Exam 14: Surgical Wound Care

What marked advantage does primary intention have over other phases of wound healing?

The physician has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?

What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?

The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?

The nurse assessing a patient's wound notes thick, yellow drainage. How will the nurse most accurately document this finding?

The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by _______ formation.

Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?

The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?

The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service? (Select all that apply.)

The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?

The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing?

What is the advantage of an occlusive dressing?

When preparing to remove a dressing, the nurse should don __________ gloves.

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?

The nurse encourages a patient recovering from a hysterectomy to drink at least _______ mL of fluid a day.

The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?

A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer. The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese. The nurse assesses the ulcer to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What nursing diagnosis will be identified as a priority?

Which are the phases of wound healing? (Select all that apply.)

The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?