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Fundamentals Exam 3
| Question | Answer |
|---|---|
| 48 hours post surgery- what would be concerning coming from a wound? | Sanguineous drainage(red and thick), internal bleeding presents with swelling, and distention |
| What nursing interventions do you implement in clients AT RISK for pressure ulcers? | Provide supportive devices, maintain skin hygiene, encourage proper nutrition, and avoid skin trauma |
| What items can a nurse not delegate to Assistive Personnel? | Step of the nursing process- ADPIE |
| Can an AP administer and enema? | Yes they can it is not apart of ADPIE |
| What are key points of an incident report? | Do not document that you made an incident report in the patients medical record. Complete within 24hrs |
| What is included in an incident report? | clients identification, time and place of incident, accurate account of the event, who you notified, what actions you took, and your signature |
| What are skin related complications of immobility? | skin breakdown, pressure ulcers, and poor skin turgor |
| What are Nursing Interventions for patients with decreased mobility to prevent skin related complications? | reposition, keep skin clean and dry, relieve pressure, raise feet off bed |
| How do you relieve pressure from the buttocks, sacrum, and heels? | keep head of bed at or below 30 degree angle |
| What are signs and symptoms of wound dehiscence and evisceration? | significant increase flow of serosanguineous fluid on wound dressing, immediate sudden straining (coughing, sneezing, and vomiting), client report "popping" or "giving way" in wound area, visualization of viscera |
| What is dehiscence? | A separation of the wound incision |
| What is evisceration? | protrusion of visceral organs through a wound opening |
| What are interventions for wound dehiscence and evisceration? | emergency treatment, call for help, stay with client, cover wound and any protruding organs with sterile towels, position client supine, observe indications of shock, maintain calm, and keep client NPO |
| What is not done while intervening wound evisceration? | do not try to reinsert organs |
| What is an alternative to sterile towels? | dressings soaked in normal sterile saline. (use towels first or if available) |
| What is serous drainage, what does it look like, and what is it composed of? | portion of the blood that is watery and clear or slightly yellow (fluid blisters) |
| What is sanguineous drainage, what does it look like, and what is it composed of? | contains serum and red blood cells. Its thick and appears reddish. Brighter drainage indicates active bleeding, dark drainage indicates older bleeding/drainage |
| What is serosanguineous drainage, what does it look like, and what is it composed of? | contains both serum and blood. Its watery and looks pale and pink due to mixture of red and clear fluid |
| What is purulent drainage, what does it look like and what is it composed of? | the result of infection. Thick and contains white blood cells, tissue, debris, and bacteria. May have a foul odor, and its color can be yellow, tan, green, or brown. Color represents the organism present |
| What is purosanguineous drainage? | mixed drainage of pus and blood (newly infected wound) |
| What does serosanguinous drainage 1 week post op indicate? | there is further damage to the wound. 5 or 6 days possible hemorrhage |
| What are Nursing Interventions for stage 3 pressure ulcer? | clean/debride, provide nutritional supplements, administer analgesics, and administer antimicrobials |
| What defines a stage 1 pressure ulcer and what dressing is used? | nonblanchable erythema of intact skin. no dressing |
| What defines a stage 2 pressure ulcer and what dressing is used? | partial thickness skin loss with exposed dermis. hydrocolloid dressing (saline or occlusive) |
| What defines a stage 3 pressure ulcer and what dressing is used? | full thickness, skin loss. hydrocolloid dressing (saline or occlusive) |
| What defines a stage 4 pressure ulcer and what dressing is used? | full thickness, skin and tissue loss. hydrocolloid dressing (saline or occlusive) preform non-adherent dressing change every 12 hours |
| What defines a unstageable pressure ulcer and what dressing is used? | obscured, full thickness skin and tissue loss. debride until staging is possible |
| What are risk factors to develop dehiscence? | chronic disease, advanced age, obesity, invasive abdominal cancer, vomiting, excessive straining, coughing, sneezing, dehydration, malnutrition, ineffective suturing, abdominal surgery, and infection |
| What are steps to irrigate a wound? | use saline, clean from the most dirty to the cleanest part |
| What PPE is used when irrigating a wound? | gloves, gown, mask, goggles |
| Blood vessels in the skin dilate to dissipate heat | true |
| Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? | Contusion |
| In which phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? | Proliferation phase |
| Which wound complication is caused by overhydration related to urinary and fecal incontinence? | Maceration |
| A stage 3 pressure injury requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes | true |
Created by:
jowalker
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