Question 1

The home care nurse visits a client to assess an abdominal surgery site.The client is elderly, lives alone, and takes multiple medications for chronic illnesses.The nurse notes that the client's wound shows signs of delayed healing.Which factor does the nurse recognize as being least likely to be a contributing factor for the delayed healing?

Accepted Answer

The delivery of meals, including two cold meals and one hot meal daily, ensures that the client is receiving nutrition, which is essential for wound healing. This factor is least likely to contribute to delayed healing compared to difficulties with dressing changes, medication effects, and avoiding showers, which could impact hygiene and wound care.

Question 2

A client arrives at a clinic with a wound received by an ax two days ago while cutting firewood.The client states that initial wound care was performed at home.The nurse assesses a deep open wound on the lower leg, which will need surgical closure.Which complication does the nurse recognize is a probability for this client?

Accepted Answer

The wound is at high risk for infection, especially from common bacteria like Staphylococcus aureus, due to being open for two days and initially treated at home.

Question 3

The nurse is caring for a client immediately after surgery.During assessment the nurse notes sanguineous drainage on the client's dressing.Which action by the nurse is most correct?

Accepted Answer

Marking and initialing the edges of the drainage with the date and time allows the nurse to monitor any increase in drainage over time, which is a standard practice for assessing post-operative wound drainage.

Question 4

The nurse is caring for a client who was involved in a motor vehicle accident.The client was thrown from the vehicle and has several areas where skin appears to have been scraped away.The nurse identifies the wounds as abrasions.Which statement is true about this type of wounds?

Accepted Answer

Abrasions are generally superficial wounds affecting the top layer of the skin and tend to heal quickly if they are properly cleaned and protected from infection. They do not typically involve deep tissue, muscle, or bone, nor do they usually require systemic antibiotics unless an infection develops.

Question 5

The nurse is preparing to irrigate a client's wound with a syringe and sterile saline.Which action by the nurse demonstrates correct procedure?

Accepted Answer

Directing the solution flow from the least contaminated area to the most contaminated area helps prevent spreading bacteria or infection further into the wound, which aligns with proper wound irrigation techniques.

Question 6

While assessing a client's surgical incision, the nurse notes that it is dry, clean, and intact, with edges approximated.The nurse is aware that which type of healing is taking place?

Accepted Answer

First intention healing, also known as primary intention, occurs when a surgical incision or a clean wound edges are brought together (approximated) with sutures, staples, or adhesive. This method promotes faster healing and reduces scarring, which matches the description of the wound observed by the nurse.

Question 7

The nurse is caring for a client with diabetes mellitus who has a non-healing wound on the bottom of the foot.Which assessment finding causes the nurse to conclude that the wound is likely infected with Clostridia?

Accepted Answer

A crackling sensation under the skin, known as crepitus, can be felt when palpating around the wound. This is indicative of gas production by the bacteria, which is a characteristic of infections caused by Clostridia species, such as Clostridium perfringens, known for causing gas gangrene.

Question 8

The nurse is caring for a client who is five days postoperative.The physician orders that every other staple be removed from the incision.The nurse notices that the staples appear to be far apart and after the first staple is removed, the incision begins to gap open.Which action will the nurse take?

Accepted Answer

The nurse should call the physician and report wound dehiscence, as the incision is gaping open after removing the first staple, indicating a potential complication that requires medical attention.

Question 9

The nurse is providing care for multiple clients in an extended care facility.Which client does the nurse identify for being at the most risk for the development of pressure injuries?

Accepted Answer

The client with diabetes mellitus who is immobile is at the most risk for the development of pressure injuries. Diabetes can impair circulation and wound healing, and immobility increases pressure on certain areas of the body, both of which significantly raise the risk of pressure injuries.

Question 10

The nurse assesses a client's wound.Which documentation will the nurse make to indicate a possible infection?

Accepted Answer

Purulent drainage and a foul odor from a wound are classic signs of infection, indicating that the wound is not healing properly and may be infected.

Question 11

The nurse answers a client's emergency call light, which is activated from the client's bathroom.The nurse discovers pinkish-gray organs protruding from the bottom of an abdominal dressing.Which action does the nurse take first?

Accepted Answer

The answer of The nurse answers a client's emergency call...

Question 12

The nurse is providing care for a client with a surgical wound exhibiting signs of delayed healing but no redness or drainage.The physician orders a culture of the wound.Which condition does the nurse understand the culture will reveal?

Accepted Answer

A culture of a wound without redness or drainage but showing signs of delayed healing can reveal a colonized wound, where bacteria are present but not causing an infection. This can impede the healing process.

Question 13

The nurse is providing discharge teaching to a client who had surgery to remove a growth on the tongue.The nurse understands that the surgery site is identified as a clean-contaminated wound.Which teaching will the nurse provide?

Accepted Answer

Clean-contaminated wounds are those that are not infected at the time of surgery but are at an increased risk of becoming infected postoperatively due to their location. In this case, because the mouth is full of bacteria (normal flora), a surgical wound in the mouth is at a higher risk for infection, even though it might not have been contaminated during the surgery. Choices A, B, and C do not accurately describe a clean-contaminated wound or its expected outcomes.

Question 14

The nurse is providing care for a client with a stage III pressure injury on the right trochanter area.The physician has ordered the use of hydrocolloid dressings.Which action will the nurse perform in the maintenance of the prescribed dressing?

Accepted Answer

Hydrocolloid dressings are designed to absorb exudate and maintain a moist environment. The nurse should inspect the dressing for escaping drainage, wrinkling, and excessive exudate to ensure it is functioning properly and to decide if a change is needed.

Question 15

The nurse is caring for a client admitted through the emergency department (ED)following an accident.The client's injuries include an open fracture of the leg and multiple bruises.Which terminology will the nurse use to document the client's wounds?

Accepted Answer

A compound fracture is another term for an open fracture, where the bone breaks through the skin. Contusions are medical terms for bruises. Therefore, "Compound leg fracture with multiple contusions" accurately describes the client's injuries.

Question 16

The nurse provides care to an obese client who is at risk for pressure injuries.The client's plan of care places the client on pressure injury prevention.Which actions should the nurse be implementing? Select all that apply.

Accepted Answer

Maintaining clean, dry, wrinkle-free linens helps prevent pressure injuries. Adequate fluid intake and nutrition support skin integrity. Regular skin assessments help identify early signs of breakdown.

Question 17

The nurse is caring for a client admitted with chronic venous insufficiency.The nurse assesses the client's lower extremities, which are edematous and discolored.Which additional finding should the nurse expect to find during assessment?

Accepted Answer

Stasis ulcers are a common finding in chronic venous insufficiency due to poor venous return, leading to increased pressure in the veins, edema, and eventually skin breakdown and ulceration, particularly around the lower legs and ankles.

Question 18

The nurse is preparing to clean a surgical wound that is closed with staples.Assessment reveals that the incision is clean, dry, well approximated, and without redness or tenderness.Which wound cleaning procedure will the nurse use?

Accepted Answer

The correct procedure for cleaning a surgical wound that is closed with staples, especially when the wound is clean, dry, and well approximated, is to use forceps with a sterile antiseptic swab and move from the superior (top) to the inferior (bottom) end of the incision. This method helps in minimizing the risk of introducing infection into the wound by cleaning from the least contaminated area (the superior end) to the more contaminated area (the inferior end).

Question 19

The nurse is providing care for a client readmitted to the hospital following a modified mastectomy.The nurse notes that the primary surgical wound is inflamed, painful, and edematous.Under the client's arm, the nurse notices a small open area draining a moderate amount of green drainage.Which condition does the nurse identify?

Accepted Answer

Sinus tract is a narrow channel that forms between infected and healthy tissue. It allows drainage to escape from the infected area.

Question 20

The nurse is providing care for a client after surgery for repair for a penetrating wound to the abdomen.Which characteristic of the wound will make the nurse most vigilant for signs of infection?

Accepted Answer

Penetrating wounds, especially those where the object remains embedded until surgery, are at a higher risk for infection. The presence of a foreign object can introduce bacteria deep into the tissues and create an environment conducive to infection.

Quiz 26: Wound Care