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Brandi Sizemore
Wound Care Post test info
| Question | Answer |
|---|---|
| Identify which of the following wounds would heal by secondary intention. (Select all that apply.) A. A pressure injury B. A surgical incision closed with staples C. An open surgical wound requiring packing D. A full-thickness burn | A. A pressure injury C. An open surgical wound requiring packing |
| Which of the following are examples of a chronic wound? (Select all that apply.) A. A surgical incision B. An abrasion from a motor vehicle accident C. A stab wound D. A peripheral vascular venous stasis injury E. A pressure injury | D. A peripheral vascular venous stasis injury E. A pressure injury |
| A wound that has healed by primary intention will have more scar formation than a wound that has healed by secondary intention. A. True B. False | B. False |
| What complication of wound healing is the nurse seeing in the scenario above? A. Fistula formation B. Evisceration C. Dehiscence D. Infection | B. Evisceration |
| What should the nurse's next action be after applying sterile gloves? A. Reinforce the dressing. B. Notify the health care provider. C. Apply sterile gauze saturated with sterile normal saline. D. Gently replace the intestinal protrusion and apply Ste | C. Apply sterile gauze saturated with sterile normal saline. |
| Which of the following may primarily contribute to the development of dehiscence and evisceration, rather than fistula formation? (Select all that apply.) A. Radiation B. Obesity C. Cancer D. Malnutrition | B.Obesity D. Malnutrition |
| Identify the patients who may be at risk for impaired wound healing. (Select all that apply.) A. An obese patient who had abdominal surgery B. An elderly patient who has peripheral vascular disease and a foot injury C. A malnourished patient with AIDS | A. An obese patient who had abdominal surgery B. An elderly patient who has peripheral vascular disease and a foot injury C. A malnourished patient with AIDS and an injury on his buttocks. F. A 17-year-old girl who smokes and has purulent drainage from |
| Which of the following patients has the most risk factors for impaired wound healing? A. An 80-year-old underweight alcoholic with an infected toe B. A 30-year-old diabetic with anemia C. An obese patient who smokes D. A child with bronchitis who is | A. An 80-year-old underweight alcoholic with an infected toe |
| Reddened areas should not be massaged to increase circulation. A. True B. False | A. True |
| 123456 Location 1 Select label... 2 Select label... 3 Select label... 4 Select label... 5 Select label... 6 Select label... | Location 1 Elbow 2 SAacrum 3 Trochanter 4 Ischial tuberosity 5 Malleolus 6 Heel |
| An elderly patient with chronic obstructive pulmonary disease (COPD) and pneumonia was admitted to the hospital. The patient reports a 40-year history of smoking. He is able to ambulate independently for short distances such as to the bathroom and does s | A. His age and chronic disease C. Poor nutritional intake and history of smoking |
| It is a very busy day on the nursing unit. The nurse has several patient admissions and discharges. One of the patients under the nurse's care has a chronic pressure injury of the coccyx. Regarding this patient's care, what can the nurse delegate to the n | A. Reporting redness of the patient’s coccyx to the nurse C. Reporting patient complaints of pain D. Turning the patient every 2 hours F. Reporting patient changes such as development of a foul wound odor |
| You are using an assessment tool to assess a patient's risk for pressure injury formation. The patient asks about the benefit of such a tool. Your best response is: A. "It is a routine assessment that we do on everyone." B. "It helps us identify people | B. "It helps us identify people who are at risk for pressure injuries and intervene appropriately." |
| A poorly nourished patient is at risk for delayed wound healing. Which of the following indicate a poor nutritional status? (Select all that apply.) A. Body weight decreased by 17% B. Lymphocyte count less than 2500 per mm3 C. Serum albumin less than 3 | A. Body weight decreased by 17% C. Serum albumin less than 3.5 g per dL |
| Injury Description 1. Blister on the elbow 2. Crater-type wound on the heel 3. Persistent redness over the greater trochanter 4. Crater-type wound with the bone visible | 1. Stage 2 pressure injury 2. Stage 3 pressure injury 3. Stage 1 pressure injury 4. Stage 4 pressure injury |
| In the care of pressure injuries, cotton-tipped applicators are used to measure wound depth. 1. True 2. False | 1. True |
| A patient is being maintained on bed rest. Which of the following are appropriate expected outcomes regarding the prevention of skin breakdown for this patient? A. Patient's position is changed at least every 2 hours. B. Patient's skin remains intact an | B. Patient's skin remains intact and without discoloration. |
| A patient has a stage 3 pressure injury on his heel. Which of the following would be an appropriate expected outcome for this patient? (Select all that apply.) A. Granulation tissue is present in wound base. B. Drainage from pressure injury site decreas | A. Granulation tissue is present in wound base. B. Drainage from pressure injury site decreases D. Surrounding skin remains intact |
| Risk Factor Assessment Intervention 1. The patient is bedridden. ______ __________Implement turning schedule; provide pressure reduction surface. 2. The patient is incontinent. Moisture __________ ____________ 3. The patient needs help moving. ______ | Risk Factor Assessment Intervention 1. The patient is bedridden. Decreased mobility/sensory perception Assess skin condition for signs of pressure damage. Implement turning schedule; provide pressure reduction surface. 2. The patient is incontinent. Mo |
| You are going to evaluate a patient's pressure injury. Which of the following should be a component of your documentation of this evaluation? (Select all that apply.) A. Surrounding skin is pink and intact, with injury decreasing in size. B. Assessment | A. Surrounding skin is pink and intact, with injury decreasing in size. C. Signs and symptoms of infection are absent; foul odor and/or purulent drainage are absent; patient afebrile. D. Injury is approximately 3 cm (1.2 in.) diameter and 2 cm (0.8 in.) |
| The patient has nausea and has refused most of his meals. His vital signs are within normal limits. Which factors influence the healing of the patient’s pressure injury? (Select all that apply.) A.The patient’s age B. The patient’s medications C. The p | A. The patient's age C. The patient's nutritional status |
| The nurse makes an ongoing assessment of the patient’s skin. A(n) ________ sign of pressure-related injury is skin that does not blanch when firmly pressed. | B. early |
| If the patient’s pressure injury worsens, whirlpool treatments can be used to loosen ________ tissue on large wounds | B. necrotic |
| A preventive measure for pressure injury development is to position the patient at a ________-degree lateral turn. | D. 30- degree |
| The nurse knows to avoid ________ reddened areas because this may cause skin breakdown. | A. massaging |
| Every time the nurse enters the room, the patient has slid to the bottom of the bed. This is an example of ________. | E. shear |
| In attempting to move himself up in bed, the patient has rubbed an area of skin on his elbows. This is an example of ________. | B. friction |
| Sort the terms into bins by selecting a term and then selecting the bin it best matches. Which of the following factors IMPEDE WOUND HEALING? PROMOTE WOUND HEALING? | IMPEDE - A> steroid therapy >C. malnutrition >D. smoking >G. diabetes PROMOTE- B. young age E. moist wound environment F. absence of inffection H. normal weight |
| A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. | False |
| Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. | True |
| Which of the following may indicate internal hemorrhage? (Select all that apply.) | - Distention or swelling of the affected body part. - A decreased blood pressure and increased pulse. - A change in the type and amount of drainage from a surgical drain |
| When teaching a patient about wound healing, what should the nurse tell the patient? | Inadequate nutrition delays wound healing and increases risk of infection. |
| Which of the following patients has the least risk for developing a wound infection? | A 30-year-old woman who had an episiotomy with childbirth. |
| The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient’s knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has | The patient is demonstrating signs of a postoperative wound infection. |
| The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? | The nurse should be alert for an increase in serosanguineous drainage from the wound |
| The nurse reports that a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient: | Is at greater risk for infection. |
| A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient’s history indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands the pa | Wound dehiscence. |
| Which of the following are common sites for the development of pressure injuries? A. sternum B. heels C. sacrum D. Lateral malleoli E. Trochanters F. Ischial tuberosities | B. heels C. sacrum D. Lateral malleoli E. Trochanters F. Ischial tuberosities |
| Identify contributing factors to pressure injury formation. (select all) A. Malnutrition B. Middle age C. Decreased sensory perception/mobility D. Anemia E. Excessive sweating F. Ethnic background | A. Malnutrition C. Decreased sensory perception/mobility D. Anemia E. Excessive sweating |
| Identify prevention strategies for pressure injuries (select all). A. Reposition pt atleast q4h; use a documented schedule. B. When the pt is in the side lyig position in bed, use the 30 degree lateral position. C. Place pt on a pressure reducing supp | B. When the pt is in the side lying position in bed, use the 30 degree lateral position. C. Place pt on a pressure reducing support F. Oral supplements should be instituted if the patient is found to be undernourished. |
| The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? | B. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. |
| A family member calls the nurse to ask for advice regarding their mother who has developed a bedsore on her right heel. The family member describes the pressure injury as a blister that has now popped and you can see redness. Based on this description at | Stage 2 |
| The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? A. To reduce the need for frequent dressing changes. B. To provide suction to remove and collect drainage from your wound to help it heal. | B. To provide suction to remove and collect drainage from your wound to help it heal. |
| A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? A. I should empty the drain when it is one-half to two-thirds full. B. If drainage suddenly stops, it | B. If drainage suddenly stops, it means the drain is ready to be removed. |
| When should wound drainage be cultured? A. When there is a change in color, amount, or odor of drainage. B. If the patient complains of pain. C. When the drain is removed. D. If the nurse empties the drainage evacuator without applying sterile gloves. | A. When there is a change in color, amount, or odor of drainage. |
| The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient: | D. empties the Hemovac drain, replaces the plug, and records the amount of drainage. |
| Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this? | A. Because drainage can be irritating to the skin and may cause skin breakdown. |
| Which of the following is inapproporaite to delegate to nursing assistive personnel (NAP)? A. Emptying a closed drainage container B. Measuring the amount of drainage C. Assessment of wound drainage. D. Reporting the amount on the patient's intake an | C. Assessment of wound drainage |
| The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse's best action? | B. Make sure there is slack in the tubing from the reservior to the wound, allowing the patient movement and avoiding pulling at the insertion site. |
| Which of the following are functions of dressings? Select all A. to promote hemostasis B. To keep the wound bed dry. C. Wound debridement D. To prevent contamination E. To increase circulation | A. To promote hemostasis C. Wound debridement' D. To prevent contamination |
| Which of the following patients would be expected to benefit from a damp to dry dressing? Select all | A. A 24 year old patient with an open and infected wound from a spider bite. D. A 30 year old after large cyst removal with necrotic tissue present in crater type wound. |
| The nurse is observing the patient's wife perform the damp-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? A. Premedicates for pain. B. Packs wound tightly. C. Leaves contact or primary | B. Packs wound tightly C. Leaves contact or primary dressing dripping moist. |
| A patient with a wound vaccum assisted closure (wound VAC) continues to complain of pain. What measures may be taken? A. Switch to the white poly vinyl alcohol (PVA) soft foam B. Decrease the pressure setting C. Administer pain medication D. Switch to | A. Switch to the white poly vinyl alcohol (PVA) soft foam B. Decrease the pressure setting C. Administer pain medication |
| During a sterile dressing change, when are the gloves changed? A. After the old dressing is removed and before creating a sterile field. B. After the old dressing is removed and before cleansing the wound. C. After the old dressing is removed, after c | B. After the old dressing is removed and before cleansing the wound. |
| A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? | A. Make sure that you have a margin of 1 to 1.5 in (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing. |
| A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? | C. Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes. |
| How can the nurse determine that negative pressure is being achieved with a wound VAC? | C. The nurse can check for air leaks by listening with a stethescope or by moving the hand around the edges of the wound while applying light pressure. |
| Which of the following is a correct sequence for changing a gauze dressing? | A. Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing. |
Created by:
Brandi Sizemore
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