Application to Nursing Care
Key Concept
Assessment Findings
Nursing Diagnosis
Incorrect method of care/malpractice
100

A wound is showing delayed healing. What should the nurse recommend the patient to add more in their diet?

  • Vitamin A and C––builds proteins

  • Vitamin B12––support growth of RBCs; enable cell replication

100

What are the phases of wound healing?

  1. hemostasis 

  2. inflammation 

  3. proliferation/granulation

  4. remodeling

100

Describe all the different stages of pressure injuries 

  • stage 1: non-blanchable erythema of intact skin 

  • stage 2: partial thickness skin loss with exposed dermis 

  • stage 3: full thickness skin loss; visible adipose tissue (fat)

  • stage 4: full-thickness skin and tissue loss; visible muscle and bone

100

What would be the nursing diagnosis for a patient that presents with an open tear on the skin, which allows bacteria inside the wound?

  • impaired skin integrity

100

Complications of wound healing and please name all 7 of them 

  • keloid 

  • contractures 

  • dehiscence  

  • evisceration 

  • stricture 

  • fistula 

  • adhesions 

200

A nurse is caring for a patient with a pressure ulcer. What type of healing process will occur with this wound? 

secondary intention

200

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and warm to the touch and the patient is requesting increased pain medication. What complication should the nurse be concerned about?

 post operative wound infection

200

This type of wound drainage is clear and watery, often indicating early wound healing.

serous drainage

200

A patient has a new abdominal wound. The wound has stopped bleeding and clots are beginning to form. What phase of healing is identified? 



hemostasis phase

200

Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer?

clean the ulcer every shift with Dakin's solution

300

What types of solutions can nurses use to irrigate a wound? (3 types)

 regular saline, sterile water, and hydrogen peroxide.

300

A patient has a pressure injury that has skin breakdown with slough and eschar present and no appearance of muscle or bone. What stage is this pressure injury?

Unstageable pressure injury

300

This classic sign of infection in a wound is characterized by redness spreading from the wound site.

erythema

300

A patient presents with an increased production of mast cells that have secreted histamine, leading to vasodilation. The extremity that the wound is present in shows edema, warmth, and throbbing. What phase of wound healing is this?

 Inflammatory Phase

300

A patient has a surgical wound on the right lower quadrant of their abdomen. The wound has purulent drainage. The nurse notices the drainage and irrigates the wound. What did the nurse do incorrectly?

The nurse did not collect a sample of the drainage for a wound culture and notify the provider before irrigating the wound.

400

What are two types of wound dressings a nurse can use? 

Hydrocolloid, Hydrogel, Foam dressings, Non-adherent dressings, Alginate dressings, collagen dressings, gauze dressings, Transparent film dressings

400

A patient has a pressure injury. Upon assessment of the wound, the nurse notes that bone and tendon are visible. What stage pressure injury is this?

Correct Answer: Stage 4

400

This type of tissue often appears as pale, yellow, and soft in the wound bed, indicating a slower healing process.

slough

400

A patient is admitted with an open wound on his right upper leg following an MVC accident. What is the priority action that the nurse should take when performing a wound dressing change to prevent the wound from becoming infected?

Hand hygiene prior to performing sterile technique wound care 

400

A nurse goes to change the dressing on a patient’s wound. She applies clean gloves and begins cleaning the wound. She collects a sample to send to the lab for testing, and then irrigates the wound. 2 days later, the wound is infected. What action did the nurse take that caused the infection. 

Gloves and procedure need to be STERILE, not just clean 

500

This condition, often caused by prolonged pressure on the skin, leads to tissue damage and open wounds.

What is a pressure ulcer or bed sore?

500

 This term describes the evaluation of a wound's color, temperature, edema, and sensation.

What is wound assessment for skin integrity?

500

A wound with black or brown tissue indicates the presence of this, signifying necrotic tissue.

eschar

500

 This phase of the nursing process involves analyzing data collected during assessment to identify patient health issues that nurses can address through interventions.

What is the nursing diagnosis phase, where nurses identify patient health problems or potential risks?

500

This error occurs when a healthcare provider neglects to inquire about patient allergies before applying a dressing, risking allergic reactions.

What is ignoring patient allergies, such as not checking for allergies before applying a dressing, risking potential allergic reactions?

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