Wound Care Post test info
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| 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 | show 🗑
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| show | D. A peripheral vascular venous stasis injury
E. A pressure injury
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| show | B. False
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| show | B. Evisceration
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| show | C. Apply sterile gauze saturated with sterile normal saline.
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| show | B.Obesity
D. Malnutrition
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| show | 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
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| show | A. An 80-year-old underweight alcoholic with an infected toe
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| show | A. True
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| 123456 Location 1 Select label... 2 Select label... 3 Select label... 4 Select label... 5 Select label... 6 Select label... | show 🗑
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| show | A. His age and chronic disease
C. Poor nutritional intake and history of smoking
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| 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 | show 🗑
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| show | B. "It helps us identify people who are at risk for pressure injuries and intervene appropriately."
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| show | A. Body weight decreased by 17%
C. Serum albumin less than 3.5 g per dL
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| show | 1. Stage 2 pressure injury
2. Stage 3 pressure injury
3. Stage 1 pressure injury
4. Stage 4 pressure injury
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| In the care of pressure injuries, cotton-tipped applicators are used to measure wound depth. 1. True 2. False | show 🗑
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| show | B. Patient's skin remains intact and without discoloration.
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| 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 | show 🗑
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| 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. ______ | show 🗑
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| show | 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.)
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| 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 | show 🗑
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| 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. | show 🗑
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| show | B. necrotic
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| show | D. 30- degree
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| The nurse knows to avoid ________ reddened areas because this may cause skin breakdown. | show 🗑
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| Every time the nurse enters the room, the patient has slid to the bottom of the bed. This is an example of ________. | show 🗑
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| In attempting to move himself up in bed, the patient has rubbed an area of skin on his elbows. This is an example of ________. | show 🗑
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| 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? | show 🗑
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| show | False
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| show | True
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| Which of the following may indicate internal hemorrhage? (Select all that apply.) | show 🗑
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| When teaching a patient about wound healing, what should the nurse tell the patient? | show 🗑
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| show | A 30-year-old woman who had an episiotomy with childbirth.
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| show | The patient is demonstrating signs of a postoperative wound infection.
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| The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? | show 🗑
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| 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: | show 🗑
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| show | Wound dehiscence.
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| 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 | show 🗑
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| 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 | show 🗑
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| 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 | show 🗑
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| show | B. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water.
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| show | Stage 2
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| 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. | show 🗑
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| 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 | show 🗑
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| show | A. When there is a change in color, amount, or odor of drainage.
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| show | D. empties the Hemovac drain, replaces the plug, and records the amount of drainage.
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| 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? | show 🗑
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| show | C. Assessment of wound drainage
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| show | 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.
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| show | A. To promote hemostasis
C. Wound debridement'
D. To prevent contamination
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| show | 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.
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| show | B. Packs wound tightly
C. Leaves contact or primary dressing dripping moist.
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| 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 | show 🗑
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| show | B. After the old dressing is removed and before cleansing the wound.
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| show | 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.
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| show | C. Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes.
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| How can the nurse determine that negative pressure is being achieved with a wound VAC? | show 🗑
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| show | A. Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing.
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Created by:
Brandi Sizemore
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