Deck 24: Wound Care and Irrigation

Question 1

While cleaning a wound,the nurse determines that undermining is at the top of the wound.Which documentation of the wound by the nurse is best?

A) Dark pink wound with undermining at 2 o'clock
B) Wound clean and without odor with slight undermining toward patient's head
C) See photograph of wound taken today
D) Pale pink wound 2 cm × 3 cm × 2 cm deep with undermining at 12 o'clock

Answer 1

Pale pink wound 2 cm × 3 cm × 2 cm deep with undermining at 12 o'clock

Question 2

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

A) The area could have an increased risk of visible scarring.
B) There is a small open area along the incision.
C) The site is without drainage or erythema.
D) The patient is quite anxious about the staple removal.

Answer 2

There is a small open area along the incision.

Question 3

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

A) They provide a skin barrier.
B) They provide gentle support.
C) They prevent scarring of the wound.
D) They collect additional drainage.

Answer 3

They provide gentle support.

Question 4

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?

A) Be prepared to use skin glue on the edges of the wound.
B) Have Steri-Strips ready to use after the staples are removed.
C) Increase the amount of protein in the patient's diet.
D) Assess the skin edges before the patient is discharged.

Question 5

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?

A) Replace the Hemovac drain when full.
B) Attach the tubing to the patient's gown.
C) Compress the Hemovac on a flat surface after emptying.
D) Apply high continual suction to the Hemovac plug.

Question 6

The nurse assesses several preoperative patients for potential postoperative referrals to the wound care team.Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing?

A) Eight weeks postpartum from live vaginal birth in for tubal ligation
B) Older than 70 years, coronary artery disease, and hypertension
C) Six-week course of chemotherapy for a cancerous tumor
D) Chronic obstructive lung disease on long-term prednisone therapy

Question 7

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

A) Assess the type of suture material used.
B) Snip off both ends of the suture material.
C) Cleanse crusting with hydrogen peroxide.
D) Plan staple removal for postoperative day 5.

Question 8

The nurse applies Steri-Strips to the patient's surgical site after suture removal.During patient teaching,what does the nurse instruct the patient to avoid doing?

A) Limit heavy lifting activities.
B) Ambulate several times a day.
C) Soak in the bathtub for relaxation.
D) Use a pillow to support incision.

Question 9

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?

A) Assess the wound for sinus tracts and tunneling.
B) Maintain oxygenation with supplemental oxygen.
C) Pack the wound lightly with a wet-to-dry dressing.
D) Provide a well-balanced diet with high-quality protein.

Question 10

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

A) An incisional ridge continues to be present.
B) The patient experiences less discomfort.
C) There is a lack of new drainage.
D) The patient states, "My wound smells funny."

Question 11

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) Apply another layer of transparent film.
B) Change the patient's negative-pressure wound therapy dressing.
C) Patch the leaks with an adhesive dressing.
D) Contain leakage with a large ABD dressing.

Question 12

The nurse is irrigating a wound with a wide opening.What equipment would be appropriate for the nurse to use?

A) A 10-mL syringe with a 20-gauge needle
B) A 35-mL syringe with a 19-gauge angiocatheter
C) A 50-mL syringe with a 27-gauge needle
D) A 60-mL syringe with a 24-gauge angiocatheter

Question 13

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

A) Reinforce the wound with a dry sterile dressing.
B) Use Steri-Strips to approximate the wound edges.
C) Ask the patient whether coughing or activity is the cause.
D) Cover the area with saline solution-moistened sterile towels.

Question 14

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

A) Scrubs the drain insertion site in a back-and-forth manner
B) Cleans the incision from wound edges toward the center
C) Applies clean gloves after removing the old dressing; inspects the wound
D) Dons sterile gloves, removes the dressing, and inspects the wound

Question 15

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?

A) Cuts the foam smaller than wound edges
B) Uses black foam to prevent granulation tissue from forming
C) Determines if the patient needs pain medication before beginning the procedure
D) Checks the dressing to ensure that the negative-pressure wound therapy tubes are functioning

Question 16

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

A) Inspect the appearance of the wound.
B) Remove excess moisture from the wound.
C) Cleanse the wound with sterile saline solution.
D) Prepare the sterile field for supplies.

Question 17

The nurse is preparing to perform a wound irrigation on a 7-year-old child who is uncooperative.Which of the following will be the most helpful in alleviating the child's fear?

A) Restrain the child because no explanations will help.
B) Have the parents leave the room.
C) Describe the wound irrigation in detail.
D) Use a doll to show the child how you will irrigate the wound.

Question 18

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

A) Empty the drain every 2 hours and measure the contents.
B) Maintain a small, steady amount of tension on the drain tubing.
C) Record the amount removed from each drain separately.
D) Keep the collection end of the drain lower than the patient's waist.

Question 19

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

A) The tympanic temperature is 39.5° C at 8 AM and noon.
B) The incision is slightly reddened and swollen without drainage.
C) The skin is spongy and warm around the incision.
D) The patient's pain has been increasing gradually.

Question 20

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

A) Applying a hydrocolloid dressing
B) Assessing the dimensions of the wound
C) Reporting visible drainage on dressing
D) Changing the first postoperative dressing

Question 21

The nursing student is listing the phases of full-thickness wound healing to the nursing mentor.Which of the following phases she lists indicate she needs further education? (Select all that apply.)

A) Inflammatory phase
B) Hemostasis
C) Primary intention
D) Proliferation
E) Remodeling
F) Secondary intention

Question 22

The nurse is assessing a wound that is healing by secondary intention.Which of the following assessments are important to address? (Select all that apply.)

A) Wound dimensions
B) Tissue type
C) Wound edges
D) Periwound skin
E) Pain
F) Undermining
G) None of the above

Question 23

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

Question 24

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.)

A) "I can set the psi between 15 and 17."
B) "I should never use this on exposed blood vessels."
C) "It is okay to use this on skin grafts."
D) "I should not use this on exposed muscles or tendon."
E) "I should never use this on patients with a coagulation disorder."

Question 25

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.

Question 26

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?

A) Notify the healthcare provider.
B) Inspect the area around the drain.
C) Ask the patient to rate his or her pain level.
D) Administer pain medication.