium.
E) Limit the fats in the patient's diet.

Question 18

The nurse manager of a long-term care facility would institute which policies to be in compliance with federal tag 314?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Periodic resident care plan revisions
B) Transfer of resident with pressure ulcers to an acute care facility
C) Documentation of a plan to reduce the development of pressure ulcers
D) A plan to assess residents for their risk of pressure ulcers
E) A method of documenting adherence to facility pressure ulcer policies and procedures

Question 19

The nurse is caring for a young patient with a large wound on the arm from necrotizing fasciitis. Which statement should the nurse make to support the patient's psychological adjustment to the wound?

A) "I think this wound makes you look dashing."
B) "What is the best time for you to have your dressing changed?"
C) "I told your mother that she probably shouldn't look at the wound yet."
D) "Let's let your family participate in the next dressing change."

Question 20

The nurse understands that to prevent pressure ulcers, pressure must be removed from high-risk areas of the body. What nursing interventions are essential to accomplish this goal?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Pull the patient up in bed every 2 hours or less.
B) Turn the patient at least every 2 hours.
C) Encourage the patient to be out of bed.
D) Position articles the patient uses just out of reach to encourage movement.
E) Float the heels off the bed with pillows beneath the ankles.

Question 21

The nurse has used the Braden Risk Assessment Scale to assess three newly admitted patients. The scores are 11, 15, and
17. The nurse prioritizes pressure ulcer prevention for the patient whose score is ________.

Question 22

A patient has a pressure ulcer on the ear where an oxygen cannula has been in place. The ulcer is shallow and long and has a black wound bed. How would the nurse stage this ulcer?

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

Question 23

A patient has been admitted with a lower leg ulcer. Which findings would suggest to the nurse that care specific to a venous ulcer should be planned?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) The area around the ulcer is crusted and edematous.
B) There is copious drainage from the wound.
C) The ulcer area has a "punched-out" appearance with defined margins.
D) The area around the wound is spongy.
E) The patient reports working in an occupation that requires lots of sitting.

Question 24

A patient is admitted with an ulcer on the right great toe. The nurse determines that the blood pressure in the patient's right arm is 138 systolic, the left arm is 136 systolic, the right ankle is 65 systolic, and the left ankle is 66 systolic. How does the nurse evaluate these readings?

A) The wound will require debridement.
B) The patient is getting adequate circulation to the feet.
C) This ulcer is not likely to heal.
D) The patient needs intravenous fluids to support intravascular volume.

Question 25

A patient has developed a hematoma under the incision for reconstruction of the great toe. What therapy would the nurse expect for this condition?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Application of cold compresses for the first 24 hours.
B) Elevation of the extremity
C) Serial assessment of the size of the hematoma
D) Application of a moisture barrier over the site
E) Aspiration

Question 26

A patient has a wound that has tunneling. What dressing technique should the nurse use?

A) Loosely pack several large pieces of dry fluffy gauze into the tunnel.
B) Pack the area with moist squares of gauze to fill the dead space.
C) Use a continuous strip of gauze to pack the tunnel.
D) Leave the space in the tunnel open for drainage.

Question 27

A patient with very thin, fragile skin has just been resuscitated in the emergency department. During the resuscitation efforts, a dressing was taped over an IV site. How should the nurse remove this dressing?

A) Grasp the tape and pull sharply and quickly.
B) Rub the sides of the tape until it loosens.
C) Hold the skin down and gently pull the tape off.
D) Allow the tape to loosen over several days and remove it in sections.

Question 28

A patient's abdominal wound has been leaking serosanguineous drainage in increasing amounts for the last 2 days. Today, when the nurse removed the dressing, the incision was open and a loop of bowel was visible. What should the nurse do prior to notifying the surgeon?

A) Replace the old dressing and tape it securely.
B) Have the patient cough to assess for protrusion of the bowel.
C) Cover the incision with a sterile saline-moistened dressing.
D) Ask the patient if the incision has felt different today.

Question 29

A patient sustained a long laceration across the cheek. During a dressing change the patient says, "I just cannot look at the incision yet. I am pretty vain about my looks." Which nursing diagnosis would the nurse prioritize?

A) Anxiety
B) Disturbed Body Image
C) Ineffective Individual Coping
D) Denial

Question 30

A patient with diabetes presents with an ulcer on the end of the great toe. Assessment reveals gangrene extending to the base of the toe. The nurse would evaluate this ulcer as matching criteria for grade ____ on the Wagner Ulcer Grade Classification System.

Question 31

The nurse is changing the dressing on an open abdominal surgical wound. How should the nurse proceed?

A) Complete the dressing change as quickly as possible.
B) Thoroughly irrigate the wound with cool normal saline.
C) Remove the old dressing and leave the wound open to air for a few minutes prior to redressing.
D) Clean the wound edges with hydrogen peroxide prior to redressing the wound.

Question 32

A patient with a diabetic foot ulcer says, "My friend took some kind of oxygen chamber treatments for her wound a year or so ago and it healed right up. Would that work for me?" What should the nurse consider prior to responding?

A) The treatment is contraindicated for people with diabetes because of the potential for hypoglycemia.
B) The technology does not improve the status of ulcers on the lower extremities.
C) Hyperbaric therapy is no longer being done because of the fire hazards involved.
D) Hyperbaric therapy has some inherent dangers but has been proven effective in helping to heal wounds.

Question 33

A patient who has a slowly healing wound from a traumatic injury is prescribed an arginine supplement. What information would the nurse provide about this supplement?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Arginine helps to build collagen for wound healing.
B) Arginine will help build blood supply to the injured area.
C) Arginine helps support the immune system.
D) Arginine is essential for coagulation.
E) Arginine decreases bacterial proliferation.

Question 34

Assessment reveals that a female patient has 4+ pitting edema in both lower extremities. Both legs are reddened, with shiny spots, and the skin is dry and flaky. Which assessment finding would the nurse interpret as the best indicator of venous insufficiency?

A) Dry skin
B) Reddened color
C) Flaking skin
D) Shiny skin

Question 35

A patient has a negative pressure wound therapy (NPWT) unit in place. How often should the nurse plan to change the dressing associated with this device?

A) Every shift
B) Daily
C) Every three days
D) Once a week