Deck 38: Providing Wound Care and Treating Pressure Ulcers

Question 1

The nurse warns the patient that one of the patient's habits has caused the reduction of functional hemoglobin, which limits the hemoglobin's oxygen carrying ability. To improve this situation, the nurse suggests that the patient quit:

A) drinking.
B) using marijuana.
C) smoking cigarettes.
D) eating excessive fats.

Answer 1

smoking cigarettes.

Question 2

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

A) add normal saline to loosen it.
B) pull it off using slow, steady pressure.
C) leave it in place and cover it with new, wet dressings.
D) moisten it with povidone iodine.

Answer 2

add normal saline to loosen it.

Question 3

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:

A) fourth intention.
B) third intention.
C) second intention.
D) first intention.

Answer 3

first intention.

Question 4

The nurse clarifies that the first stage of wound healing is:

A) proliferation.
B) maturation.
C) reconstruction.
D) inflammation.

Question 5

A nurse performing a right eye irrigation will position the patient:

A) upright with the head hyperextended.
B) upright with the head tilted toward the left eye.
C) supine with the head hyperextended.
D) supine with the head tilted toward the right eye.

Question 6

A nurse caring for a patient with a Stage I pressure ulcer would most appropriately select:

A) nonocclusive dressing.
B) exudate absorbing dressing.
C) hydrocolloid dressing.
D) thin film dressing.

Question 7

A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?

A) From left to right across the abdomen
B) From right to left across the abdomen
C) From the top of the wound to the bottom
D) From each of the four sides toward the wound

Question 8

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

A) restlessness, rising pulse, and falling blood pressure.
B) restlessness, falling pulse, and rising blood pressure.
C) headache, rising pulse, and falling blood pressure.
D) lethargy, falling pulse, and rising blood pressure.

Question 9

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use:

A) paper tape.
B) Montgomery straps.
C) Karaya paste.
D) elastic adhesive tape.

Question 10

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

A) keep the wound dry.
B) help destroy microorganisms in an infected wound.
C) occlude air and promote breakdown of necrotic tissue.
D) leave the dressing in place for 10 days.

Question 11

A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a(n):

A) abrasion.
B) laceration.
C) hematoma.
D) avulsion.

Question 12

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

A) drawing the wound edges together by negative pressure.
B) interrupting the proliferation of bacteria in the wound.
C) strengthening the wall of the wound.
D) making an air occlusive cover for the wound.

Question 13

A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, "I think something just let go." The initial intervention by the nurse should be to:

A) seat the patient in a nearby chair.
B) assist the patient in a supine position.
C) ask someone to quickly get an abdominal binder.
D) instruct the patient to pant to reduce abdominal tension.

Question 14

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

A) increased pallor of the surgical site.
B) complaint of constipation.
C) excessive gas.
D) increased serosanguineous drainage from the wound.

Question 15

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

A) uses one alcohol wipe to clean both the spout and the plug.
B) compresses the device in the hand before closing.
C) refrains from touching the drainage spout with the hand.
D) points the device away from herself while opening it.

Question 16

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

A) from the outer abdomen toward the wound.
B) in a circular motion around the wound circling to the outside.
C) from the left to the right across the wound.
D) directly over the wound.

Question 17

A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:

A) pull to the right.
B) pull outward.
C) pull to the left.
D) rotate.

Question 18

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

A) an infection is in progress at the wound site.
B) vessels have dilated and allowed plasma to leak into the wound site.
C) he has lain in one position for such a long time that swelling has occurred.
D) there is probably a deeper injury than what appears on the surface.

Question 19

The nurse gives an example of a wound that heals by second (secondary) intention as a:

A) laceration with edges that do not approximate.
B) surgical incision closed with staples.
C) chest wound left open for a closed system.
D) puncture wound sutured with silk suture.

Question 20

The nurse chooses a nonadherent dressing to apply to a wound because the nonadherent dressing:

A) is smaller and less bulky and will absorb more drainage.
B) retains sterility longer than plain gauze.
C) allows drainage to seep through the barrier and be absorbed on the other side.
D) does not require the use of tape to make it adhere to the skin.

Question 21

The nurse explains to the patient that the foot will be submerged in warm water for a maximum of ______ minutes.

Question 22

The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

A) excessive production of blood factors.
B) atherosclerosis.
C) diminished lung function.
D) slow metabolism.
E) increased immunity.

Question 23

The nurse places Dakin solution in a wound to accomplish chemical ___________.

Question 24

The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the:

A) scapula.
B) sacrum.
C) heel.
D) femoral head.

Question 25

The nurse recognizes that of the drugs a patient is currently taking, several contribute to delayed healing, such as: (Select all that apply.)

A) vitamin C.
B) antineoplastic drugs.
C) pyrixidine.
D) heparin.
E) steroids.

Question 26

The nurse assesses the large raised scar on the African American patient. The nurse documents the lesion as a _______________.

Question 27

The nurse changing a patient's surgical dressing will: (Prioritize the steps. Separate the letters by a comma and a space as follows: A, B, C, D, E, F, G.)

A) Apply new dressing.
B) Remove old dressing.
C) Gather supplies.
D) Wash hands.
E) Don clean gloves.
F) Document findings.
G) Apply sterile gloves.

Question 28

The nurse is concerned about an HIV immunocompromised patient's ability to heal because of the lack of: (Select all that apply.)

A) hemoglobin.
B) adequate fibroblast function.
C) synthesis of collagen.
D) intrinsic factor.
E) adequate phagocytosis.

Question 29

The nurse irrigating an infected wound of the hand would: (Prioritize the steps. Separate the letters by a comma and a space as follows: A, B, C, D, E, F, G.)

A) Open sterile irrigation basin and solution.
B) Don sterile gloves to apply dressing.
C) Pour irrigating solution in basin.
D) Irrigate keeping the syringe tip 1 inch from the wound surface.
E) Document procedure.
F) Pat wound dry and redress.
G) Place pad under the infected hand.