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Fundamentals Test 4
| Question | Answer |
|---|---|
| Who is at higher risk for surgical complications? | Infants, elderly, immunocompromised |
| What complication are young and elderly patients at higher risk of? | Dehydration |
| What will the nurse do if there is some drainage on a surgical dressing? | Mark the area with a pen and write date and time to enable close monitoring of drainage. |
| How do wound vacuum devices assist in wound healing? | Drawing wound edges together by negative pressure. |
| Describe how to remove staples from the patient's skin? | Place staple remover under the staple, press down on the handle of the tool, and pull outward. |
| What postoperative complications can develop and what manifestations should the nurse watch for? | Infection (fever, rising pulse, redness and warmth), Hemorrhage (restlessness, rising pulse, falling blood pressure), Dehiscence (increased serosanguineous drainage on the dressing) |
| For which patients would coughing after surgery be contraindicated? | Patients who have had brain surgery. These patients will use deep breathing and incentive spirometer. |
| What interventions will help a postoperative patient that is complaining of gas pains? | Walking frequently. |
| Name the three distinct phases of wound healing. What is the typical timeframe for each phase? | Inflammation, proliferation, and maturation. Inflammation begins immediately and lasts 1-4 days. Proliferation begins on Day 3 or 4 and lasts 2-3 weeks. Maturation begins about 3 weeks after injury and can last for 2 years. |
| Identify factors that affect wound healing. | Age, nutrition, lifestyle habits, overall health, diminished lung function, slow metabolism, other diseases (such as diabetes and heart disease) |
| Identify the basic wound types (abrasion, hematoma, laceration). | An abrasion is a scraping away of skin tissue. A hematoma is a pooling of blood under unbroken skin. A laceration is a torn, ragged, or mangled wound. |
| While you are changing a dressing, what aspects of the wound and dressing should you assess? | REEDA (redness, edema, ecchymosis, discharge, and approximation of wound). |
| What is an example of a wound healing by first intention? | A surgical incision that is well-approximated |
| What is an example of a wound healing by second intention? | A laceration with jagged edges that do not approximate. |
| What is an example of a wound healing by third intention? | An abdominal incision that is left open to drain and will be surgically closed at a later time. |
| What type of dressing would be used for a stage I pressure ulcer? | Thin film. |
| When changing a dressing on a horizontal incision, which direction should the nurse pull to remove the tape from the old dressing? | From each of the four sides toward the wound. |
| What is the main purpose of using a hydrocolloid dressing? | Occlude air and promote breakdown of necrotic tissue. |
| Why would a nurse choose to use a non-adherent dressing? | It allows drainage to seep through a barrier and be absorbed on the other side. It does not stick to the wound. |
| What is the proper method to clean a wound? | In a circular motion around the wound, circling to the outside. |
| Why is it important for the immobilized patient to do frequent deep breathing exercises? | Prevention of hypostatic pneumonia |
| Patients faced with movement restriction may experience which type of emotional response? | Depression |
| Air-fluidized therapy is not recommended for patients with what conditions? | Spinal cord injury or unstable spine. |
| When is a continuous passive motion machine used? | Exercise the joint after joint replacement surgery. |
| What is the nurse's responsibility regarding the continuous passive motion machine? | Verify the settings for the prescribed flexion and extension limits. |
| How do you assess the patient who is in traction? | Make sure that the patient's extremity is not touching the bed frame. Ensure that the weights hang freely from the bed frame and do not touch the floor. |
| Why is Buck's traction used? | Reduce muscle spams that accompany fractures. |
| How should the nurse handle a freshly applied plaster cast? | With the palms of the hand and flat part of the fingers (no fingertips!!) |
| What should the nurse do prior to placing a patient in a mechanical lift? | Widen the stance of the lift's base and lock it. |
| How should a patient using crutches correctly climb the stairs? | Bring the good leg up first when going up the stairs. |
| What important assessment should be done in the patient using a brace, splint, or prostheses? | A frequent, thorough assessment of skin integrity. |
| What are the signs of altered circulation and perfusion to watch for in a patient with a cast? | Pale or blue skin, decreased movement of area distal to injury, numbness, decreased pulses, decreased capillary refill. |
| How do you properly apply an elasticized bandage to a patient's exremity? | By overlapping turns of the bandage equally. |
| What are the major dangers of immobilization? | Pressure injuries, loss of bone mass, pneumonia, and permanent loss of function. |
| Explain complementary therapies. | Holistic treatments used in conjunction with other medical treatments. |
| What is imagery? | Using a visual stimulus to produce a particular physiologic change that can decrease stress or promote healing. |
| What is meditation? | Involves focusing attention on a single repetitive stimulus, thereby decreasing all other stimuli |
| What is the basis of chiropractic therapy? | Manipulation of the spine for symptomatic relief and improved functioning. |
| What is the nurse's role when patients choose to use complementary and alternative therapies? | Asking if the patient is taking over-the-counter herbal remedies. Instructing the patient to inform the health care provider when such therapies are being used. |
| What is an appropriate nursing intervention if an old dressing becomes stuck to a patient's wound? | Wet it with normal saline to loosen the dressing. |
| Why does inflammation occur after an injury or surgery? | Blood vessels have dilated and allowed plasma to leak into the wound site. |
| Why are Montgomery straps used to secure a dressing? | To decrease skin irritation from tape when frequent dressing changes are necessary. |
| How do range-of-motion exercises improve venous circulation? | Through compression of muscles on venous walls. |
| What is a normal finding at the pin sites of a patient in skeletal traction? | Drainage of clear fluid. |
| What is the major advantage of a low-air-loss mattress? | Reduction of friction. |
| What are the normal limits of capillary refill? | Three seconds or less for adults. Five seconds or less for the elderly. |
| What are nursing interventions for evisceration? | Place the patient in supine position. Place large sterile dressings over the viscera. Soak the dressings in sterile normal saline. Notify surgeon immediately. |
| What are the characteristics of a partial-thickness wound? | Superficial wounds, heal more quickly by producing new skin cells, Fibrin clot forms framework for growing new cells. |
| How long should a cold compress be applied to a wound? | 20 minutes. |
| How can a nurse reduce the incidence of edema in an extremity with a plaster of Paris cast on? | Elevate the extremity on one to two pillows. |
| After the removal of a cast, how should the nurse expect the skin to appear? | Dry and dirty. |
| How long does it take for a cast to dry? | 30 minutes. |
| To ensure proper functioning, what action must the nurse take after emptying a Hemovac or Jackson-Pratt drain? | Compress the drain prior to inserting the plug. |
| When applying a pressure bandage, how should the wrap be terminated? | Circular turn. |
| To ensure proper height of a walker, the patient's elbows should be bent to which angle? | 15 to 30 degrees |
| What is a keloid? | A large raised scar, commonly found in African-Americans. |
| What is the maximum weight that can be applied with skin traction? | 15 pounds. |
Created by:
ms_molly
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