Exam 38: Wound Care and Irrigations

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

What should the nurse do when removing intermittent sutures?

What should the nurse do when performing suture or staple removal?

The nurse answers the patient's call light to find the patient agitated and stating that she "felt something pop." The nurse finds that the patient's abdominal surgical wound has eviscerated.What should the nurse do?

_____________ uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

___________ is black, brown, or tan tissue in the wound that should be removed before wound healing can begin.

Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

The nurse is explaining wound healing to a patient.Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is considered a __________ drainage system.

A failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level is known as ______________.

When teaching about wound care in the home environment, the nurse instructs the patient and caregiver to:

The nurse is caring for a patient who has a dressing over a surgical wound created the night before.The dressing has never been changed.How should the nurse proceed?

The _____________ is composed of newly formed collagen, and the nurse can usually feel it along a healing wound.It is usually present directly under the suture line between days 5 and 9.

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

Wounds that have been approved for treatment using NPWT include which of the following? (Select all that apply.)

___________ are threads of wire or other materials used to sew body tissues together.

The nurse is caring for a patient with a large stasis ulcer.She has just changed the wound dressing and is using a negative-pressure wound system.What can the nurse tell the patient about the functioning of this system?

The nurse is caring for a patient who has had major abdominal surgery.She is concerned about the possibility of dehiscence.During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply.)

Which of the following approaches is correct technique when wound irrigation is performed?

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing.Which of the following can be appropriately delegated to the nurse assistant?