Wound Care ( Chap 38 and 39)

Question 1

When is healing by primary intention expected?

a. When the wound is left open and is allowed to heal
b. When a surgical wound is left open for 3 to 5 days
c. When connective tissue development is evident
d. When the edges of a clean incision remain close together

Answer 1

ANS: D
Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

Question 2

The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed?

a. Change the dressing so she can assess the wound.
b. Administer an analgesic 30 to 45 minutes before a dressing change.
c. Culture the wound if wound exudate is present.
d. Administer an analgesic 30 minutes after a dressing change.

Answer 2

ANS: B
To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth.

Question 3

The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system?

a. Decreases the amount of angiogenesis
b. Reduces mechanical stretch of tissue
c. Dressing should not need to be changed for 48 hours
d. Helps create a dry environment

Answer 3

ANS: C
The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels), and that this stimulates the production of new blood vessels via mechanical stretch of the tissue. The dressing placed into the wound maintains a moist environment to facilitate healing. A suction device is placed over the dressing, and the dressing, suction, and wound area are covered with a transparent dressing, which provides the air-tight seal necessary for negative-pressure wound therapy (NPWT).

Question 4

The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock. How should the nurse proceed?

a. Use irrigation pressures of less than 4 psi.
b. Cleanse in a direction from most contaminated to least contaminated.
c. Irrigate so that the solution flows from least contaminated to most contaminated.
d. Irrigate with clean irrigation solution only.

Answer 4

ANS: C
When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.

Question 5

The nurse is changing a surgical dressing and is cleansing the wound. She knows that:

a. the incision line should be cleansed last.
b. she should start at one end of the incision line and swab the entire length.
c. she should start at the center of the incision line and swab toward one end.
d. she should work in a circular motion around the incision line.

Answer 5

ANS: C
The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke.

Question 6

The nurse answers the patient’s call light to find the patient agitated and stating that she “felt something pop.” The nurse finds that the patient’s abdominal surgical wound has eviscerated. What should the nurse do?

a. Try to reinsert the abdominal contents.
b. Cover the wound with a dry sterile dressing.
c. Notify the surgeon when he makes rounds.
d. Cover the wound with a moist saline dressing.

Answer 6

ANS: D
This is a surgical emergency, and the nurse needs to cover the wound with a moist saline dressing, immediately notify the surgeon, and prepare the patient for emergency surgery.

Question 7

The nurse prepares to irrigate the patient’s wound. What is the primary reason for this procedure?

a. Decrease scar formation.
b. Remove debris from the wound.
c. Improve circulation from the wound.
d. Decrease irritation from wound drainage.

Answer 7

ANS: B
Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. The primary purposes of wound irrigation do not include decreasing scar formation, improving circulation, or decreasing irritation.

Question 8

Which of the following approaches is correct technique when wound irrigation is performed?

a. Placing the patient in supine position
b. Placing the syringe directly into the wound
c. Using sterile technique for a chronic wound
d. Selecting a soft catheter for deep wounds with small openings

Answer 8

ANS: D
If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds).

Question 9

On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

a. Graft sites
b. Wounds with exposed blood vessels
c. Necrotic tissue
d. Wounds with exposed muscle or tendons

Answer 9

ANS: C
Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone.

Question 10

When should a nurse consider culturing a wound?

a. When the tissue is clean and dry
b. When exudate is not present
c. When the patient is afebrile
d. When the surrounding area shows inflammation

Answer 10

ANS: D
Consider culturing a wound if it has a foul, purulent odor; inflammation surrounds the wound; a nondraining wound begins to drain; or the patient is febrile.

Question 11

When teaching about wound care in the home environment, the nurse instructs the patient and caregiver to:

a. make normal saline with 8 teaspoons of salt and .1 gallon of distilled water.
b. use normal saline for 1 week and then discard it.
c. not apply topical anesthetics before wound care.
d. call the physician’s office to have someone come to the home and complete the wound care.

Answer 11

ANS: A
Teach the patient and caregiver how to make normal saline, especially if cost is an issue. They can make normal saline by using 8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month. The saline solution should be allowed to reach room temperature before use. Commonly used topical anesthetic solutions include 2% and 4% lidocaine jelly, which inactivates exposed wound pain receptors. Some patients need to receive wound care management in an outpatient wound care clinic. Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies.

Question 12

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

a. The wound edges are separated.
b. No drainage or erythema is present.
c. The patient is anxious about their removal.
d. A cosmetically aesthetic result would not be achieved.

Answer 12

ANS: A
Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges, normal color, and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, the wound has not healed properly. Notify the health care provider because sutures or staples may need to remain in place. Absence of drainage and erythema would indicate that sutures are ready for removal. Steps could be taken to relieve the patient’s anxiety, but suture removal is based on the condition of the wound. Timing of suture removal is based on adequate wound healing.

Question 13

What should the nurse do when removing intermittent sutures?

a. Snip both sides of the suture before removing.
b. Snip the suture as close to the knot as possible.
c. Snip the suture as close to the skin as possible.
d. Pull up the knot to apply as much tension as possible.

Answer 13

ANS: C
Snip the suture as close to the skin as possible at the end distal to the knot. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knot of the suture with forceps, and gently pull up the knot while slipping the tip of the scissors under the suture near the skin.

Question 14

What should the nurse do when performing suture or staple removal?

a. Snip both ends of the sutures.
b. Apply tension to the suture line to remove the sutures.
c. Pull the exposed surface of the suture through the tissue below the epidermis.
d. Apply Steri-Strips if any separation greater than the width of two stitches is present.

Answer 14

ANS: D
Apply Steri-Strips if any separation greater than two stitches or two staples in width is apparent, to maintain contact between wound edges. This supports the wound by distributing tension across the wound and eliminates closure technique scarring. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knotted end with forceps, and in one continuous smooth action, pull the suture through from the other side; this smoothly removes the suture without additional tension to the suture line. Tension on the suture line is not required. Never pull the exposed surface of any suture into tissue below the epidermis. The exposed surface of any suture is considered contaminated.

Question 15

The physician reports that he is expecting that the patient’s wound will have an output of close to 500 mL per day. The nurse anticipates placement of which of the following?

a. Dry sterile dressing
b. Jackson-Pratt (JP) drain
c. Hemovac drain
d. No drain

Answer 15

ANS: C
If drainage accumulates in the wound bed, wound healing is delayed. Drainage is removed by using a closed or an open drain system, even if the amount of drainage is small. A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range; the Hemovac drain accommodates more drainage, usually up to 500 mL in 24 hours.

Question 16

What is an appropriate technique for the nurse to implement for drainage evacuation?

a. Replace the Hemovac drain fully expanded.
b. Attach the drainage tubing to the patient’s gown.
c. Tilt the evacuator of the Hemovac away from the plug.
d. Complete the dressing change before the drainage evacuation.

Answer 16

ANS: B
Pinning drainage tubing to the patient’s gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times.

Question 17

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?

a. Place a safety pin on the part of the drain outside the body.
b. Replace the cap immediately after emptying.
c. Pin the drainage tubing to the patient’s gown.
d. Place the Hemovac on a flat surface.

Answer 17

ANS: D
Place the evacuator on a flat surface with the open outlet facing upward; continue pressing downward until the bottom and the top are in contact; hold the surfaces together with one hand, quickly cleanse the opening and the plug with the other hand, and immediately replace the plug; and then secure the evacuator to the patient’s bed. Compression of the surface of the Hemovac creates a vacuum. Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation. Be sure the Penrose drain has a sterile safety pin in place. This pin prevents the drain from being pulled below the skin’s surface. Compress the bulb of a JP drain over the drainage container. Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container. Replacing the cap immediately prevents tension on the drainage tubing, but does not help to reestablish the vacuum.

Question 18

The nurse is explaining wound healing to a patient. Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

a. A reduction in the size of the wound is noted.
b. The epithelial cells duplicate.
c. Synthesis of collagen occurs at the site.
d. Blood flow to the wound and arrival of white blood cells are increased.

Answer 18

ANS: D
Vasodilatation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (white blood cells) arrive in the wound to begin wound cleanup. Macrophages, a type of white blood cell, appear and begin to regulate wound repair. The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound. It is during the proliferative stage, not the inflammatory stage, that contraction causes a reduction in the size of the wound, duplication of epithelial cells occurs, and collagen is synthesized.

Question 19

For absorption of heavy exudate from a wound, a nurse selects which of the following dressings?

a. Alginates
b. Hydrogel
c. Hydrocolloid
d. Transparent film

Answer 19

ANS: A
Alginates are used for absorption of heavy to moderate wound exudate. Hydrogels are used for dry wounds to wounds with minimal exudate. Hydrocolloids are used to absorb minimal to moderate exudate. Transparent film has no absorption quality.

Question 20

The nurse is educating a patient about his role in wound healing. Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level?

a. Age
b. Smoking
c. Underlying cardiopulmonary conditions
d. Hemoglobin

Answer 20

ANS: B
Factors that decrease oxygenation include decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions. Smoking is the only one of these factors that can be modified by the patient alone. Age causes vascular changes.

Question 21

The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing. Which of the following can be appropriately delegated to the nurse assistant?

a. Performing a sterile dressing change
b. Observing for any drainage on the dressing
c. Performing wound assessment during the dressing change
d. Notifying the physician of drainage present on the dressing

Answer 21

ANS: B
Wound assessment and sterile dressing changes cannot be delegated to nursing assistive personnel (NAP). The nurse can direct the NAP to report any drainage from the wound that is present on the sheets or as strike-through from the dressing. The NAP should not be reporting this to a physician.

Question 22

You are irrigating a wound and are trying to make sure you get the wound adequately cleansed. Which of the following should you avoid?

a. Inserting the tip of a soft catheter into a deep wound
b. Using a 19-gauge angiocatheter
c. Pushing the tip inside a deep wound that has a small opening
d. Using a large syringe

Answer 22

ANS: C
Do not force a catheter into a wound because this will cause tissue damage. Using a 19-gauge angiocatheter and a 35-cc syringe is acceptable. If you need to irrigate a deep wound with a small opening, use a soft catheter and insert it 1.3 cm to avoid touching the fragile inner wall of the wound.

Question 23

How does the skin defend the body? (Select all that apply.)

a. Skin serves as a sensory organ for pain.
b. Skin serves as a sensory organ for touch.
c. Skin serves as a sensory organ for temperature.
d. Skin has an acid pH.

Answer 23

ANS: A, B, C, D
The skin defends the body by serving as a sensory organ for pain, touch, and temperature, and it has an acid pH, which is often called the “acid mantle.”

Question 24

Physiologically, wound healing occurs in the same way for all patients, with some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes which of the following cells? (Select all that apply.)

a. Liver cells
b. Skin cells
c. Renal tubules
d. Central nervous system neurons

Answer 24

ANS: A, C, D
Physiologically, wound healing occurs in the same way for all patients, with skin cells and some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes cells of the liver, renal tubules, and central nervous system neurons.

Question 25

You are explaining wound healing to your patient. You are trying to explain the healing process in a full-thickness wound. Which of the following phases should you include in your explanation? (Select all that apply.)

a. Hemostasis
b. Inflammation
c. Proliferation
d. Maturation

Answer 25

ANS: A, B, C, D

In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation.

Question 26

You are explaining negative-pressure wound therapy (NPWT) to a patient. Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

a. NPWT optimizes blood flow.
b. NPWT will remove wound fluid.
c. NPWT will maintain a moist environment.
d. NPWT will apply positive pressure to the wound.

Answer 26

ANS: A, B, C

NPWT supports wound healing by optimizing blood flow, removing wound fluid, and maintaining a moist environment.

Question 27

Wounds that have been approved for treatment using NPWT include which of the following? (Select all that apply.)

a. Pressure ulcers
b. Diabetic ulcers
c. Traumatic wounds
d. Venous stasis ulcers

Answer 27

ANS: A, B, C, D
Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT.

Question 28

The nurse is caring for a patient who has had major abdominal surgery. She is concerned about the possibility of dehiscence. During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply.)

a. Age
b. Malnutrition/obesity
c. Gender
d. Use of steroids

Answer 28

ANS: B, D

Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids.

Question 29

The _____________ is composed of newly formed collagen, and the nurse can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9.

Answer 29

ANS:
healing ridge
The healing ridge is composed of newly formed collagen, and you can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. Lack of a ridge is cause for concern, and you will need to begin interventions promptly to reduce mechanical strain on the wound.

Question 30

Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

Answer 30

ANS:
tertiary
Healing by tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed. Scarring is usually minimal.

Question 31

___________ is black, brown, or tan tissue in the wound that should be removed before wound healing can begin.

Answer 31

ANS:
Eschar
Black, brown, or tan tissue in the wound is eschar that should be removed before wound healing can begin.

Question 32

_____________ uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

Answer 32

ANS:
Irrigation
Irrigation uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

Question 33

A failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level is known as ______________.

Answer 33

ANS:
dehiscence
Dehiscence, a failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level. It occurs fairly early after surgery (5 to 8 days after surgery) in patients in whom the normal healing response lags

Question 34

___________ are threads of wire or other materials used to sew body tissues together.

Answer 34

ANS:
Sutures
Sutures are threads of wire or other materials used to sew body tissues together.

Question 35

The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is considered a __________ drainage system.

Answer 35

ANS:
closed
A closed drainage system such as the JP drain (Figure 38-8) or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device.

Question 36

The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _____ dressing.

a. pressure
b. alginate
c. foam
d. hydrocolloid

Answer 36

ANS: A
Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate.

Question 37

The nurse is changing a dry, woven gauze dressing when she notices that the gauze has inadvertently stuck to the wound. What should the nurse do?

a. Pull the dressing off to aid in debridement.
b. Recover the dressing and leave in place.
c. Moisten the gauze to minimize trauma.
d. Ensure that the shiny side of the dry gauze dressing does not stick.

Answer 37

ANS: C
When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma. Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound.

Question 38

The nurse is caring for a patient who has a wound healing by primary intention that has little to no drainage. Which dressing is most appropriate for this type of wound?

a. Moist-to-dry dressing
b. Hydrocolloid dressing
c. Dry dressing
d. Hydrogel dressing

Answer 38

ANS: C
Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris. Hydrogel dressings (e.g., Curasol, IntraSite Gel, Vigilon) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues.

Question 39

The nurse would consider a dry dressing appropriate for a wound that requires which of the following?

a. Protection
b. Debridement
c. Absorption of heavy exudate
d. Healing by second intention

Answer 39

ANS: A
A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention.

Question 40

What should the nurse do for a patient who is having a wet-to-dry dressing applied?

a. Moisten the old inner dressing to remove it.
b. Pack the gauze in flat pieces into the wound.
c. Wet the new inner dressing with a cytotoxic solution.
d. Apply a secondary dressing over the inner wet packing.

Answer 40

ANS: D
The primary purpose of wet-to-dry dressings is to mechanically debride a wound. The moistened contact layer of the dressing (primary dressing) increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides the wound of tissue when the dressing is removed. The moistened gauze must be covered with a secondary dressing layer that is dry. It is incorrect technique and a common error by some clinicians to moisten the dried gauze before removing it. This defeats the purpose of using this type of dressing and reduces the amount of debris that the dressing will remove. Open or “fluff” the woven gauze that will be placed directly against the wound bed. Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions.

Question 41

Moist-to-dry dressings consist of gauze moistened with an appropriate solution. What should the nurse do when caring for a patient who has a pressure wound that requires debridement?

a. Saturate the primary dressing with saline or lactated Ringer’s solution.
b. Moisten the primary dressing with saline or lactated Ringer’s solution.
c. Moisten the primary dressing with acetic acid.
d. Moisten the primary dressing with povidone-iodine.

Answer 41

ANS: B
Moist-to-dry dressings consist of gauze moistened with an appropriate solution. Commonly used wetting agents include normal saline and lactated Ringer’s solution, which are isotonic solutions that aid in mechanical debridement. A dressing that is too wet causes tissue maceration and bacterial growth. It also does not dry out and therefore does not remove necrotic tissue when it is being removed from the wound. Acetic acid is effective against Pseudomonas aeruginosa but is toxic to fibroblasts in standard dilutions. Povidone-iodine is a rapid-acting antimicrobial agent for cleansing intact skin and is never used on a healthy granulating wound bed.

Question 42

The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

a. filling two thirds of the wound cavity.
b. leaving saline-soaked folded gauze squares in place.
c. putting the dressing in very tightly.
d. extending only to the upper edge of the wound.

Answer 42

ANS: D
Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface. If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed.

Question 43

What should the nurse do for a patient with a sudden severe hemorrhage?

a. Go for help.
b. Drape the patient.
c. Apply direct pressure.
d. Put on clean or sterile gloves.

Answer 43

ANS: C
Apply direct pressure immediately. Seek assistance after pressure is applied. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities.

Question 44

What should the nurse anticipate might happen to a patient if bleeding cannot be controlled?

a. Skin dryness
b. Bradycardia
c. Hypovolemic shock
d. Hypertension

Answer 44

ANS: C
Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shock. Hypertension is an increase in blood pressure.

Question 45

How should the nurse proceed when applying a pressure bandage?

a. Elevate the extremity or area of bleeding.
b. Wrap pressure-bandage gauze in a proximal-to-distal direction.
c. Apply pressure to diminish the pulse to the distal body part.
d. Wrap tape around the circumference of the site to secure the gauze padding.

Answer 45

ANS: A
As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity.

Question 46

Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond?

a. Initiate intravenous (IV) therapy.
b. Order blood for transfusions.
c. Remove and reapply any dressings.
d. Monitor vital signs every 15 minutes.

Answer 46

ANS: D
Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a provider’s order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.

Question 47

The patient is being sent home from the hospital after a cardiac catheterization. What should the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site?

a. Call the physician.
b. Call 9-1-1.
c. Apply pressure to the site.
d. Apply a new bandage.

Answer 47

ANS: C
Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site.

Question 48

The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon?

a. Pull the pipe out in the direction of entry.
b. Push the pipe through to the other side, then out.
c. Leave the pipe in place.
d. None of the above.

Answer 48

ANS: C
If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures.

Question 49

For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond?

a. Culture the wound.
b. Leave the current dressing in place.
c. Apply gauze over the top of the dressing.
d. Remove and stretch the film more tightly over the wound.

Answer 49

ANS: A
Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained.

Question 50

The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed?

a. Apply a film dressing after culturing the wound.
b. Apply a film dressing after cleansing the area.
c. Choose another type of dressing for this wound.
d. Keep the wound open to air.

Answer 50

ANS: C
If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, rather than transparent film dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and family that collection of wound fluid under the dressing is not “pus,” but rather is a result of normal interaction of body fluids with the dressing.

Question 51

In what type of wound is a foam dressing contraindicated?

a. Shallow stage II ulcer
b. Exudative stage II ulcer
c. Wound that has tunneling
d. Wound that is infected

Answer 51

ANS: C
Foam dressings are not appropriate when there is wound tunneling because the dressing expands, which can enlarge the tunnels. International pressure ulcer guidelines recommend foam for use on exudative stage II and shallow stage II pressure ulcers. Foam dressings are also used to dress infected wounds.

Question 52

When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as:

a. an expected occurrence.
b. a wound infection requiring a culture.
c. an adverse reaction to the hydrocolloid components.
d. excessive exudate requiring a different type of dressing.

Answer 52

ANS: A
Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odor. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound.

Question 53

What should the nurse remember to do when applying a hydrocolloid dressing?

a. Apply granules after applying the wafer.
b. Never use a secondary dressing.
c. Hold the dressing in place.
d. Use silk tape to hold the dressing in place.

Answer 53

ANS: C
Hold the dressing in place for 30 to 60 seconds after application. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case of a deep wound, hydrocolloid granules or paste is applied before the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic, paper tape around the edges of the hydrocolloid dressing.

Question 54

Which of the following is an appropriate procedure for the nurse to implement during the application of an absorption or alginate dressing?

a. Never cut the dressing to fit the wound.
b. Irrigate the wound gently to remove residual gel.
c. Fill the wound cavity entirely with the dressing material.
d. Never use a secondary dressing.

Answer 54

ANS: B
Cleanse the area gently with moist 4 × 4 sterile gauze pads, swabbing exudate away from the wound, or spray with a wound cleanser. Cleansing effectively removes any residual dressing gel without injuring newly formed delicate granulation tissue formed in the healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid.

Question 55

The nurse is caring for a patient who had a negative-pressure wound dressing. The nurse realizes that the system is working properly when the vacuum setting is set at which of the following levels?

a. –40 mm Hg
b. –210 mm Hg
c. –125 mm Hg
d. –25 mm Hg

Answer 55

ANS: C
The target negative pressures for wound healing range from –50 mm Hg to –175 mm Hg, but a setting of –125 mm Hg is most common.

Question 56

The nurse is caring for a patient who has a negative-pressure dressing. The nurse realizes that typically the dressing should be changed:

a. every shift.
b. daily.
c. every 8 hours.
d. every 48 hours.

Answer 56

ANS: D
You will typically change an entire NPWT dressing and wound filler every 48 hours or 3 times per week. The schedule for changing NPWT dressings varies and is based on the type and condition of the wound. An infected wound may need a dressing change every 24 hours, whereas a clean wound can be changed 3 times a week.

Question 57

The nurse is preparing to apply a gauze bandage to a dressing on the patient’s wrist. How should the nurse proceed?

a. Use a 3-inch bandage.
b. Use a 2-inch bandage.
c. Apply from the elbow toward the wrist.
d. Secure the bandage with a safety pin.

Answer 57

ANS: B
When applying a gauze or elastic bandage, you select a type of bandage and bandage width depending on the size and shape of the body part to be bandaged. For example, 3-inch bandages are used most commonly for the adult leg. A smaller, 2-inch bandage normally is used for the upper extremity. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage.

Question 58

Which of the following tasks might be delegated to nursing assistive personnel (NAP)?

a. Pressure dressing to an actively bleeding wound
b. Chronic wound that needs a nonsterile moist-to-dry dressing change
c. Hydrogel dressing change
d. Wound assessment during the dressing change

Answer 58

ANS: B
The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see facility policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated.

Question 59

Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.)

a. Maintains a moist environment
b. Prevents the spread of microorganisms
c. Increases patient comfort
d. Controls bleeding

Answer 59

ANS: A, B, C, D
Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding.

Question 60

Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.)

a. Burns
b. Surgical incisions
c. Infected wounds
d. Deep pressure ulcers

Answer 60

ANS: A, C, D
Healing by secondary intention occurs when a wound is left open. Healing results in the formation of granulation tissue from the bottom of the wound and eventual epithelialization from the sides of the wound to close the defect. During the process of epithelialization, epithelial cells migrate and proliferate from the wound edges to cover the wound surface. Burns, infected wounds, and deep pressure ulcers heal in this manner.

Question 61

Hydrocolloid dressings are used for which of the following? (Select all that apply.)

a. Maintaining a moist wound environment
b. Autolytic debriding of necrotic wounds
c. Absorption of moderately draining wounds
d. Protecting from friction

Answer 61

ANS: A, B, C
Hydrocolloid dressings comprise elastometric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction.

Question 62

Negative-pressure wound therapy (NPWT) would be contraindicated in which of the following? (Select all that apply.)

a. Dehisced wounds
b. Pressure ulcers
c. Malignancies
d. Necrotic tissue with eschar

Answer 62

ANS: C, D
NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together. It is commonly used for acute, chronic, traumatic, and dehisced wounds; pressure ulcers; and partial-thickness burns and as a bolster for skin grafts. Contraindications for NPWT for chronic wounds are exposed vital organs, inadequately debrided wounds, untreated osteomyelitis or sepsis near a wound, untreated coagulopathy, necrotic tissue with eschar, and malignancy within a wound.

Question 63

In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.)

a. Remove the binder and assess the skin and wound every 8 hours.
b. Evaluate the patient’s ability to breathe deeply and cough effectively every 4 hours.
c. Evaluate the patient’s pulmonary function every 8 hours.
d. Remove the binder at least daily.

Answer 63

ANS: A, B
Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patient’s ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function.

Question 64

The nurse is demonstrating a dressing change to a nursing student. What key safety features should she emphasize during the process? (Select all that apply.)

a. Knowing the type of wound
b. Knowing the expected amount of drainage
c. Knowing the patient’s blood type
d. Knowing whether drainage tubes are present

Answer 64

ANS: A, B, D
It is important to:
1. Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used.
2. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing.
3. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing.
Knowing the patient’s blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done.

Question 65

A __________ dressing comes in direct contact with the wound bed.

Answer 65

ANS:
primary
A primary dressing comes in direct contact with the wound bed

Question 66

_____________ dressings cover or hold primary dressings in place.

Answer 66

ANS:
Secondary
Secondary dressings cover or hold primary dressings in place.

Question 67

___________ healing takes place when tissue is cleanly cut and the margins are reapproximated.

Answer 67

ANS:
Primary
Primary healing takes place when tissue is cleanly cut and the margins are reapproximated.

Question 68

_______________ dressings are used for wounds that require debridement.

Answer 68

ANS:
Moist-to-dry
Moist-to-dry dressings are used for wounds that require debridement.

Question 69

A _______________ is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters.

Answer 69

ANS:
transparent dressing
A transparent dressing is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing. These dressings manage superficial, minimally draining wounds and often are used for protection over high-friction areas and over IV catheters.

Question 70

_______________ is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.

Answer 70

ANS:
Negative-pressure wound therapy (NPWT)
NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.