chap 38 part 5 ques 37 Flashcards
What are some of the ways that a dressing can be secured?
tape
stretch roller gauze
elastic bandage
montgomery straps
mesh netting
What are the purpose of Montgomery straps, and how would they be applied?
allow changing the dressing without removing and reapplying tape
adhered to either side of the wound and ties pull the tapes toward each other, relieving the tension around the wound
What are the advantages of a secured dressing?
Secures dressing in place
What is the proper technique for applying tape to a dressing?
ensure tape adheres to the skin for several inches on either side of the dressing
length of tape across middle of a large dressing
do not apply tape over irritated or broken skin
tape across a joint or crease
Sutures or staples might be kept in longer, for what type of patient?
older adults; prolonged healing time
injury from debris or chemical
Eye irrigation
wax or debris blocks ear canal and prevents sound from reaching tympanic membrane
Ear irrigation
infection or surgical preparation
Vaginal irrigation
What types of dressing would most likely be used on Stage II
hydrocolloid,
foam, or
hydrogel dressing,
which will protect against bacterial contamination.
What types of dressing would most likely be used on Stage III
use a dressing that will absorb exudate and maintain a moist environment.
For infected ulcers, always use a non-occlusive dressing
For infected ulcers, always use what type of dressing
a non-occlusive dressing
What is important for the nurse to do after each dressing change?
Date, initials and document
What is the purpose of negative pressure treatment with ulcers?
Increases development of granulation tissue, speeds healing rate, and reduces hospitalizations while minimizing the need for dressing changes.
observe dressing area when assessing vital signs
check setting on NPWT unit and assess working correctly
ensure tubing is not pressing on skin
assess for proper collapse of dressing
dressing changes
wound assessment
documentation
is the nurse’s responsibility for the wound vac?
What is the nurse’s responsibility for the wound vac?
observe dressing area when assessing vital signs
check setting on NPWT unit and assess working correctly
ensure tubing is not pressing on skin
assess for proper collapse of dressing
dressing changes
wound assessment
documentation
What are the benefits of applying heat to an injured area? (5)
Improves blood flow to injured body part; promotes delivery of nutrients and removal of waste; lessens venous congestion in injured tissues
improves delivery of leukocytes and antibiotics to wound site
promote muscle relaxation and reduces pain from spasm or stiffness
increased blood flow; provides local warmth
promotes movement of waste products and nutrients
Improves blood flow to injured body part; promotes delivery of nutrients and removal of waste; lessens venous congestion in injured tissues
improves delivery of leukocytes and antibiotics to wound site
promote muscle relaxation and reduces pain from spasm or stiffness
increased blood flow; provides local warmth
promotes movement of waste products and nutrients
are the benefits of applying heat to an injured area? (5)
What are the benefits of applying cold to an injured area?
reduces blood flow to injured body part, preventing edema formation; reduces inflammation
reduces localized pain
reduces oxygen needs of tissues
promotes blood coagulation at injury site
relieves pain
reduces blood flow to injured body part, preventing edema formation; reduces inflammation
reduces localized pain
reduces oxygen needs of tissues
promotes blood coagulation at injury site
relieves pain
are the benefits of applying cold to an injured area
Your patient is going home from the hospital with sutures. When would the sutures most likely be removed?
A.3-5 days
B.5-7 days
C.7-10 days
D.14 days
C. 7-10
Which of the following statements is true regarding dressing changes?
A. A dressing change can be performed as needed without obtaining a physician’s order. (Require medical order)
B. Irrigation can be performed without a physician’s order. (only with an order)
C. Clean gloves and forceps are used for fresh sterile wounds that are touched.(sterile gloves or sterile forceps whenever you touch an open or fresh surgical wound)
D. Clean the wound with warm water. (allow a refrigerated solution to come to room temperature)
D. Clean the wound with warm water. (allow a refrigerated solution to come to room temperature)
How long can cold compress therapy be applied? A. 10 minutes B. 20 minutes C. 30 minutes D. 45 minutes
B. 20
Which of the following is an example of an open wound? A. Hematoma B. Contusion C. Laceration D. Sprain
C. Laceration
Which of the following is considered a complication of wound healing? A. Debridement B. Phagocytosis C. Culture specimen D. Dehiscence
D. Dehiscence
A wound that would require removal of the eschar will appear: A. Red B. Yellow C. Black D. Green
C. Black
Which of the following measures should a nurse perform for a patient who has a nursing diagnosis of Risk for infection related to nonintact skin?
A. Use clean gloves for an open wound
B. Use sterile gloves for an open wound
C. Apply alcohol to wound
D. Apply gauze to wound
B. Use sterile gloves for an open wound
Which of the following dressings allows the nurse to assess the wound without removing it?
A. ABD pad
B. Conform
C. DuoDerm
D. Opsite
D. Opsite
Which of the following wound debridement methods is best used for small, uninfected wounds?
A. Sharp
B. Enzymatic
C. Autolytic
D. Mechanical
C. Autolytic
Which of the following interventions would be used in the plan of care for a patient that has just returned from surgery after having a debridement of a Stage IV ulcer?
A. Place OpSite on wound three times a day.
B. Medicate the patient after the dressing change to promote rest.
C.Encourage smoking cessation.
D.Encourage whirlpool bath once per week.
C.Encourage smoking cessation.
Your patient is being discharged home and will need wound care and dressing changes twice per day. You understand that the family requires more teaching about wound care and dressing changes when a family member states:
A. “I will clean the scissors with warm, soapy water.” (then boil for 10m and store in covered container)
B. “I will write down what the incision looks like.”
C. “I have arthritis, so my daughter will help me change the dressing.”
D. “I will be careful pulling off the tape.”
A. “I will clean the scissors with warm, soapy water.” (then boil for 10m and store in covered container)
You check a doctor’s order that reads: Irrigate abdominal wound 3 times daily with 100 mL normal saline. What should you do?
A. Irrigate the wound twice a day.
B. Pour the NS into the wound directly from a new bottle.
C. Apply a dry dressing over the moist dressing.
D. Change into sterile gloves after removing the old dressing.
D. Change into sterile gloves after removing the old dressing.
Which of the following patients should you assess first after receiving shift report?
A. A 75-year-old woman who is lying with a hot water bottle on her back.
B. A 52-year-old woman who has a heat lamp for her sacral ulcer.
C. A 63-year-old woman who has an ice pack on his broken leg.
D. A 24-year-old woman who has a cold pack on after nasal surgery.
A. A 75-year-old woman who is lying with a hot water bottle on her back.
