Wound Healing
What are the stages of wound healing? (in order)
Hemostasis
Inflammatory
Proliferation
Maturation
A wound with well defined edges that has been made deliberately during surgery is classified as:
intentional wound
A pressure ulcer that presents with full-thickness skin and tissue loss is classified as:
Stage 4
Serosanguineous drainage appears
pink to light red and watery
A patient with excessive moisture around a wound due to urinary incontinence is at risk for:
A. necrosis
B. desiccation
C. maceration
D. edema
C. Maceration
In which phase of wound healing does the wound fill with granulation tissue?
Proliferation
Which type of wound results from a tearing of the skin with an irregular object?
a. contusion
b. abrasion
c. laceration
d. avulsion
C. Laceration
Which scale is commonly used to assess the risk of pressure ulcer development?
Braden scale
The purpose of a hemovac drain is to:
A. absorb drainage into a dressing
B. allow open drainage
C. use suction to remove wound drainage
D. Prevent bacterial contamination
C. Use suction to remove wound drainage
A patient has increased redness, swelling, and warmth at the wound site. The nurse suspects:
Infection
Which local factor delays wound healing?
A. Adequate hydration
B. Low levels of oxygenation
C. Proper nutrition
D. Clean, moist wound bed
B. Low levels of oxygenation
Which type of wound is caused by a blunt instrument that does not break the skin but causes tissue damage?
Contusion
Which patient is at highest risk for developing a pressure injury?
A. a 70-year-old patient who is incontinent and bedridden
B. a 45-year-old patient with controlled diabetes
C. a 30-year-old patient on bed rest for one day
D. a 50-year-old patient with a sprained ankle
A. A 70-year-old patient who is incontinent and bedridden
How should a nurse clean a wound (in what motion)
From the least contaminated area to the most contaminated
What wound complication is characterized by a partial or complete separation of wound layers?
Dehiscence
A surgical incision that heals with well-approximated edges is an example of what type of healing?
A chronic wound is best described as a wound that:
A. follows the expected healing process
B. heals within 4 weeks
C. has delayed healing due to underlying conditions
D. is always infected
C. Has delayed healing due to underlying conditions
What is not included on the scale you used for pressure injuries?
A. sensory perception
B. moisture
C. activity level
D. blood pressure
D. Blood pressure
Possible infection
A nurse observes bowel loops protruding from an abdominal wound. What should the nurse do first?
A. apply sterile normal saline dressings
B. push the organs back into the wound
C. apply dry sterile gauze
D. elevate the patient's legs
A. Apply sterile normal saline dressings
A patient with diabetes is at increased risk for delayed wound healing due to:
Poor collagen formation
A scraping injury that removes the top layer of skin is classified as:
Abrasion
A stage 3 pressure injury differs from stage 2 because it:
a. affects only the epidermis
b. includes full-thickness skin loss
c. has intact skin with non-blanchable redness
d. is restricted to the dermis
When documenting wound assessment, which characteristic is most important to include?
A. the patient's pain rating
B. the last dressing change time
C. the wound size, drainage, and appearance
D. the type of bandage applied
C. the wound size, drainage, and appearance
A fistula is best described as:
A. a wound that heals by secondary intention
B. A deep tunnel leading to bone exposure
C. an abnormal connection between two body structures
D. an open wound that requires debridement
C. An abnormal connection between two body structures