Question 1

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.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient has been admitted with a...

Question 2

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.
Standard Text: Select all that apply.

Accepted Answer

Arginine is an amino acid that plays a role in wound healing by promoting collagen synthesis, increasing blood flow to the area, and supporting the immune system. It is not essential for coagulation and does not directly decrease bacterial proliferation.

Question 3

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.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient has developed a hematoma under...

Question 4

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

Accepted Answer

Using a continuous strip of gauze to pack the tunnel allows for even distribution of the dressing material, which supports healing by absorbing exudate and maintaining a moist environment. This method also facilitates easier and less painful dressing changes.

Question 5

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?

Accepted Answer

The significant difference between the arm systolic blood pressures and the ankle systolic blood pressures suggests poor circulation to the feet, which can impede healing of the ulcer. This condition, known as peripheral artery disease (PAD), is indicated by an ankle-brachial index (ABI) less than 1.0, suggesting that the ulcer may not heal well due to inadequate blood flow.

Question 6

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.

Accepted Answer

The answer of A patient with diabetes presents with an...

Question 7

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?

Accepted Answer

Reddened color of the skin is a common indicator of venous insufficiency, reflecting changes in blood flow and possible inflammation or stasis beneath the skin surface.

Question 8

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?

Accepted Answer

The presence of a black wound bed indicates the involvement of necrotic tissue, which means the ulcer cannot be staged until the necrotic tissue is removed. Therefore, the ulcer is classified as unstageable.

Question 9

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?

Accepted Answer

The nurse should cover the exposed tissues with a sterile saline-moistened dressing to prevent further contamination and protect the tissues. This is an emergency situation that requires immediate intervention. Choices A, B, and D are not appropriate actions in this situation.

Question 10

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?

Accepted Answer

The nurse should consider that hyperbaric therapy has some inherent dangers but has been proven effective in helping to heal wounds. The nurse should also provide education to the patient about the risks and benefits of this treatment option and discuss with the healthcare provider if it is appropriate for them. Option A is not true, as hypoglycemia is not a contraindication for hyperbaric therapy. Option B is not true, as hyperbaric therapy has been shown to improve wound healing in some cases. Option C is not true, as hyperbaric therapy is still being used today with proper precautions in place to prevent fire hazards.

Question 11

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?

Accepted Answer

In a patient with thin, fragile skin, there is a high risk of skin tears when removing dressings or tape. The nurse should hold the skin down and gently pull the tape off to minimize the risk of injury to the skin. Grasping and pulling sharply, rubbing the sides of the tape or allowing the tape to loosen over several days can cause skin tears, which delays healing and may increase the risk of infection.

Question 12

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 ________.

Accepted Answer

The answer of The nurse has used the Braden Risk...

Question 13

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

Accepted Answer

Completing the dressing change quickly minimizes the time the wound is exposed to potential environmental contaminants, reducing the risk of infection.

Question 14

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?

Accepted Answer

NPWT dressings are typically changed every 48 to 72 hours (every three days) unless there is heavy exudate or infection, which may necessitate more frequent changes.

Question 15

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?

Accepted Answer

The patient's statement indicates a concern for body image, which suggests Disturbed Body Image. Anxiety may also be a concern, but the emphasis on the patient's appearance makes Body Image the priority. Ineffective Individual Coping and Denial may be relevant as well, but do not appear to be the primary concerns based on the information provided.

Quiz 60: Caring for the Patient With Wounds

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. Standard Text: Select all that apply.

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. Standard Text: Select all that apply.

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. Standard Text: Select all that apply.