Exam 24: Wound Care and Irrigation

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

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

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

The nurse notes evisceration of the patient's abdominal incision.Which nursing intervention is the priority before collaborating with the surgeon?

The nurse teaches a patient about Steri-Strips after suture removal.What information does the nurse include in patient teaching?

2. A _____ ______wound is a total loss of epidermis and dermis and in some cases is as deep as the muscle layer or bone; it heals by scar formation.

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

The nurse teaches a patient about self-care of two Jackson-Pratt drains after breast surgery.What does the nurse include in patient teaching?

The nurse needs to apply a dry sterile dressing.Which should the nurse implement first?

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?

1. A ______ __________ wound is a loss of the epidermis and superficial dermal layers and heals by regeneration.

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

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

A patient has an abdominal wound with a Hemovac drain in place.Which technique should the nurse implement to maintain optimal suction in the drain?

The nurse prepares to remove the patient's sutures and staples.Which step should the nurse implement before proceeding with the removal?

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 should the nurse do first?

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

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.)