Basic Wound Care
A wound whose edges are brought together with sutures, staples, or adhesive heals by this type of intention.
What is primary intention?
The nurse wears this type of gloves when removing a soiled dressing during a clean dressing change.
What are clean gloves?
This must be performed before and after touching a patient.
What is hand hygiene?
After performing hand hygiene, this is the first PPE item donned in the CDC sequence.
What is the gown?
The Joint Commission requires nurses to use at least this many patient identifiers before medications, treatments, procedures, or specimen collection.
What are two patient identifiers?
Before helping a patient stand or walk, the nurse assesses strength, balance, ability to follow directions, and this previous safety concern.
What is the patient’s fall history or fall risk?
Wound length, width, and depth should be measured and documented using this unit.
What are centimeters?
If the old dressing sticks to the wound, the nurse should do this instead of pulling it away.
What is moisten it with the prescribed solution?
When hands are not visibly soiled, this is the preferred method of hand hygiene in most clinical situations.
What is an alcohol-based hand rub?
This is the last PPE item donned and should extend over the wrists of the isolation gown.
What are gloves?
These two pieces of information are commonly used as acceptable patient identifiers.
What are the patient’s full name and date of birth?
Before standing a patient who has been lying down, the nurse allows the patient to sit at the bedside in this position.
What is dangling?
This moist, pink-to-red tissue indicates the growth of new blood vessels and healthy wound healing.
What is granulation tissue?
When cleansing a wound, the nurse moves in this direction to avoid carrying microorganisms into the cleanest area.
What is from the least contaminated area to the most contaminated area?
The nurse must use soap and water instead of alcohol-based hand rub when the hands are in this condition.
What is visibly soiled?
Because their outside surfaces are considered highly contaminated, these are removed first in the CDC’s first doffing example.
What are gloves?
The Joint Commission specifically states that this location-based information is not an acceptable patient identifier.
What is the patient’s room number or physical location?
This device is secured snugly around the patient’s waist to provide safer assistance during transfers or ambulation.
What is a gait belt?
Thick drainage that may be yellow, green, tan, or brown is documented using this term.
What is purulent drainage?
After removing the old dressing and gloves, the nurse must perform this action before applying clean gloves and handling the new dressing.
What is hand hygiene?
The CDC recommends scrubbing the hands with soap for at least this long.
What is 20 seconds?
Goggles or a face shield should be removed by touching only these clean areas.
What are the headband or earpieces?
Blood and other specimen containers must be labeled at this location and time.
What is in the patient’s presence immediately after collection?
A patient with one weak leg should hold a cane on this side of the body.
What is the stronger side?
This complication occurs when the edges of a surgical wound partially or completely separate.
What is dehiscence?
The nurse uses each gauze pad for only this many cleansing strokes before discarding it.
What is one stroke?
Gloves do not replace hand hygiene; therefore, the nurse performs hand hygiene at this point after completing patient care.
What is immediately after removing gloves?
State the sequence for removing PPE.
What is gloves, goggles or face shield, gown, mask or respirator, and hand hygiene?
DON=Gown,Mask,Googles,Gloves
Instead of asking, “Are you Mary Smith?” the nurse should use this safer identification method.
What is asking the patient to state their full name and date of birth and comparing the information with the identification band and record?
State the correct sequence for walking with a standard walker when one leg is weak.
What is walker forward, weak leg forward, and then strong leg forward?