Lab Quiz 1: Wound Care

The nurse is planning care for her patient who has a stage II pressure ulcer. Care should include which of the following? (Select all that apply.)

A. A heat lamp to dry the wound

B. Application of topical antibiotics

C. Nutritional assessment

D. Maintaining moisture in the wound

ANS: B,C,D

The nurse knows that mechanical debridement involves all of the following except:

A. wet to dry dressings.

B. whirlpool baths.

C. damp to dry dressing.

D. enzymatic dressing.

ANS: D

Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?

A. "The wound will be red."

B. "The wound will have pus."

C. "The wound will be warm."

D. "The wound will need to be treated ."

ANS: B

An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105 per gram of tissue sampled when cultured. The wound will need to be treated for the infection.

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

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 tissues below the epidermis.

D. Apply Steri-Strip if any separation greater than the width of two stitches is present.

ANS: D

How should the nurse identify a patient before obtaining a laboratory specimen?

A. Use at least two patient identifiers.

B. Look at the chart before entering the room.

C. Ask the patient his name.

D. Check the patient's armband twice.

ANS: A

The nurse knows the layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect is:

A. stratum germinativum.

B. epidermis.

C. subcutaneous layer.

D. stratum corneum.

ANS: C

The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

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?

A. A reduction in the size of the wound is noted.

B. The epithelial cells duplicate.

C. Synthesis of collagen occurs at the site.

D. Blood flow to the wound and arrival of white blood cells are increased.

ANS: D

The nurse knows to irrigate a deep wound with:

A. A 5-mL syringe.

B. A 10-mL syringe.

C. A 3-mL syringe.

D. A 30-mL syringe.

ANS: D

A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi

When collecting specimens, the nurse should: (Select all that apply.)

A. wear gloves and perform hand hygiene.

B. handle excretions discreetly.

C. explain the procedure to the patient.

D. allow patients to collect their own urine specimens.

ANS: A,B,C,D

When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should:

A. obtain a wound culture.

B. apply pressure-reducing devices.

C. use dressings with increased moisture absorption.

D. monitor the patient for systemic signs and symptoms.

ANS: C

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

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.

ANS: A,B,C,D

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention?

A. Edema in the sacrum

B. Skin texture

C. Skin temperature

D. Pallor or mottling of the skin

ANS: C

When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as:

A. an expected occurrence.

B. a wound infection requiring a culture.

C. an adverse reaction to the hydrocolloid components.

D. excessive exudate requiring a different type of dressing.

ANS: A

The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed?

A. Apply a film dressing after culturing the wound.

B. Apply a film dressing after cleansing the area.

C. Choose another type of dressing for this wound.

D. Keep the wound open to air.

ANS: C

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.)

A. Hemostasis

B. Inflammation

C. Proliferation

D. Maturation

ANS: A,B,C,D

In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation.

For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond?

A. Culture the wound.

B. Leave the current dressing in place.

C. Apply gauze over the top of the dressing.

D. Remove and stretch the film more tightly over the wound.

ANS: A

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

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 towards one end.

D. she should work in a circular motion around the incision line.

ANS: C

The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.)

A. Edema

B. Shivering

C. Bleeding

D. Circulatory issues

ANS: A, B, D

Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy.

Which of the following is the best example of accurate documentation?

A. "Abdominal wound is 5 cm in length without redness, edema, or drainage."

B. "OD to be irrgated qd with NS."

C. "No complaint of abdominal pain this shift."

D. "Patient watching TV entire shift."

ANS: A

What should the nurse remember to do when applying a hydrocolloid dressing?

A. Apply granules after applying the water.

B. Never use a secondary dressing.

C. Hold the dressing in place.

D. Use silk tape to hold the dressing in place.

ANS: C