ATI Questions wound care from RN review modules Flashcards
An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client
is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain
medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication.
His incision is approximated and free of redness, with scant serous drainage on the dressing.
Which of the
following risk factors for poor wound healing does this client have? (Select all that apply.)
A.Extremes in age B.Impaired circulation C.Impaired/suppressed immune system D.Malnutrition E.Poor wound care
A.INCORRECT:
The client is not at either extreme of the age spectrum.
B.CORRECT:
Diabetes mellitus places this client at risk for impaired circulation.
C.CORRECT:
Diabetes mellitus places this client at risk for impaired immune system function.
D.INCORRECT:
There is no indication that the client is malnourished.
E.INCORRECT:
There is no indication that there have been any breaches in aseptic technique during
wound care.
A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.)
A.Increase in incisional pain B.Fever and chills C.Reddened wound edges D.Increase in serosanguineous drainage E.Decrease in thirst
A.CORRECT:
Pain and tenderness at the wound site are expected findings with an incisional infection.
B.CORRECT:
Fever and chills are expected findings with an incisional infection.
C.CORRECT:
Reddened or inflamed wound edges are expected findings with an incisional infection.
D.INCORRECT:
Serosanguineous drainage is more common immediately after surgery. Purulent
drainage is an expected finding with an incisional infection.
E.INCORRECT:
Changes in thirst have many causes. That finding alone does not indicate an
incisional infection.
A nursing instructor is reviewing the wound healing process with a group of nursing students. They
should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.)
A.Stage III pressure ulcer B.Sutured surgical incision C.Casted bone fracture D.Laceration sealed with adhesive E.Open burn area
A.CORRECT:
Open pressure ulcers heal by secondary intention, which is the process for wounds that
have tissue loss and widely separated edges.
B.INCORRECT:
Sutured surgical incisions heal by primary intention, which is the process for wounds
that have little or no tissue loss and well-approximated edges.
C.INCORRECT:
Unless the bone edges have pierced the skin, a casted bone fracture is an injury to
underlying structures and does not require healing of the skin.
D.INCORRECT:
Lacerations sealed with tissue adhesive heal by primary intention, which is the
process for wounds that have little or no tissue loss and well-approximated edges.
E.CORRECT:
Open burn areas heal by secondary intention, which is the process for wounds that
have tissue loss and widely separated edges
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his
surgical incision. The nurse checks the client’s surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.)
A.Cover the area with saline-soaked sterile dressings.
B.Apply an abdominal binder snugly around the abdomen.
C.Use sterile gauze to apply gentle pressure to the exposed tissues.
D.Position the client supine with his hips and knees bent.
E.Offer the client a warm beverage, such as herbal tea.
A.CORRECT:
The nurse should cover the wound with a sterile dressing soaked with sterile normal saline
solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene.
B.INCORRECT:
An abdominal binder can help prevent, not treat, a wound evisceration.
C.INCORRECT:
The nurse should not handle or apply pressure to any exposed organs or tissues
because these actions increase the risks of trauma and perforation.
D.CORRECT:
This position minimizes pressure on the abdominal area.
E.INCORRECT:
The nurse must keep the client NPO in anticipation of the surgical team taking him
back to the surgical suite for repair of the evisceration.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the
following interventions should the nurse use to help maintain the integrity of the client’
s skin? (Select all that apply.)
A.Keep the head of the bed elevated 30 degrees.
B.Massage the client’s bony prominences frequently.
C.Apply cornstarch liberally to the skin after bathing.
D.Have the client sit on a gel cushion when in a chair.
E.Reposition the client at least every 3 hr while in bed.
A.CORRECT:
Slight elevation reduces shearing forces that could tear sensitive skin on the sacrum,
buttocks, and heels.
B. INCORRECT:
Massaging the skin over bony prominences can traumatize deep tissues.
C.INCORRECT:
Cornstarch can create gritty particles that can abrade sensitive skin.
D.CORRECT:
The client should sit on a gel, air, or foam cushion to redistribute weight away from
ischial areas.
E.INCORRECT:
Frequent position changes are important for preventing skin breakdown, but every
3 hr is not frequent enough. The nurse should reposition the client at least every 2 hr.
A nurse is teaching a group of nursing students about the National Pressure Ulcer Advisory Panel’s
classification system for pressure ulcers. Use the ATI Active Learning Template: Basic Concept to complete this item. Under Related Content, list the six pressure ulcer stages along with a brief description of the assessment findings typical for ulcers at each stage.
Using the ATI Active Learning Template: Basic Concept
●Related Content
◯Suspected deep tissue injury – Discolored but intact skin from damage to underlying tissue.
◯Stage I – Intact skin with an area of persistent, nonblanchable redness, typically over a bony
prominence, that may feel warmer or cooler than adjacent tissue. The tissue is swollen and has
congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear
blue or purple.
◯Stage II – Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible
and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the
ulcer may become infected, possibly with pain and scant drainage.
◯Stage III – Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer
may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with
or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and
infection are common.
◯Stage IV – Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,
bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling,
undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
◯Unstageable – No determination of stage because eschar or slough obscures the wound
