Show:
Wound Healing
Types of Wounds
Best Action by the nurse is...
S/Sx of infection or at risk for
Wound Dressings and Drains
100
You reassess a pt's wound and notice redness and swelling but no drainage. Which phase of healing is this? A) Inflammatory phase B) Reconstructive phase C) Remodeling phase D) Maturation phase
What is A) inflammatory phase
100
The nurse is providing care to a pt who just had a bowel resection. The pt's wound will be closely monitored for inf because it falls under the classification as... A) Contusion wounds B) Closed wounds C) Open wounds D) Laceration wounds
What is C) open wounds
100
The first step a nurse must take to contribute to the development of a care plan for a pt with a pressure ulcer is A) Determine the location of the ulcer B) Measure the length of the ulcer C) Gather all of the available data D) Assess the color of the drainage
What is C) gather all of the available data
100
When irrigating the pts wound with a syringe, direct the flow of soln from superior area to inferior area of the wound. The rationale behind this is... A) Direct the flow of soln from the least contaminated area to the most contaminated area B) Use gravity in increasing the force of the irrigation C) Assist the nurse in proceeding in an organized manner D) Slow the irrigation of the wound to eliminate pt discomfort
What is A) direct the flow of soln from the least contaminated to the most contaminated
100
The nurse checks the pts JP drain following surgery and explains to the pt that a closed drain speeds healing and facilitates wound drainage by... A) Gravity B) Absorption C) Penetration D) Suction
What is D) suction
200
The pt's wound is showing delayed healing. Diet is a possible cause. The nurse instructs the pt to eat more A) Vitamin D B) Fiber C) Protein D) Vitamin B
What is C) Protein
200
During the initial assessment the nurse finds that the pts bone is visible in the decubitus. Which stage? A) one B) two C) three D) four
What is D) stage 4
200
The nurse determines the best way to clean an intact incision is to... A) Use 1 cotton ball to make a circular sweep then dispose B) Don sterile gloves and clean around the wound in a circular manner C) Use antiseptic swabs and clean from inferior end to the superior end D) Use cotton balls and forceps, cleaning from the superior end to the inferior end
What is D) use cotton balls and forceps, cleaning from the superior end to the inferior end
200
When assessing a pts wound, the nurse suspects the wound has been infected with Clostridia why? A) The drainage from the wound has changed from serous to purulent B) The area surrounding the wound is bright red and draining serosanguineous material C) A crackling sensation can be felt when palpating around the wound D)The wound is not well approximated as it appeared yesterday
What is C) a crackling sensation can be felt when palpating around the wound
200
The pts wound has a slight amt of drainage and will benefit from a dressing that provides a moist environment. Which dressing will the nurse apply? A) Hydrofiber B) Hydrocolloid C) Gauze D) (ABD) abdominal dressing pads
What is B) Hydrocolloid
300
The incision is dry, clean and intact. This is healing by... A) Tertiary intention B) First intention C) Second intention D) Third intention
What is B) first intention
300
A contusion is 3 inches in diameter on the right thigh. The nurse describes this as... A) scrape or a scratch B) an object embedded in the skin C) a discoloration of skin D) a cut or tear in the skin
What is C) discoloration of the skin
300
Prevention of wound infection requires diligent nursing care. the first and most important step for the nurse is to take while emptying a JP drain is A) Don sterile gloves B) Wash his or her hands C) Wipe the drain spout with alcohol D) Assess the contents of the drain
What is B) Wash hands
300
The nurse applies several 4x4's around a pts wound with a large amt of drainage because... A)Drainage in direct contact with the wound can cause infection B) The drainage must be kept close to the wound to promote healing C) It allows fibroblasts to begin the granulation process. D) It lowers the pt's risk for wound separation
What is A) Drainage in direct contact with the wound can cause infection
300
The nurse got caught up with a pt having complications and is already 2 hours late in packing another pts wound. He/She should delegate the wound packing to... A) anyone she can find B) the charge nurse C) experienced unlicensed assistive personnel D) Noone
What is D) NOONE. Never under any circumstances should a wound packing be delegated
400
A stage 3 pressure ulcer is in the reconstruction phase of healing when... A) A healing ridge has developed beneath the wound B) The wound becomes warm to touch C) Pink or red tissue can be seen in the wound D) A scab has formed over the wound
What is C) pink or red tissue can be seen in the wound
400
A pt was involved in a motorcycle accident and thrown from the bike. Pt hit the pavement and has several areas where the skin has been scraped away. This wound is called... A) Lacerations B) Contusions C) Punctures D) Abrasions
What is D) abrasions
400
Upon answering the pts call light the nurse finds the pt's wound has eviscerated. The nurses first action is... A) Call the Dr. and collect sterile towels and saline B) Cover the wound with sterile dressings soaked in saline C) Obtain samples of purulent drainage and send them to the lab D) Prepare to do a dressing change with sterile kerlix gauze
What is B) cover the wound with sterile dressings soaked in saline (if you did not get this right...you do not listen at all in class)
400
Which of the following pt's are felt to be at the least risk for developing pressure ulcers and t/f must be carefully monitored by the nurse? (3) A) a 40 yr old with bilateral leg casts B) a 59 yr old 1 day postop appendectomy C) an 80 yr old with hx of strokes D) 66 yr old with DM E) 32 yr old quadriplegic
What is B) a 59 yr old 1 day postop appendectomy
400
A pt has a wet to damp drsg ordered for a wound. The nurse will A) Apply the drsg 2x qday B) Moisten the drsg with sterile water C) change the drsg frequently to prevent drying out D) apply the drsg utilizing clean technique
What is C) Change the drsg frequently to prevent drying out
500
A pt's wound is healing by third intention. The nurse charts A) Wound approximately 2" x 3" granulation tissue visable, draining serous fluid B) Wound intact and draining a mod amt of serosanguineous fluid C) Wound 4" diameter, open with jagged edges draining sanguineous fluid D) Wound 6" long with well approximated edges, reddened around incision without drainage.
What is A) Wound approx 2x3" , granulation tissue visible and draining serous fluid
500
How would the nurse explain a clean-contaminated wound? A) although the wound is an incision, it was grossly contaminated during surgery so notify Dr. if drainage increases B) Your incision seems to be developing a purulent drainage. If a foul odor, notify Dr. C) Your drainage cultured a high number of microorg, but since we have no evidence of inf and you are on atb, no need to worry D) Surgical wounds are exposed to normal flora on the skin. Important to watch for S/Sx of inf, such as drainage that turns yellow or green
What is D) Surgical wounds are exposed to normal flora on the skin. it is important to watch for signs and symptoms of infection such as yellow green drainage.
500
The nurse notes an increase in serosanguineous drainage from the patients incision. The most appropriate action for the nurse is to ... A)Notify the Dr of increasing amts of clear drainage B)Draw a circle around the drainage with date time and initials on the drsg. C)Change the drsg to decrease the pt's risk for infection D)Immediately call the lab and order a WBC count
What is B) draw a circle around the drainage with date time and initials on the drsg
500
During the am assessment the nurse notices a change in the pts wound. Which of the following samples of documentation indicate infection? A) Incision intact, mod amt of purulent drainage noted with a foul odor B) Dressing dry and intact with sm amt of serosanguineous drainage noted. C) Incision line well approximated, mod amt of drainage noted D) Inc intact with sm amt of pink granulation along incision line. No drainage noted at this time.
What is A) Incision intact mod amt of purulent drainage foul odor
500
The nurse notes that there is a large amt of sanguineous drainage on the pts drsg. There are no orders for a drsg change by the Dr. The nurse will A) Circle the drainage on the drsg and record the time of assessment B) Continue to monitor the dressing C) Reinforce the drsg with additional drsgs D) Carefully clean around the wound
What is C) Reinforce the drsg with additional drsgs