Rationales from Sept 2 - Test 7: Wound Care, Communication, and Safety

During which wound-healing phase is dehiscence most common?

The proliferation/granulation phase.

What factors increase the risk of wound dehiscence?

Impaired wound healing, increased internal pressure, and strain on wound edges.

How should ear irrigation be performed to reduce tympanic membrane injury?

Tilt the head toward the affected ear and aim the syringe toward the upper ear-canal wall.

Why should strong pressure not be used during ear irrigation?

It can increase inner-ear pressure and damage the tympanic membrane.

What are important risk factors for pressure injuries?

Inability to respond to pressure discomfort, moisture exposure, limited mobility, and inadequate nutrition.

Who generally requires a complete bed bath?

A completely dependent client.

Does obesity alone require a complete bed bath?

No, encourage the most independent form of bathing possible.

Does an early Alzheimer disease diagnosis automatically require a complete bed bath?

No, encourage independent bathing if possible.

How should bathing be handled for a client with a fiberglass cast?

Protect the cast from getting wet and allow independent bathing.

What should happen to tubes and lines when an autopsy will be performed?

Leave them in place until the autopsy is completed.

What are key elements of postmortem care?

Confirm death, maintain dignity, and involve family in care.

What characterizes a Stage 1 pressure injury?

Non-blanchable erythema; spongy or boggy edema may be present.

What characterizes a Stage 2 pressure injury?

Partial-thickness skin loss; a shallow pink/red moist open area may be present.

What characterizes a Stage 3 pressure injury?

Full-thickness skin loss with exposed adipose tissue.

What characterizes a Stage 4 pressure injury?

Full-thickness loss with exposed fascia, muscle, or bone.

When is a pressure injury considered unstageable?

When slough or eschar obscures the full extent of the wound.

What are key findings of a deep tissue injury (DTI)?

Localized non-blanchable dark discoloration; may feel boggy.

What communication techniques help a client with severe hearing loss?

Use hand gestures, minimize background noise, and use adaptive devices.

What environmental change improves communication with hearing loss?

Turn off/minimize background noise.

What type of alarm clock may help a client with severe hearing loss?

A vibrating alarm clock.

What telephone adaptation may help severe hearing loss?

An amplified telephone ringer.

What television adaptation may help a client with hearing loss?

Closed captioning.

Should the nurse shout or use a high-pitched voice for hearing loss?

No, avoid shouting and speak in lower tones.

What should the nurse teach before sputum specimen collection?

Do not brush teeth before collection.

What position should be used for sputum specimen collection?

Semi-Fowler or high-Fowler position.

How long should suctioning last during sputum specimen collection?

Never longer than 10-15 seconds.

What should the nurse tell a client to expect during suctioning?

Coughing may occur due to the catheter.

How should a non-rebreather mask fit?

Snugly.

How should the valves on a non-rebreather mask function?

They open with exhalation and close with inhalation.

What oxygen flow rate is required for a non-rebreather mask?

10-15 L/min, keeping the reservoir bag partially inflated.

How can blanchability of a reddened area be assessed?

Palpate to determine whether the redness blanches.

What interventions are indicated for pressure-injury prevention/care?

Do not massage reddened areas; prevent shear/friction.

What type of dressing may be used to protect a superficial pressure injury?

A transparent dressing.

What position can reduce prolonged sacral pressure?

Turn the client about 30 degrees laterally.

Should reddened pressure areas be massaged to improve circulation?

No, massage can worsen skin injury.

What fall-prevention teaching is important for older adults at home?

Make home modifications and wear non-slip footwear.

Are socks alone appropriate footwear for fall prevention?

No, use non-slip, closed-heel footwear.

How often should older adults have eye examinations?

Annually.

What is a contracture?

Shortening of connective tissue causing a joint to become fixed.

What interventions help prevent contractures?

Range-of-motion exercises, splinting, and stretching.

What is multimodal pain control?

Using multiple classes of analgesics to maximize pain relief.

Where should the nurse stand when assisting a client with hemiparesis during a transfer?

On the client's weakest side.

Where should the nurse stand during a transfer if the client has equal strength?

In front of the client.

On which side should a cane be held?

The unaffected/stronger side.

What is the walking sequence with a cane?

Advance the cane first, then the affected leg, then the unaffected leg.

What is the walking sequence with a walker?

Move the walker forward first, then the weaker leg, then the stronger leg.

How should a prosthetic limb fit?

Snugly without rubbing.

How should an orthotic device be applied?

Over clothing.