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Wound care
| Question | Answer |
|---|---|
| A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound usually develops postoperatively within 14 days T or F | T |
| Healing by primary intention when the edges of a clean surgical incision are stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms T or F | T |
| Which of the following may indicate internal hemorrhage | 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 |
| 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 |
| When teaching a patient about would healing what should the nurse tell the patient | Inadequate nutrition delays woumd healing and increases risk of infection |
| The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patients knee appears red and is very warm to the touch. The patient requests pain medication. What would be a correct explanation of what the nurse has assessed | 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 serosanguinous drainage from the wound |
| The nurse reports that 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 patient has diabetes, incision I'm abdomen, obese, and smokes what should he be observed for | Wound dehiscence |
| Which areas are most common for pressure ulcers | Heels, sacrum, lateral malleoli, trochanters, ischial tuberosities |
| Identify contributing factors to pressure injury formation | Malnutrition, decreased sensory perception/mobility, anemia, excessive sweating |
| Identify prevention strategies for pressure injuries | When the patient is in the side-lying position in bed, use the 30-defree lateral position, place patient on a pressure reducing support surface, oral supplements should be instituted if the patient is found to be undernourished |
| The nurse is observing the patients wife perform treatment of her husband's pressure.injury. which action, if made by the patients wife, indicates that further instructions is needed | She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water |
| Bed sore on right heel a blister that has pooped and can see redness what stage is it | Stage 2 |
| The patient asks the nurse what the purpose is for Hemovad drain. What is the nurses best response | To provide suction to remove and collect drainage from your wound to help it heal |
| A patient is to go with a Jackson-Pratt drain. what indicates further teaching to a patient | If drainage suddenly stops it means the drain is ready to be removed |
| When should the wound drainage be cultured | 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 further instruction needed? The patient: | Empties the Hemovac drain, replaces the plug, and records the amount of drainage |
| Because a patient has a penrose drain the nurse inspects the skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this | Because drainage can be irritating to the skin and may cause skin breakdown |
| The patient complains it feels like the drain is pulling on my surgical site what should the nurse do | Make sure there is a slack in the tubing from the reservoir to the wound allowing the patientovement and avoiding pulling at the insertion site |
| What are functions of dressings | To promote hemostasis, wound debridement, to prevent infection |
| A patient with a wound vacuum assisted closure continues to complain of pain what measure should be taken | Switch to the White polyvinyl alcohol soft foam, decrease the pressure setting, administer pain medication |
| During a sterile dressing change when are gloves changed | After the old dressing is removed and before cleansing the wound |
| Why are Montgomery ties being used instead of tape | 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 | The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound |
| Correct order for changing gauze dressing | Remove old dressing, discard gloves and preform hand hygiene, create sterile field, apply gloves, clean wound, blot dry, apply new dressing |
Created by:
Hydecar