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Wound care quizz
| Question | Answer |
|---|---|
| A contaminated or traumatic wound may show sx of infection withing 24hrs. A surg. wound infection usually develops post-op within 14 days. | False. A contaminated traumatic wound shows sx of infection w/n 2-3 days. A surg wound infection would shows post-op w/n 4-5 days. |
| Healing by primary intention is expected when the edges of a clean surg. incision are sutured or stapled together, tissue loss is minimal or absent and the wound is uncontaminated by microorganisms. | True |
| which of the following pt has the least risk of developing a wound infection: -an 80 yr old man who has a burn -a 17 yr old pt who has a metal fragment lodge in his thigh -a 30 yr old woman who had episiotomy with childbirth -a pt receive chemotherap | a 30 yr old who has episiotomy with childbirth. |
| when teaching pt about wound healing, what should the nurse tell the pt | inadequate nutrition delays wound healing and increase risk of infection. |
| the nurse is caring for pt who had knee replacement surg. 5 days ago. The pt's knee appears red and warm to the touch. The pt requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? | the pt is demonstrating sx of post-op wound infection. |
| the nurse caring for a pt after major abdominal surg, which of the following demonstrates correct understanding of wound dehiscence | the nurse should be alert for an increase in serosanguineous drainage from the wpound. |
| the nurse report that pt has a wound on his abdomen that is healing by secondary intention, the nurse understands this means the pt | has a greater risk for infection |
| a post op diabetic pt had an exploratory laparotomy (incision in the abdomen) 5 days ago. the pt hx indicates obesity with a body mass index of 32 and smoking 1 pack/day. Based on this information, the nurse understand the pt should be observed for | wound dehiscence |
| which of the following is the common sites for development of pressure injuries: | heels, sacrum, lateral malleoli, trochanters, ischial tuberosities. |
| contributing factors to pressure injury formation | malnutrition, decreased sensory perception/ mobility, anemia, excessive sweating. |
| prevention strategies for pressure injuries | when the pt is in the side-lying position in bed, use the 30 degree lateral position, place pt on a pressure reducing support surface, ,oral supplements should be instituted if the ppt is found to be undernourished. |
| the pt asks the nurse what is the purpose of his Hemovac drain, what is the nurse best response | to provide suction to remove and collect drainage from your wound to help it heal |
| a pt is going home with a Jackson-Pratt drain. Which of the following statement id made by the pt, indicates further teaching is needed | if drainage suddenly stops, it means the drain is ready to be removed. |
| when should wound drainage be cultured? | when there is a change in color, amount, or odor of drainage. |
| the nurse is teaching a pt how to empty his Hemovac drain, which action of the pt indicates that further information is needed | empties the Hemovac drain, replaces the plug, and records the amount of the drainage. |
| Because a pt has Penrose drain, the nurse inspect the pt's skin and changes the dressing by placing a drainage sponge around the drain, What is the rationale of doing this | bc drainage can be irritating to the skin and may cause skin breakdown. |
| Function of wound dressing | to promote hemostasis, wound debridement, to prevent contamination |
| which of the following pt expected to benefit from damp-to-dry dressing: -24 yr old w. open and infected wound from a spider bite. -7 yr old w. abrasion of the knees -50 yr opl w. post op knee replacement incision -30 yr old after large cyst removal w | 24 yr. old w. open and infected wound from spider bite, 30 yr. old w. large cyst removal w. necrotic tissue present in crater type wound. |
| the nurse is observing the pt's wife perform damp to dry dressing change. which action indicates that further instruction is needed | leaves contact or primary dressing dripping moist |
| a pt w. wound vacuum assisted closure (wound V.A.C) continue to complain of pain. What measures maybe taken | switch to the white polyvinyl alcohol (PVA) soft foam, decrease the pressure setting, administer pain medication. |
| during a sterile dressing change, when are the gloves changed | after the old dressing is removed and b4 cleansing the wound. |
| a pt states that she is un able to get her transparent dressing to stay in place, what instruction would the nurse provide pt | make sure that you have a margin of 1-1.5 inches (2.5-3.75 cm) around the wound, and that the skin is thoroughly dry b4 applying the dressing. |
| a pt is asking the nurse why Montgomery ties are being used instead of regular tape. What is the nurse best response? | Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing change |
| how can the nurse determine that negative pressure id being achieved with a wound VAC? | the nurse can check for air leaks by listening w. a stethoscope 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? | removing old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing. |
Created by:
hazeltran