Chapter 32 Flashcards
Upon assessment of a client’s wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when
the nurse performs wound care. What is the phase of wound healing characterized by the nurse’s assessment?
A) Proliferation phase
B) Hemostasis
C) Inflammatory phase
D) Maturation phase
A) Proliferation phase
The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds
easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction
of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms
Upon responding to the client’s call bell, the nurse discovers the client’s wound has dehisced. Initial nursing
management includes calling the physician and doing which of the following?
A) Covering the wound area with sterile towels moistened with sterile 0.9% saline
B) Closing the wound area with Steri-Strips
C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze
D) Holding the wound together until the physician arrives
A) Covering the wound area with sterile towels moistened with sterile 0.9% saline
If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also
be placed in the low Fowler’s position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.
The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The
wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this
wound?
A) Stage I pressure ulcer
B) Stage II pressure ulcer
C) Stage III pressure ulcer
D) Stage IV pressure ulcer
C) Stage III pressure ulcer
Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial
and may present as a blister or abrasion.
When measuring the size, depth, and wound tunneling of a client’s stage IV pressure ulcer, what action should the nurse
perform first?
A) Perform hand hygiene.
B) Insert a swab into the wound at 90 degrees.
C) Measure the width of the wound with a disposable ruler.
D) Assess the condition of the visible wound bed
A) Perform hand hygiene.
Hand hygiene should precede any wound assessment or wound treatment.
The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing
A) Penrose drain
A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure
dressings all utilize a suction device or collection reservoir and are considered to be closed systems.
Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound
B) Ecchymosis
A closed wound results from a blow, force, or strain caused by trauma (such as a fall, an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur.
Examples include ecchymosis and hematomas. An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for
infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.
What are the two major processes involved in the inflammatory phase of wound healing?
A) Bleeding is stimulated, epithelial cells are deposited
B) Granulation tissue is formed, collagen is deposited
C) Collagen is remodeled, avascular scar forms
D) Blood clotting is initiated, WBCs move into the wound
D) Blood clotting is initiated, WBCs move into the wound
The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two
major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation.
A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would
be important to promote wound healing at this time?
A) Administer pain medications on a p.r.n. and regular basis.
B) Assist in moving to prevent strain on the suture line.
C) Tell the client that a mild fever is a normal response.
D) If a scar forms over a joint, it may limit movement.
B) Assist in moving to prevent strain on the suture line.
The proliferative phase of wound healing begins within two to three days of the injury. Collagen synthesis and accumulation continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations.
A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A) An infant B) A young adult C) A middle adult D) An older adult
D) An older adult
An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in
diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses,
with pathologic changes that impede the healing process.
A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate
a need for more information?
A) “I will drink a lot of orange juice and drink milk, too.”
B) “I will take the zinc supplement the doctor recommended.”
C) “I will restrict my diet to fats and carbohydrates.”
D) “I will drink 8 to 10 glasses of water every day.”
C) “I will restrict my diet to fats and carbohydrates.”
Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are
necessary to rebuild cells and tissues. Vitamins C and D, zinc, and adequate fluids are also necessary for wound healing.
What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection
D) Risk for Infection
Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as
infections, because corticosteroids decrease the inflammatory process that may in turn delay healing
A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one
would be most at risk?
A) A client 83 years of age who is mobile
B) A client 92 years of age who uses a walker
C) A client 75 years of age who uses a cane
D) A client 86 years of age who is bedfast
D) A client 86 years of age who is bedfast
Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.
What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings?
A) Change position at least once each shift.
B) Implement a turning schedule every two hours.
C) Use ring cushions for heels and elbows.
D) Do not turn; use pressure-relieving support surface
B) Implement a turning schedule every two hours.
To protect clients at risk from the adverse effects of pressure, implement turning using an every-2-hour schedule in the
health care setting. More frequent position changes may be necessary. Never use ring cushions or “donuts.”
A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation
A) Full-thickness skin loss
A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss.
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse
do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
A) Document the assessments and intervention.
B) Reinforce the dressing with additional layers.
C) Administer pain medications intramuscularly.
D) Notify the physician and prepare for surgery
D) Notify the physician and prepare for surgery
Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.
A nurse assessing a client’s wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria
D) White blood cells, debris, bacteria
Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent
drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous
membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged
The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the
wound. What should the nurse do after reading this information?
A) Question the physician about the accuracy of this agent.
B) Refuse to use 0.9% normal saline on a wound.
C) Document the rationale for not changing the dressing.
D) Continue with the dressing change as planned.
D) Continue with the dressing change as planned
Although various antiseptic cleaning agents could be used to clean a wound, sterile 0.9% normal saline is usually the agent of choice. Other agents may be caustic to skin and tissues.
A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during
dressing changes. Which response by the nurse is appropriate?
A) “Oh, for gosh sakes…it doesn’t look that bad!”
B) “I understand, but you are going to have to look someday.”
C) “I respect your wish not to look at it right now.”
D) “You won’t be able to go home until you look at it.”
C) “I respect your wish not to look at it right now.”
The sight of the wound may disturb a client. If the wound involves a change in normal body functions or appearance, the client may not want to look at the wound. With patience and emotional support, clients learn to cope with and adapt to their wounds in time.
A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the
client indicates the need for further education?
A) “I understand the rebound effect of heat.”
B) “I will put the heat packs only on the sore on my leg.”
C) “I will only leave the heat packs on for 20 minutes.”
D) “I will leave the heat packs on for an hour.”
D) “I will leave the heat packs on for an hour.”
Initially, temperature receptors in the skin are strongly stimulated. This response decreases rapidly for the first few
seconds after being stimulated and more slowly for the next 30 minutes as the receptors adapt to the temperature. Be
sure to tell clients that increasing the temperature or lengthening the time of application can seriously damage tissues.
Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest
C) Thorough hand hygiene
The single most important information on which to educate clients and caregivers about home wound care is the
importance of thorough hand hygiene to prevent wound infections
Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client?
A) Secure the heating pad to the client’s clothing with safety pins.
B) Place a heavy towel or blanket over the heating pad to maximize heat effects.
C) Use a heating pad with a selector switch that can be turned up by the client if needed.
D) Place a heating pad anteriorly or laterally to, not under, the body part
D) Place a heating pad anteriorly or laterally to, not under, the body part
Guidelines include: Place a heating pad anteriorly or laterally to, not under, the body part. If the heating pad is between
the client and the mattress, heat dissipation may be inadequate, leading to burning of the client or the bed linens. Avoid
using pins to secure a heating pad because there is a danger of electric shock if a pin touches a wire. Do not cover the
heating pad with anything that might be heavy; heat may accumulate and burn the client when it cannot dissipate normally from the pad. Use a heating pad with a selector switch that cannot be turned up beyond a safe temperature.
A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth.
How could the nurse describe the laceration wound in the client’s medical record?
A) A clean separation of skin and tissue with a smooth, even edge
B) A separation of skin and tissue in which the edges are torn and irregular
C) A wound in which the surface layers of skin are scraped away
D) A shallow crater in which skin or mucous membrane is missing
B) A separation of skin and tissue in which the edges are torn and irregular
A laceration wound can be described as a separation of skin and tissue in which the edges are torn and irregular. An incision wound is described as a clean separation of skin and tissue with a smooth, even edge. An abrasion is a wound in which the surface layers of skin are scraped away. Ulceration is a shallow crater in which skin or mucous membrane is missing.
A nurse caring for a post-operative client observes the drainage in the client’s closed wound drainage system. The
drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulen
C) Serosanguineous
The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and
red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.
An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A) Beta-hemolytic streptococcus B) Age C) Venous insufficiency D) Hemangioma
C) Venous insufficiency
Leg and foot ulcers occur from various causes, but the most common are ulcers secondary to venous insufficiency,
arterial insufficiency, and neuropathy.
Which of the following clients would be considered at risk for skin alterations? Select all that apply.
A) A teenager with multiple body piercings
B) A homosexual in a monogamous relationship
C) A client receiving radiation therapy
D) A client undergoing cardiac monitoring
E) A client with diabetes
A) A teenager with multiple body piercings
C) A client receiving radiation therapy
E) A client with diabetes
Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual
relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and
respiratory disorders are not risk factors
A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold
therapy? Select all that apply.
A) Constricts peripheral blood vessels
B) Reduces muscle spasms
C) Increases blood flow to tissues
D) Increases the local release of pain-producing substances
E) Reduces the formation of edema and inflammation
A) Constricts peripheral blood vessels
B) Reduces muscle spasms
E) Reduces the formation of edema and inflammation
The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold
reduces blood flow to tissues and decreases the local release of pain-producing substances such as histamine, serotonin,
and bradykinin. This action in turn reduces the formation of edema and inflammation. Decreased metabolic needs and
capillary permeability, combined with increased coagulation of blood at the wound site, facilitate the control of bleeding
and reduce edema formation. Cold also reduces muscle spasms, alters tissue sensitivity (producing numbness), and
promotes comfort by slowing the transmission of pain stimuli.
Which of the following are functions of the skin? Select all that apply. A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological
A) Protection
B) Temperature regulation
C) Sensation
E) Immunological
The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production,
immunological, absorption, and elimination.
While performing a bed bath, the nurse notes an area of tissue injury on the client’s sacral area. The wound presents as a
shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the
correct name of this wound?
A) Stage II pressure ulcer
B) Stage I pressure ulcer
C) Stage III pressure ulcer
D) Stage IV pressure ulcer
A) Stage II pressure ulcer
Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II
is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is
defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.
A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in
this client?
A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin.
B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or
shear.
C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or
cooler as compared with adjacent tissue.
D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough
C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or
cooler as compared with adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with dark skin tones. The area may be preceded by tissue that
is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. Evolution may include a thin blister over a
dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid, exposing
additional layers of tissue even with optimal treatment.
A nurse inspecting a client’s pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat;
bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
C) Stage III
In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not
exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence.
In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without
slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.
Which of the following is an accurate step when applying a saline-moistened dressing on a client’s wound?
A) Do not use irrigation to clean the wound before changing the dressing.
B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it.
C) Exert light pressure to pack the wound tightly with moistened dressing.
D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.
D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.
Answer D is the correct step in the procedure. The wound should be cleaned, if needed, using sterile forceps. Irrigation
may be used as ordered or required. The wound should be cleaned from the top to the bottom, and from the center to the
outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate
it. The dressing should be gently and loosely packed inside the wound.
A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of
dressing for this wound?
A) Saline-moistened dressing
B) Dressing secured with Montgomery straps
C) Hydrocolloid dressing
D) Foam dressing
C) Hydrocolloid dressing
Hydrocolloid dressings are used for wounds that are shallow to moderate depth with minimal drainage. Saline-moistened
dressing is often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure
dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings
are recommended for chronic wounds
Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers
D) Pressure ulcers
Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008; Thompson, 2008).
A student has been assigned to provide morning care to a client. The plan of care includes the information that the client
requires partial care. What will the student do?
A) Provide total physical hygiene, including perineal care.
B) Provide total physical hygiene, excluding hair care.
C) Provide supplies and orient to the bathroom.
D) Provide supplies and assist with hard-to-reach areas.
D) Provide supplies and assist with hard-to-reach areas.
Morning care is often identified as either self-care, partial care, or complete care. Clients requiring partial morning care most often receive care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach
