Exam 25: Wound Care and Irrigation

The nurse is irrigating a wound with a wide opening.What equipment would be appropriate for the nurse to use?

The nurse assesses a patient's wound and notices leakage at the edge of the transparent film of the negative-pressure wound therapy.Which does the nurse implement to promote wound healing and prevent infection?

The nurse is preparing to use high-pressure pulsatile lavage to irrigate a necrotic wound.Which of the following statements indicate a need for further education on this type of irrigation? (Select all that apply.)

The nurse prepares to apply a dressing for a patient who has a full-thickness wound with moderate exudate and necrosis.Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound?

The nurse is caring for a patient who has a Jackson-Pratt drain in place on postoperative day 1.The NAP reports there is no drainage and the patient is complaining of pain at the site.What will the nurse do first?

The nurse applies Steri-Strips to the patient's surgical site after suture removal.During patient teaching, what does the nurse instruct the patient to avoid doing?

The nurse is assessing the negative-pressure wound therapy system and notes a large leak.The previous nurse had already attempted to repair the leak by applying more transparent dressing three different times.What action by the nurse is most appropriate?

The nurse is listing factors that affect wound healing to a student nurse.What factors does the nurse include? (Select all that apply.)

The nurse prepares to assess the patient's wound after removing the dressing.Which does the nurse implement to promote infection control?

The nurse assesses a patient with a surgical incision.What is an expected patient outcome on the fourth postoperative day?

The nurse evaluates the surgical incision before removing the patient's staples.What assessment finding would suggest staple removal is contraindicated for now?

A patient's wound does not seem to be healing.What assessment finding would the nurse correlate with this situation?

The nurse assesses several preoperative patients for potential postoperative referrals to the wound care team.Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing?

The nurse performs a dressing change for a patient with a negative-pressure wound therapy device.Which step does the nurse implement to facilitate wound healing?

The nurse is performing a wound assessment after removing the soiled dressing.What finding would indicate a problem requiring additional assessment?

The nurse is preparing to remove the skin staples from an older adult's incision.Which action will the nurse take to prevent a complication as a result of age and its effect on healing?

The nurse is caring for a patient whose wound looks like the following.What wound care does the nurse prepare to implement for this wound?

A nurse assesses the patient's wound and notes the following appearance.What action by the nurse is most appropriate?

The nurse assigns patient care to nursing assistive personnel (NAP).Which wound care task can the nurse assign to NAP?

The nurse is preparing to remove a patient's sutures.What technique demonstrates correct technique?