Wounds
This wound is classified as a closed wound.
1) large bruise on side of face
2) surgical incision that is sutured closed
3) Puncture wound that is healing
4) Abrasion on the leg
What is a large bruise on the side of the face?
The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when she walks into the room. In addition to notifying the physician, what should the nurse do?
a. Cover the wound with a sterile gauze pad.
b. Cover the wound with a transparent dressing.
c. Put pressure on the wound with a sterile gauze pad.
d. Cover the wound with gauze soaked with normal saline.
What is "Cover the wound with gauze soaked with normal saline"
The nurse knows the following types of wounds heal by tertiary intention:
a. An acute wound in which the patient has sutures placed when it happened
b. A pressure ulcer that was treated with dressing changes and healed
c. An acute wound in which surgical glue was used to close the wound
d. A wound that was left open initially and closed later with sutures
What is "a wound left open initially and closed later with sutures"
The staff nurse reviews the nursing documentation in a client’s chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client’s sacral area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss with exposed dermis
What is partial-thickness skin loss with exposed dermis
The nurse is performing a focused wound assessment on a patient. The following should be included in the documentation: (Select all that apply.)
a. Location and size
b. Characteristics of the wound bed
c. Patient’s response to wound treatment
d. Patient’s pain level
e. Presence of drainage
What is A, B, C, E
The nurse knows a stage III pressure ulcer is:
a. a pressure ulcer that involves exposure of bone and connective tissue.
b. a pressure ulcer that does not extend through the fascia.
c. a pressure ulcer that does not include tunneling.
d. a partial-thick wound that involves the epidermis.
What is "a pressure ulcer that does not extend through the fascia"
The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What should the nurse do first?
a. Notify the physician.
b. Notify the wound care nurse.
c. Stop the procedure.
d. Give the patient pain medication.
What is "stop the procedure"
The nurse knows that mechanical debridement involves all of the following except:
a. wet to dry dressings.
b. whirlpool baths.
c. damp to dry dressing.
d. enzymatic dressing.
What is "enzymatic dressing".
When assessing red, intact skin with changes in sensation, temperature, or firmness - the nurse should classify the wound as which stage?
What is a stage 1 pressure injury
The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.)
a. A patient who has diabetes
b. A patient with COPD on long-term steroid therapy
c. A patient with on bed rest who is repositioned
d. A patient who is obese and sweats excessively
What is A, B, C, D (all of the above)
The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a “popping sensation” and a wetness in her dressing. The nurse immediately suspects:
a. a wound infection.
b. the stitches came loose.
c. wound dehiscence.
d. wound crepitus.
What is "wound dehiscence"
The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is:
a. the wound will be completely healed in 72 hours.
b. the wound will show signs of healing within 2 weeks.
c. the patient will develop no new pressure ulcers.
d. the patient will ambulate twice a day.
What is "the wound will show signs of healing within 2 weeks".
The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?
a. “The wound will be red.”
b. “The wound will have pus.”
c. “The wound will be warm.”
d. “The wound will need to be treated.”
What is "the wound will have pus"
When assessing skin that is not intact, has exposed dermis, is red and presents as a ruptured serum-filled blister, the nurse will classify this as what stage of pressure injury?
What is a stage 2 pressure injury
The nurse knows that the cause of pressure ulcers includes the following factors: (Select all that apply.)
a. Intensity of the pressure
b. Duration of the pressure
c. The tissue’s ability to tolerate the pressure
d. The person’s age
What is A, B, C, D (all of the above)
The nurse is repositioning her patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the HOB should be placed at:
a. flat.
b. 90 degrees.
c. 30 degrees.
d. 45 degrees.
What is 30 degrees
The nurse understands the rationale for drying a wound after irrigation is:
a. to ensure the new dressing adheres to the wound.
b. to ensure the new dressing remains occlusive.
c. to prevent skin breakdown from moisture.
d. to prevent infection from irrigate solution.
What is "to prevent skin breakdown from moisture"
The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is:
a. the patient will remain free of wound infections during the hospitalization.
b. the patient will report pain management strategies and reduce pain to a tolerable level.
c. the patient will turn self in bed using over trapeze every two hours using assistance when needed.
d. the patient will consume adequate nutrition to meet nutritional requirements within 1 week.
What is "The patient will report pain management strategies and reduce pain to a tolerable level".
When assessing a wound that is full-thickness tissue loss, covered in eschar and slough - the nurse will classify this wound as what stage?
What is unstageable
The nurse is using the Braden scale to assess the patient’s risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.)
a. Activity
b. Friction and shear
c. Moisture
d. Sensory perception
e. Cognition
What is A, B, C, D
The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse classify this pressure injury?
1. Stage 1 pressure injury
2. Stage 2 pressure injury
3. Stage 3 pressure injury
4. Stage 4 pressure injury
What is a stage 3 pressure injury
The nurse knows that a hydrocolloid dressing is appropriate for the following type of wound:
a. A wound with a large amount of drainage
b. A wound that is tunneling
c. A postsurgical incision with staples
d. A wound with a moderate amount of drainage
What is "A wound with a moderate amount of drainage"
The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if:
a. the nurse asks the UAP to assess the wound.
b. the nurse asks the UAP to report increased wound drainage.
c. the nurse asks the UAP to observe changes in dietary intake.
d. the nurse asks the UAP to change the dressing.
What is "the nurse asks the UAP to assess the wound".
A wound has full thickness tissue loss with exposed muscle, tendon, and bone. Has undermining and tunneling present. This is classified as what type of pressure injury?
What is a stage 4 pressure injury
The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.)
a. Edema
b. Shivering
c. Bleeding
d. Circulatory issues
What is A, B, D