Wensdays final Surgical wound care chapter 13 Christensen Flashcards
- Immediately after an injury, the wound healing process begins and follows the same pattern. Place the following phases of wound healing in the correct order.
- Maturation phase
- Inflammatory phase
- Hemostasis phase
- Reconstruction phase
Hemostasis, Inflammatory, Reconstruction, Maturation
When caring for a patient needing wound care, your first step is to:
A. Wash your hands.
B. Explain the procedure to the patient.
C. Assemble all equipment and supplies.
D. Check the medical record for the physician’s orders.
Check the medical record for the physicians orders
You are the nurse caring for a patient with a wound on the right arm. The wound is covered by a bandage. When assessing the skin that is distal to the bandage, you would assess for signs of:
A. Circulatory impairment
B. Inflammation
C. Bacteria
D. Impaired skin integrity
Circulatory impairment
A patient is 3 days post-op from abdominal surgery. Which of the following conditions would the nurse assessing the abdominal incision consider normal? Select all that apply.
A.
Clean, well-approximated edges
B.
Staples or sutures intact
C.
A foul-smelling odor
D.
A small amount of serous drainage
Clean well approximated edges
Staples or sutures intact
A small amount of serous drainage
When classifying wounds, which of the following classifications results from the presence of gastrointestinal products?
A. Contaminated
B. Clean-contaminated
C. Dirty
D. Clean
Contaminated
If a patient with an abdominal incision begins to cough, which intervention is the most appropriate?
A. Sit the patient up to a semi-Fowler’s position.
B. Apply a pillow to the incision with slight pressure.
C. Roll the patient to the left side.
D. Offer the patient a drink of water.
B Apply a pillow to the incision with slight pressure
When removing staples from a surgical incision, which of the following interventions is most appropriate?
A. Remove every other staple, then wait several days to remove the rest.
B. Remove the middle staples first, then proceed to the outer edges, and apply dressing.
C. Remove all the staples. If edges pull apart, apply steri-strips.
D. Remove every other staple first and replace with steri-strips while monitoring that incision remains closed.
C remove all the staples, If edges pull apart apply steri strips
The physician has ordered a sterile dry dressing change. The most appropriate way to cleanse the wound and surrounding area is to use a(n):
A. Sterile swab to soak up any drainage, then apply a clean dressing
B. Aseptic swab, start from the incision outward, one stroke per swab, then allow to air dry
C. Aseptic swab, start at the top of the incision, using the same swab until dirty, then get a clean swab
D. Aseptic swab, start on the side of the wound closest to you, one stroke per swab
B Aseptic swab, start from the incision outward, one stroke per swab, then allow to air dry
The physician has ordered for your patient’s leg wound to be irrigated using an antiseptic solution. To reduce the chance of contamination you would:
A. Direct the solution toward unhealthy tissue to healthy tissue within the wound.
B. Place the tip of the syringe touching the area needing to being cleaned.
C. Have the solution flow from the least contaminated to the most contaminated area.
D. Instill the solution with force to remove any debris quickly from the wound.
C have solution flow from least contaminated to the most contaminated area
A patient has come to the PACU after hip replacement surgery. Following your assessment, you need to set up a plan of care. The highest priority nursing diagnosis would be:
A. Tissue perfusion, ineffective
B. Nutrition: less than body requirements, imbalanced
C. Nutrition: more than body requirements, imbalanced
D. Skin integrity, impaired
skin integrity, impaired
