Question 1

The nurse is caring for a client who is receiving negative-pressure wound therapy for an infected leg wound and is aware that the dressing on this wound must be changed how often?

Accepted Answer

The dressing on a wound receiving negative-pressure wound therapy must be changed every 24 hours.

Question 2

The nurse is caring for an older adult client who was admitted to the hospital after having a stroke.The client was in extremely critical condition on admission to the emergency department and a Braden Risk Assessment Scale was not completed.On the client's fifth day of hospitalization,the nurse notes that the client has developed a stage one pressure injury on the elbow of the side affected by the stroke.Which is the implication of this situation in relation to reimbursement for care of the pressure injury?

Accepted Answer

Medicare has specific guidelines regarding the reimbursement for the treatment of pressure injuries acquired in the hospital. If an initial skin assessment is not completed and documented, and a patient develops a pressure injury during their hospital stay, it is often considered a result of hospital-acquired conditions (HACs). Medicare may not reimburse for the treatment of such conditions, as they are considered preventable through proper care and assessment.

Question 3

The nurse is caring for a client with a large venous injury that has just begun to show signs of healing.The nurse contacts the healthcare provider and asks for a change from the chemical method of debridement for which reason?

Accepted Answer

Chemical debridement may damage newly healing tissue because it can be non-selective, potentially harming both necrotic and healthy tissue.

Question 4

The nurse is caring for a client who is at high risk for pressure injury formation because of which factors? Select all that apply.

Accepted Answer

The answer of The nurse is caring for a client...

Question 5

The nurse is caring for four clients who have had surgery and knows that which client would benefit the most from the application of a spiral elastic bandage?

Accepted Answer

A spiral elastic bandage is most beneficial for areas of the body that are cylindrical in shape and vary in circumference, such as the ankle. It provides even pressure and support, which is ideal for post-surgery recovery in limb surgeries, particularly in the ankle area.

Question 6

The nurse has applied an occlusive dressing to a stage 1 pressure injury and knows that this type of dressing assists in debridement of the wound in which way?

Accepted Answer

Occlusive dressings help maintain a moist wound environment, which facilitates the body's natural enzymatic processes to debride the wound.

Question 7

The nurse has completed the Braden Risk Assessment Scale on a client who has been diagnosed with a pelvic fracture and has not been able to get out of bed for the last 6 days.This morning the client's score is 10,so the nurse will institute which measures that will help prevent further skin injury? Select all that apply.

Accepted Answer

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

Question 8

The nurse is preparing to change the dressing of a client who had abdominal surgery 3 days ago.The nurse notes that the incision has purulent drainage and appears very puffy.The client states that the pain level has increased from a 3 to a 7 in the last 24 hours.Which is the nurse's next action in regard to this client's wound?

Accepted Answer

The presence of purulent drainage, increased puffiness, and a significant increase in pain level are signs of a possible infection or complication. The nurse's next action should be to contact the client's surgeon after obtaining the client's vital signs to report these findings and receive further instructions.

Question 9

The nurse is completing a skin assessment at the beginning of the shift and will pay particular attention to which areas of the body that are most prone to skin breakdown? Select all that apply.

Accepted Answer

Areas most prone to skin breakdown, especially in immobile patients, include bony prominences where the skin is in close proximity to bone, such as the heels and sacrum. These areas bear the weight and pressure when a person is lying down or sitting for prolonged periods, increasing the risk of pressure ulcers.

Question 10

While making rounds,the charge nurse observes a staff nurse cleaning a surgical wound and notes that the staff nurse has cleaned the wound from the top to the bottom of the wound.Which action should the charge nurse take in this situation?

Accepted Answer

Cleaning a surgical wound from the top to the bottom is the correct technique. It helps prevent contamination from the surrounding skin and ensures that any debris or exudate is moved away from the clean area towards the more contaminated area. This method minimizes the risk of introducing infection into the wound.

Question 11

The nurse is caring for 4 clients with wounds and would ask that which client be evaluated further for negative-pressure wound therapy?

Accepted Answer

The answer of The nurse is caring for 4 clients...

Question 12

The healthcare provider has ordered an elastic bandage to be applied to a wound on a client's femur.The nurse will begin to apply the bandage at which point on the client's leg?

Accepted Answer

The nurse should begin applying the elastic bandage at the knee, which is distal to the wound on the femur, to ensure proper compression and support as the bandage is wrapped upward toward the wound.

Question 13

The nurse is observing a second nurse who is changing a dressing.While observing the procedure,which would cause the nurse to stop the second nurse and take over the procedure?

Accepted Answer

The second nurse used one swab to clean the wound. This is incorrect because a new swab should be used for each stroke to prevent contamination of the wound.

Question 14

A client is slated to begin negative-pressure wound therapy tomorrow and the nurse is reinforcing the teaching about this therapy.Which statement by the client requires further teaching by the nurse?

Accepted Answer

Negative-pressure wound therapy duration varies greatly depending on the wound's severity, type, and individual healing rates. It can extend beyond 10 days, often for several weeks or longer, not just a standard period.

Question 15

The home health nurse is making the first visit to a client who will continue to need sterile dressing changes after abdominal surgery.In assessing the home environment,which must be considered when performing the home dressing change?

Accepted Answer

The presence of a cat that is allowed on the furniture poses a risk of contamination to the sterile field needed for dressing changes.

Question 16

The nurse is preparing to change the dressing and clean the wound of a client who had hip replacement surgery one day ago.The nurse plans to use which solution for the most effective cleaning of the wound?

Accepted Answer

Normal saline is the most appropriate choice for cleaning wounds because it is isotonic and does not irritate or damage the tissue, promoting optimal wound healing conditions.

Question 17

The nurse is preparing to change a dry dressing of a surgical wound and will use which technique to ensure that the wound stays clean during the procedure?

Accepted Answer

The nurse should wear a mask and use clean gloves to remove the outer dressing to prevent contamination and maintain cleanliness during the procedure.

Question 18

The nurse is using wet-to-dry dressing changes to assist in debridement of an open abdominal wound and knows that which step must be performed to ensure that the newly granulated tissue in the wound will not be injured during the dressing changes?

Accepted Answer

Soaking the dressing with normal saline prior to removal helps to loosen the dressing and minimize trauma to the new granulation tissue, preventing injury during the dressing change.

Question 19

The wound care nurse has been asked by the healthcare provider to begin negative-pressure wound therapy on a client.Upon assessment of the wound,the nurse notes that the wound still requires a great deal of debridement.Which should the nurse do in this situation?

Accepted Answer

Negative-pressure wound therapy (NPWT) is most effective on wounds that have been properly debrided. If a wound requires significant debridement, it is important to address this need before applying NPWT. Therefore, the nurse should contact the healthcare provider to arrange for debridement of the wound.

Question 20

The nurse is caring for a client who sustained second-degree burns to both feet.The healthcare provider has ordered debridement of necrotic tissue by mechanical means.The nurse will use which debridement technique that would be the BEST method to complete this task?

Accepted Answer