Question 1

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

Accepted Answer

A) Graft sites 
B) Wounds with exposed blood vessels 
C) Necrotic tissue 
D) Wounds with exposed muscle or tendons 
A) Graft sites 
B) Wounds with exposed blood vessels 
C) Necrotic tissue 
D) Wounds with exposed muscle or tendons C

Question 2

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.

Accepted Answer

tertiary
Healing by tertiary intention is sometimes called delayed primary intention or closure.It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.Then the wound edges are sutured or stapled closed.Scarring is usually minimal.

Question 3

Healing by primary intention is expected to occur with which of the following situations?

Accepted Answer

A) The wound is left open and is allowed to heal. 
B) A surgical wound is left open for 3 to 5 days. 
C) Connective tissue development is evident. 
D) The edges of a clean incision remain close together. 
A) The wound is left open and is allowed to heal. 
B) A surgical wound is left open for 3 to 5 days. 
C) Connective tissue development is evident. 
D) The edges of a clean incision remain close together. D

Question 4

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

Accepted Answer

A) Snip both ends of the sutures. 
B) Apply tension to the suture line to remove the sutures. 
C) Pull the exposed surface of the suture through the tissue below the epidermis. 
D) Apply Steri-Strip if any separation greater than the width of two stitches is present. 
A) Snip both ends of the sutures. 
B) Apply tension to the suture line to remove the sutures. 
C) Pull the exposed surface of the suture through the tissue below the epidermis. 
D) Apply Steri-Strip if any separation greater than the width of two stitches is present.

Question 5

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?

Accepted Answer

A) Performing a sterile dressing change 
B) Observing for any drainage on the dressing 
C) Performing wound assessment during the dressing change 
D) Notifying the physician of drainage present on the dressing 
A) Performing a sterile dressing change 
B) Observing for any drainage on the dressing 
C) Performing wound assessment during the dressing change 
D) Notifying the physician of drainage present on the dressing

Question 6

The physician expects that the patient's wound will have an output of close to 500 mL/day.The nurse anticipates placement of which of the following?

Accepted Answer

A) Dry sterile dressing 
B) Jackson-Pratt (JP)drain 
C) Hemovac drain 
D) No drain 
A) Dry sterile dressing 
B) Jackson-Pratt (JP)drain 
C) Hemovac drain 
D) No drain

Question 7

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.

Accepted Answer

healing ridge
The healing ridge is compo

Question 8

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

Accepted Answer

A) make normal saline with 8 teaspoons of salt and 1 gallon of distilled water. 
B) use normal saline for 1 week and then discard it. 
C) not apply topical anesthetics before wound care. 
D) call the physician's office to have someone come to the home and complete the wound care. 
A) make normal saline with 8 teaspoons of salt and 1 gallon of distilled water. 
B) use normal saline for 1 week and then discard it. 
C) not apply topical anesthetics before wound care. 
D) call the physician's office to have someone come to the home and complete the wound care.

Question 9

The nurse is changing a surgical dressing and is cleansing the wound.She knows that:

Accepted Answer

A) the incision line should be cleansed last. 
B) she should start at one end of the incision line and swab the entire length. 
C) she should start at the center of the incision line and swab toward one end. 
D) she should work in a circular motion around the incision line. 
A) the incision line should be cleansed last. 
B) she should start at one end of the incision line and swab the entire length. 
C) she should start at the center of the incision line and swab toward one end. 
D) she should work in a circular motion around the incision line.

Question 10

The nurse is explaining healing of a full-thickness wound to a patient.Which of the following phases should the nurse include in the explanation? (Select all that apply. )

Accepted Answer

A) Hemostasis 
B) Inflammation 
C) Proliferation 
D) Maturation 
A) Hemostasis 
B) Inflammation 
C) Proliferation 
D) Maturation

Question 11

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

Accepted Answer

A) Pressure ulcers 
B) Diabetic ulcers 
C) Traumatic wounds 
D) Venous stasis ulcers 
A) Pressure ulcers 
B) Diabetic ulcers 
C) Traumatic wounds 
D) Venous stasis ulcers

Question 12

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

Accepted Answer

A) Age 
B) Malnutrition/obesity 
C) Gender 
D) Use of steroids 
A) Age 
B) Malnutrition/obesity 
C) Gender 
D) Use of steroids

Question 13

What should the nurse do when removing intermittent sutures?

Accepted Answer

A) Snip both sides of the suture before removing. 
B) Snip the suture as close to the knot as possible. 
C) Snip the suture as close to the skin as possible. 
D) Pull up the knot to apply as much tension as possible. 
A) Snip both sides of the suture before removing. 
B) Snip the suture as close to the knot as possible. 
C) Snip the suture as close to the skin as possible. 
D) Pull up the knot to apply as much tension as possible.

Question 14

The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock.How should the nurse proceed?

Accepted Answer

A) Use irrigation pressures of less than 4 psi. 
B) Cleanse in a direction from most contaminated to least contaminated. 
C) Irrigate so that the solution flows from least contaminated to most contaminated. 
D) Irrigate with clean irrigation solution only. 
A) Use irrigation pressures of less than 4 psi. 
B) Cleanse in a direction from most contaminated to least contaminated. 
C) Irrigate so that the solution flows from least contaminated to most contaminated. 
D) Irrigate with clean irrigation solution only.

Question 15

You are explaining negative-pressure wound therapy (NPWT)to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply. )

Accepted Answer

A) NPWT optimizes blood flow. 
B) NPWT will remove wound fluid. 
C) NPWT will maintain a moist environment. 
D) NPWT will apply positive pressure to the wound. 
A) NPWT optimizes blood flow. 
B) NPWT will remove wound fluid. 
C) NPWT will maintain a moist environment. 
D) NPWT will apply positive pressure to the wound.

Question 16

What is an appropriate technique for the nurse to implement for drainage evacuation?

Accepted Answer

A) Replace the Hemovac drain fully expanded. 
B) Attach the drainage tubing to the patient's gown. 
C) Tilt the evacuator of the Hemovac away from the plug. 
D) Complete the dressing change before the drainage evacuation. 
A) Replace the Hemovac drain fully expanded. 
B) Attach the drainage tubing to the patient's gown. 
C) Tilt the evacuator of the Hemovac away from the plug. 
D) Complete the dressing change before the drainage evacuation.

Question 17

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

Accepted Answer

Eschar
Black,brown,or tan tiss

Question 18

How does the skin defend the body? (Select all that apply. )

Accepted Answer

A) Skin serves as a sensory organ for pain. 
B) Skin serves as a sensory organ for touch. 
C) Skin serves as a sensory organ for temperature. 
D) Skin has an acid pH. 
A) Skin serves as a sensory organ for pain. 
B) Skin serves as a sensory organ for touch. 
C) Skin serves as a sensory organ for temperature. 
D) Skin has an acid pH.

Question 19

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

Accepted Answer

A) Decrease scar formation. 
B) Remove debris from the wound. 
C) Improve circulation from the wound. 
D) Decrease irritation from wound drainage. 
A) Decrease scar formation. 
B) Remove debris from the wound. 
C) Improve circulation from the wound. 
D) Decrease irritation from wound drainage.

Question 20

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

Accepted Answer

Irrigation
Irrigation uses the

Exam 40: Wound Care and Irrigations

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

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.

Healing by primary intention is expected to occur with which of the following situations?

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

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?

The physician expects that the patient's wound will have an output of close to 500 mL/day.The nurse anticipates placement of which of the following?

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.

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

The nurse is changing a surgical dressing and is cleansing the wound.She knows that:

The nurse is explaining healing of a full-thickness wound to a patient.Which of the following phases should the nurse include in the explanation? (Select all that apply. )

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

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

What should the nurse do when removing intermittent sutures?

The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock.How should the nurse proceed?

You are explaining negative-pressure wound therapy (NPWT)to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply. )

What is an appropriate technique for the nurse to implement for drainage evacuation?

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

How does the skin defend the body? (Select all that apply. )

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

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

Using Evidence in Practice

Admitting, Transfer, and Discharge

Communication and Collaboration

Documentation and Informatics

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Medical Asepsis

Sterile Technique

Safe Patient Handling, Transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Patient Safety

Disaster Preparedness

Pain Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Intravenous and Vascular Access Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Pressure Injury Prevention and Care

Dressings, Bandages, and Binders

Therapeutic Use of Heat and Cold

Home Care Safety

Home Care Teaching

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