Wound Care Flashcards
A nurse is documenting data about a deep necrotic wound on a patient’s left buttock. The nurse observes a yellowish – tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type of necrotic tissue as
Fibrin.
Slough.
Gangrene.
Eschar.
Slough
A nurse is caring for a patient who has developed a stage 1 pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer?
Zinc oxide.
Nystatin.
Papain – urea.
Poly yin B.
Zinc oxide.
A nurse is caring for a patient who has multiple sclerosis and has a chronic non healing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?
Tricyclic antidepressants.
Corticosteroids.
Beta blockers.
Anticholinergics.
Corticosteroids.
A patient who has a full – thickness wound continues to experience considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
Wet – to – dry.
Anti microbial.
Gauze.
Hydrogel.
Hydrogel
A nurse is caring for a patient who is admitted with multiple wounds sustained in a motor – vehicle crash. Understanding the patient’s specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient’s plan of care to prevent a prolongation of this phase?
Leave nonbleeding wounds open to air
Administer 325 mg aspirin PO as needed for pain
Initiate mechanical debridement
Apply oxygen at 2 L/min via nasal cannula
Apply oxygen at 2 L/min via nasal cannula
A nurse is caring for a patient with a stage IV sacral pressure ulcer for which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for this patient?
Placing a transplant dressing over the ulcer
Applying larvae to the wound bed
Changing dressings using the wet – to – dry method
Using a topical enzyme solution in the wound’s base
Changing dressings using the wet – to – dry method
A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis?
Transparent
Hydrofiber
Alginate
Biologic
Alginate
A nurse is documenting data about a healing wound on a patient’s lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as
Serisanguineous
Sanguineous
Serous
Purulent
Serisanguineous
A nurse assessing a pressure ulcer over a patient’s right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is
Unstageable
A suspected deep tissue injury
Stage IV
Stage III
Stage III
