Surgical Wound Care ( ch 14 foundations) Flashcards
The nurse instructs a patient who has a drain in a surgical wound that the wound will heal by:
tertiary intention.
To assist the postoperative patient to cough, the nurse:
splints the abdomen with a pillow.
-is helpful to relieve stress on the suture line.
The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as:
sanguineous.
-The term sanguineous means bloody. It is indicative of active bleeding.
The nurse explains that the advantage of an occlusive dressing is that it:
keeps the incision moist and increase epithelialization.
When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should:
moisten the dressing with sterile water.
The nurse instructs the patient in home wound irrigation to hold the hand-held showerhead approximately ______ inches from the wound .
12
The nurse follows the basic concept of wound irrigation when directing the flow of the irrigant:
from the area of least contamination to the area of most contamination.
- to prevent microorganisms from entering the wound.
The nurse observes a loop of bowel protruding from the surgical incision. The nurse’s initial intervention should be to:
cover the bowel with a sterile saline dressing.
*Although the RN must be notified, covering the loop of bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line.
The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. If the wound begins to separate after removal of 3 of the 15 staples, the nurse should:
leave the 12 staples in place and record the separation.
Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by:
circling and dating the outline of the exudate on the dressing.
The Centers for Disease Control (CDC) classifies wounds according to the amount of contamination. An uninfected surgical wound with less than a 5% chance of becoming infected postoperatively is classified as a:
clean wound.
Hemostasis begins as soon as the injury occurs and a clot begins to form. The substance in the clot that holds the wound together is:
fibrin.
When blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain, the nurse knows that the wound is in which phase?
Inflammatory
Primary intention has a marked advantage over other phases of wound healing because:
minimal scarring results.
For the first 24 hours following surgery, the nurse assesses for bleeding by observing the dressing and the area under the patient every:
2 to 4 hours.
To keep the patient comfortable during a dressing change, the nurse may administer an analgesic:
at least 30 minutes before the dressing change.
The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound, which when removed results in:
mechanical debridement.
During assessment of a postoperative patient, the nurse discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. The nurse recognizes these findings as indicative of:
internal hemorrhage.
The usual length of time before suture removal is:
7 to 10 days.
The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. It is considered abnormal if the drainage exceeds:
300 mL.
The nurse recognizes that the Jackson-Pratt drainage removal system is classified as a(n):
closed drainage system.
The nurse caring for a patient with a surgical wound promotes healing by:
encouraging the consumption of small frequent meals.
The nurse instructing a patient about the effects of smoking informs the patient that smoking:
interferes with normal cellular mechanisms that promote release of oxygen.
*Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.
The nurse instructing a patient about the effects of diabetes mellitus informs the patient that diabetes mellitus:
causes hemoglobin to have a greater affinity for oxygen.
*Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.
The nurse assessing a patient’s wound notes a clear watery drainage. The nurse documents this finding as:
serous drainage.
- has the appearance of clear, watery plasma.
The nurse assessing a patient’s wound notes thick, yellow drainage. The nurse documents this finding as:
purulent drainage.
- has the appearance of thick, yellow, green, tan, or brown drainage
The nurse assessing a patient’s wound notes pale red watery drainage. The nurse documents this finding as:
serosanguineous drainage.
- is pale, red, and watery and is a mixture of serous and sanguineous drainage.
The nurse assessing a patient’s wound notes bright red drainage. The nurse documents this finding as:
sanguineous drainage.-
- is bright red and indicates active bleeding.
The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. The nurse recognizes this as an indication of:
dehiscence.
Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction
b. Hemostasis
c. Inflammatory
d. Maturation
