CH 38 Providing Wound Care and Treating Pressure Injuries
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The nurse clarifies that the first stage of wound healing is:
proliferation.
maturation.
reconstruction.
inflammation.
ANS: D
Inflammation is the first stage of wound healing, followed by the proliferation, maturation, and reconstruction stages.
DIF: Cognitive Level: Knowledge
REF: p. 761
OBJ: Theory #1
TOP: Inflammatory Process
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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:
fourth intention.
third intention.
second intention.
first intention.
ANS: D
A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first, or primary, intention. Wounds that are not closed heal by either second (secondary) or third (tertiary) intention.
DIF: Cognitive Level: Comprehension
REF: p. 762
OBJ: Theory #1
TOP: Wound Healing Stages
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse gives an example of a wound that heals by second (secondary) intention as a:
laceration with edges that do not approximate.
surgical incision closed with staples.
chest wound left open for a closed system.
puncture wound sutured with silk suture.
ANS: A
A secondary intention healing occurs when there is a jagged wound whose edges do not approximate.
DIF: Cognitive Level: Comprehension
REF: p. 762
OBJ: Theory #1
TOP: Wound Types
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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:
an infection is in progress at the wound site.
vessels have dilated and allowed plasma to leak into the wound site.
he has lain in one position for such a long time that swelling has occurred.
there is probably a deeper injury than what appears on the surface.
ANS: B
As part of the healing process, histamines and prostaglandins have caused small vessels to dilate and leak plasma and electrolytes into the wound site causing swelling, which causes the wound to become reddened and swollen as the phagocytosis cleans up the microorganisms.
DIF: Cognitive Level: Application
REF: p. 761
OBJ: Theory #3
TOP: Swelling and Inflammation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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:
drinking.
using marijuana.
smoking cigarettes.
eating excessive fats.
ANS: C
Smoking reduces the functional hemoglobin which, in turn, reduces the amount of oxygen carried to the cells of the body.
DIF: Cognitive Level: Analysis
REF: p. 762
TOP: Smoking
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
OBJ: Theory #2
A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:
restlessness, rising pulse, and falling blood pressure.
restlessness, falling pulse, and rising blood pressure.
headache, rising pulse, and falling blood pressure.
lethargy, falling pulse, and rising blood pressure.
ANS: A
If hemorrhage occurs, it can lead to hypovolemic shock. Indicators of hemorrhage include restlessness, rising pulse, and falling blood pressure.
DIF: Cognitive Level: Application
REF: p. 765
OBJ: Theory #2
TOP: Hemorrhage
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
increased pallor of the surgical site.
complaint of constipation.
excessive gas.
increased serosanguineous drainage from the wound
ANS: D
Increase in the serosanguineous drainage from the surgical wound is a common sign of impending dehiscence.
DIF: Cognitive Level: Application
REF: p. 766
OBJ: Theory #4
TOP: Dehiscence KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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:
seat the patient in a nearby chair.
assist the patient in a supine position.
ask someone to quickly get an abdominal binder.
instruct the patient to pant to reduce abdominal tension.
ANS: B
The patient is likely experiencing wound dehiscence and should immediately be assisted into a supine position. This eliminates the force of gravity from putting additional stress on the suture line and possibly causing evisceration.
DIF: Cognitive Level: Application
REF: p. 766
OBJ: Theory #4
TOP: Dehiscence and Evisceration
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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:
uses one alcohol wipe to clean both the spout and the plug.
compresses the device in the hand before closing.
refrains from touching the drainage spout with the hand.
points the device away from herself while opening it.
ANS: A
Separate alcohol swabs should be used to clean the spout and the plug.
DIF: Cognitive Level: Application
OBJ: Clinical Practice #1
REF: p. 768|Step 38-1
TOP: Drainage Devices
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
The nurse chooses a nonadherent dressing to apply to a wound because the nonadherent dressing:
is smaller and less bulky and will absorb more drainage.
retains sterility longer than plain gauze.
allows drainage to seep through the barrier and be absorbed on the other side.
does not require the use of tape to make it adhere to the skin.
ANS: C
Telfa dressings have a shiny, nonadherent surface; the shiny side is applied to the wound to prevent the dressing from sticking to the skin. The drainage seeps through the barrier and is absorbed on the other side. It does require some sort of adhesive or binder to keep the pad in place.
DIF: Cognitive Level: Comprehension REF: p. 769
TOP: Dressings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
OBJ: Clinical Practice #1
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:
paper tape.
Montgomery straps.
Karaya paste.
elastic adhesive tape.
ANS: B
removing tape.
Montgomery straps allow the dressing to be changed without constantly applying and
DIF: Cognitive Level: Analysis
REF: p. 770
OBJ: Clinical Practice #1
TOP: Securing Dressings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
A nurse caring for a patient with a Stage I pressure ulcer would most appropriately select:
nonocclusive dressing.
exudate absorbing dressing.
hydrocolloid dressing.
thin film dressing.
ANS: D
Thin film dressings are used on Stage I ulcers to protect them from shearing forces and to keep them moist.
DIF: Cognitive Level: Application
REF: p. 769
OBJ: Clinical Practice #2
TOP: Treatment of Ulcers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has (an):
abrasion.
laceration.
hematoma.
avulsion.
ANS: C
A hematoma is a pooling of blood under unbroken skin. An abrasion is a scraping away of skin tissue. A laceration is a torn, ragged, or mangled wound, and a contusion is a bruise.
DIF: Cognitive Level: Comprehension REF: p. 765
OBJ: Theory #1
TOP: Documentation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:
from the outer abdomen toward the wound.
in a circular motion around the wound circling to the outside.
from the left to the right across the wound.
directly over the wound.
ANS: B
A circular motion around the wound toward the outside keeps the wound area cleanest.
DIF: Cognitive Level: Application
REF: p. 776|Skill 38-1
OBJ: Clinical Practice #1
TOP: Wound Cleaning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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?
From left to right across the abdomen
From right to left across the abdomen
From the top of the wound to the bottom
From each of the four sides toward the wound
ANS: D
The tape should be removed by pulling it off toward the wound. This helps prevent alteration of the wound.
DIF: Cognitive Level: Application
REF: p.770
ГОР: Wound Care KEY: Nursing Process Step: Implementatior
MSC: NCLEX: Physiological Integrity: Reduction of Rist
OBJ: Clinical Practice #1
A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
keep the wound dry.
help destroy microorganisms in an infected wound.
occlude air and promote breakdown of necrotic tissue.
leave the dressing in place for 10 days.
ANS: C
Hydrocolloid dressings are air occlusive dressings used on noninfected wounds that provide a moist environment for wound healing. They can be left in place for up to 7 days.
DIF: Cognitive Level: Comprehension REF: p. 769
OBJ: Clinical Practice #1
TOP: Hydrocolloid Dressing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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:
add normal saline to loosen it.
pull it off using slow, steady pressure.
leave it in place and cover it with new, wet dressings.
moisten it with povidone iodine.
ANS: A
If the dressing sticks to the wound, normal saline should be added to loosen it. Pulling loose a stuck dressing damages new tissue. Leaving it in place does not promote a clean wound.
Povidone iodine must be ordered.
DIF: Cognitive Level: Analysis
REF: p. 775|Skill 38-1
OBJ: Clinical Practice #3
TOP: Wet to Dry Dressings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
A nurse performing a right eye irrigation will position the patient:
upright with the head hyperextended.
upright with the head tilted toward the left eye.
supine with the head hyperextended.
supine with the head tilted toward the right eye.
ANS: D
The patient should be positioned supine with the head tilted toward the affected eye. This position allows the irrigation solution to drain away from the eye and not contaminate the other eye.
DIF: Cognitive Level: Application
REF: p. 783|Step 38-4
OBJ: Clinical Practice #3
TOP: Eye Irrigations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:
pull to the right.
pull outward.
pull to the left.
rotate.
ANS: B
The handles should be squeezed together all the way. This depresses the center of the staple and allows it to be lifted outward from the skin.
DIF: Cognitive Level: Application
OBJ: Clinical Practice #4
REF: p. 782|Step 38-3
TOP: Staple Removal
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:
drawing the wound edges together by negative pressure.
interrupting the proliferation of bacteria in the wound.
strengthening the wall of the wound.
making an air occlusive cover for the wound.
ANS: A
A vacuum-assisted dressing that is accomplished by a special dressing and vacuum device applies negative pressure to the wound, which increases blood flow, increases oxygenation, and improves the delivery of nutrients to the wound.
DIF: Cognitive Level: Knowledge
REF: p. 771
OBJ: Theory #6
TOP: Vacuum-Assisted Dressing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the:
scapula.
sacrum.
heel.
femoral head
ANS: C
Debridement is not recommended for treatment of a pressure ulcer on the heel because of the small amount of tissue available at that site.
DIF: Cognitive Level: Knowledge
REF: p. 769
OBJ: Clinical Practice #2
TOP: Debridement
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
The nurse is concerned about an HIV immunocompromised patient's ability to heal because of the lack of: (Select all that apply.)
hemoglobin.
adequate fibroblast function.
synthesis of collagen.
intrinsic factor.
adequate phagocytosis.
ANS: B, C, E
Persons who are immunosuppressed have inadequate fibroblast function, phagocytosis, and synthesis of collagen.
DIF: Cognitive Level: Comprehension
REF: p. 765
OBJ: Theory #2
TOP: Immunocompromise
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse recognizes that of the drugs a patient is currently taking, several contribute to delayed healing, such as: (Select all that apply.)
Vitamin C.
antineoplastic drugs.
pyrixidine.
heparin.
steroids.
ANS: B, D, E
Drugs such as antineoplastic agents, anticoagulants, steroids, and immunosuppressants all delay healing.
DIF: Cognitive Level: Comprehension
REF: p. 765
OBJ: Theory #2
TOP: Delayed Healing
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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.)
excessive production of blood factors.
atherosclerosis.
diminished lung function.
slow metabolism.
increased immunity.
ANS: B, C, D
Age slows metabolism and production of blood factors. Decreased lung function reduces the body's supply of oxygen and slows healing, Atherosclerosis impairs blood flow.
DIF: Cognitive Level: Comprehension
REF: p. 762
OBJ: Theory #2
TOP: Factor That Affect Wound Health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse places Dakin solution in a wound to accomplish chemical_______________.
ANS: debridement
Dakin solution is placed in a wound to destroy the necrotic tissue so that granulation tissue can form to heal the wound (debridement).
DIF: Cognitive Level: Knowledge
REF: p. 768
OBJ: Clinical Practice #2
TOP: Chemical Debridement
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
The nurse assesses the large raised scar on the African American patient. The nurse documents the lesion as a____________.
ANS: keloid
Keloids are large raised permanent scars resulting from colloid overgrowth that are seen most frequently on darkly pigmented skin.
DIF: Cognitive Level: Comprehension
REF: p. 762
TOP: Keloid
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
OBJ: Theory #1
The nurse explains to the patient that the foot will be submerged in warm water for a maximum of ________ minutes.
ANS:
20
Warm soaks that involve submerging the limb should only last for 15 to 20 minutes.
DIF: Cognitive Level: Knowledge
REF: p. 786
OBJ: Clinical Practice #5
TOP: Foot Soak
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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.)
Open sterile irrigation basin and solution.
Don sterile gloves to apply dressing.
Pour irrigating solution in basin.
Irrigate keeping the syringe tip 1 inch from the wound surface.
Document procedure.
Pat wound dry and redress.
Place pad under the infected hand
ANS:
A, C, G, B, D, F, E
Prior to donning gloves, the basin and solution should be opened, the basin filled with the solution, and the pad placed under the wound. The gloves are donned, the irrigation completed, the wound dried and redressed, and the intervention documented
DIF: Cognitive Level: Application
REF: p. 778|Step 38-2
OBJ: Clinical Practice #3
TOP: Wound Dressing Change
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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.)
Apply new dressing.
Remove old dressing.
Gather supplies.
Wash hands.
Don clean gloves.
Document findings.
Apply sterile gloves.
ANS:
C, D, E, B, G, A, F
The nurse gathers needed equipment for time management, washes hands, dons clean gloves to remove old dressing, dons sterile gloves to apply new dressing, and documents the outcome.
DIF: Cognitive Level: Application
OBJ: Clinical Practice #1
EF: P. 775|Skill 38-I
OP: Dressing Chang
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control