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Providing Wound Care and Treating Pressure Ulcers

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Fundamentals Test sobre Providing Wound Care and Treating Pressure Ulcers , creado por Amanda Burton el 04/10/2017.
Amanda Burton
Test por Amanda Burton, actualizado hace más de 1 año
Amanda Burton
Creado por Amanda Burton hace más de 6 años
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Resumen del Recurso

Pregunta 1

Pregunta
Your patient has had abdominal surgery for a ruptured appendix and requires postoperative care and dressing changes. The wound has been left open, and irrigation's are ordered. When irrigating a wound, it is most important to:
Respuesta
  • irrigate slowly to prevent discomfort
  • ensure the solution reaches the depths of the wound
  • prevent wetting of the bed and covers
  • use vigorous irrigation flow from the syringe

Pregunta 2

Pregunta
If a wound appears infected, you should:
Respuesta
  • cleanse it with an antiseptic solution
  • obtain an order for culture to be performed
  • apply an antibiotic ointment
  • change the dressing every 2 hours

Pregunta 3

Pregunta
The assessment of the wound indicates healing is occurring when:
Respuesta
  • the center tissue is white
  • bleeding has stopped
  • there is no further drainage from the wound
  • pink granulation tissue is visible

Pregunta 4

Pregunta
When assessing for wound infection, you know that signs of wound infection may be:
Respuesta
  • a rise in temperature
  • increasingly rapid respirations
  • a WBC above 10,000/dl
  • restlessness and discomfort
  • purulent drainage
  • tenderness around the wound

Pregunta 5

Pregunta
When caring for a pressure ulcer, you know that:
Respuesta
  • eschar must usually be removed before the wound will heal
  • pink granulation tissue should be cleansed with antiseptic solution
  • keeping the wound dry and covered will aid healing
  • heat treatments hurt new tissue and slow healing

Pregunta 6

Pregunta
Hydrocolloid dressing are useful for open wound dressings because they:
Respuesta
  • keep the wound moist while blocking entry of microorganisms
  • debride the wound and soften eschar
  • supply bacteriostatic action to clean the wound
  • contain an antiseptic, allow moisture to evaporate, and protect the wound.

Pregunta 7

Pregunta
If you are assisting a surgical patient to the bathroom and he suddenly says, "It feels like something has given way," you would suspect that [blank_start]dehisence[blank_end] has occurred.
Respuesta
  • dehisence

Pregunta 8

Pregunta
Proper technique for removal of sutures is to:
Respuesta
  • clip the suture below the knot
  • assure the patient that suture removal does not hurt
  • refrain from pulling an exposed suture through the wound
  • apply a Steri-strip before removing the suture

Pregunta 9

Pregunta
Heat is helpful in healing a wound because it:
Respuesta
  • causes constriction of blood vessels and reduces edema
  • soothes nerve endings, lessening pain
  • causes vasodilation, bringing oxygen and nutrients to the injury
  • causes vasodilation, which moves blood out of the area

Pregunta 10

Pregunta
The ulcer appears as a defined area of persistent redness in lightly pigment skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
Image:
Stage I Pressure Ulcer Buttocks High (binary/octet-stream)
Respuesta
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
  • Eschar

Pregunta 11

Pregunta
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
Image:
Stage 2 Pressure Ulcer (binary/octet-stream)
Respuesta
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
  • Eschar

Pregunta 12

Pregunta
Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Image:
Stage 3 Pressure Ulcer (binary/octet-stream)
Respuesta
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
  • Eschar

Pregunta 13

Pregunta
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be present.
Image:
Stage 4 Pressure Ulcer (binary/octet-stream)
Respuesta
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
  • Eschar

Pregunta 14

Pregunta
An unstageable wound, that is thick dry black necrotic tissue.
Image:
Eschar (binary/octet-stream)
Respuesta
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
  • Eschar

Pregunta 15

Pregunta
These wounds heal more quickly, as new skin cells are produced by the epithelial cells remaining in the dermal layer of the skin. Ex: 1st or 2nd degree burns
Respuesta
  • Partial-thickness
  • Full-thickness
  • Contusion
  • Hematoma

Pregunta 16

Pregunta
These wounds occur when the dermal layer is no longer present except at the wound margins all the way to tendons or bones.
Respuesta
  • Partial-thickness
  • Full-thickness
  • Contusion
  • Hematoma

Pregunta 17

Pregunta
A closed wound that tissue injury without breaking of skin.
Respuesta
  • Contusion (bruise)
  • Hematoma
  • Sprain
  • Incision

Pregunta 18

Pregunta
A closed wound that tissue injury that damages a blood vessel; pooling of blood under the unbroken skin.
Respuesta
  • Contusion (bruise)
  • Hematoma
  • Sprain
  • Incision

Pregunta 19

Pregunta
A closed wound that wrenching or twisting of a joint with partial rupture of its ligaments; causes swelling
Respuesta
  • Contusion (bruises)
  • Hematoma
  • Sprain
  • Incision

Pregunta 20

Pregunta
An open wound that is a surgically made separation of tissues with clean, smooth edges.
Respuesta
  • Incision
  • Laceration
  • Puncture
  • Abrasion

Pregunta 21

Pregunta
an open wound that is from traumatic separation of tissues with irregular, torn edges.
Respuesta
  • Incision
  • Laceration
  • Abrasion
  • Puncture

Pregunta 22

Pregunta
An open wound that is from a traumatic scraping away of surface layers of skin.
Respuesta
  • Incision
  • Laceration
  • Abrasion
  • Puncture
  • Penetrating

Pregunta 23

Pregunta
An open wound that is a variable size through the skin and underlying tissues made by a bullet or metal or wood fragment; may extend deeply into the body.
Respuesta
  • Incision
  • Laceration
  • Abrasion
  • Puncture
  • Penetrating

Pregunta 24

Pregunta
An open wound made by a sharp, pointed object through the skin or mucous membranes and underlying tissue.
Respuesta
  • Incision
  • Laceration
  • Abrasion
  • Puncture
  • Penetrating

Pregunta 25

Pregunta
An open wound that is tearing away of a structure or a part, such as a fingertip, accidentally or surgically.
Respuesta
  • Puncture
  • Penetrating
  • Avulsion
  • Ulceration
  • Perforation

Pregunta 26

Pregunta
An open wound that is an excavation of skin and underlying tissue injury or necrosis.
Respuesta
  • Penetrating
  • Avulsion
  • Ulceration
  • Perforation
  • Crush

Pregunta 27

Pregunta
An open wound is an internal organ or body cavity tissue opened, usually because of infection or a penetrating wound.
Respuesta
  • Penetrating
  • Avulsion
  • Ulceration
  • Perforation
  • Crush

Pregunta 28

Pregunta
An open wound that is a tissue significantly disrupted or compressed because of high level of force being applied.
Respuesta
  • Avulsion
  • Ulceration
  • Perforation
  • Crush

Pregunta 29

Pregunta
This occurs in the form of fibrous connective tissue that does not have the same functional characteristics as the tissue lost when the wound occurred.
Respuesta
  • Replacement
  • Regeneration
  • Inflammation
  • Necrosis

Pregunta 30

Pregunta
If the blood supply has been disrupted to the new wound bed and necrosis has occurred, the affected tissue must heal by [blank_start]regeneration[blank_end].
Respuesta
  • regeneration
  • replacement
  • inflammation
  • debridement

Pregunta 31

Pregunta
Which of these affected tissues will regenerate if lost.
Respuesta
  • Skin
  • Heart muscle
  • nerve cells
  • mucous membranes
  • bone marrow
  • bone
  • liver
  • kidney
  • lung tissue
  • ear drum

Pregunta 32

Pregunta
No matter what cause of the wound, healing occurs in [blank_start]3[blank_end] distinct phases.
Respuesta
  • 3
  • 2
  • 4
  • 5

Pregunta 33

Pregunta
A phase of the wound healing process begins immediately after injury and lasts about 3 or 4 days. It includes constriction of blood vessels, platelet aggregation, and the formation of fibrin.
Respuesta
  • Inflammatory phase
  • Proliferation or reconstruction phase
  • Maturation or remodeling phase

Pregunta 34

Pregunta
The inflammatory phase is the process of
Respuesta
  • hemostasis
  • homeostasis
  • hemorrhage

Pregunta 35

Pregunta
Full thickness wounds heal how
Respuesta
  • from bottom-up
  • from top to bottom
  • over 24 hours
  • by drying out the bed

Pregunta 36

Pregunta
The collection of plasma and electrolytes leaking into the interstitial spaces causes [blank_start]edema[blank_end].
Respuesta
  • edema
  • collagen
  • necrosis
  • inflammation

Pregunta 37

Pregunta
The phagocytic cells remove debris and protect against bacterial invasion by engulfing of microorganisms or foreign particles called [blank_start]phagocytosis[blank_end].
Respuesta
  • phagocytosis

Pregunta 38

Pregunta
The clinical signs of inflammatory process are as follows:
Respuesta
  • Swelling or edema
  • Erythema
  • Cyanosis
  • increased temperature
  • pain steming from pressure
  • numbness
  • loss of function

Pregunta 39

Pregunta
This phase of wound healing begins on the third or fourth day after injury and lasts 2 to 3 weeks while macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen.
Respuesta
  • Inflammatory phase
  • Proliferation or reconstruction phase
  • Maturation or remodeling phase

Pregunta 40

Pregunta
This phase of wound healing begins about 3 weeks after injury, scar formation, is the process of collagen lysis and collagen synthesis by the macrophages to produce the strongest scar tissue possible.
Respuesta
  • Inflammatory phase
  • Proliferation or reconstruction phase
  • Maturation or remodeling phase

Pregunta 41

Pregunta
If collagen overgrowth occurs, which is frequent in dark-pigmented skin, a permanent raised, enlarged scar called this occurs
Image:
Keloids (binary/octet-stream)
Respuesta
  • Keloids
  • Adhesions
  • First intention
  • Second intention

Pregunta 42

Pregunta
The interior of the body, has fibrous bands that hold together tissues that are normally separated and may grow and interfere with function of the internal organs. What are these fibrous bands called
Respuesta
  • adhesions
  • lesions
  • abrasions
  • keloids

Pregunta 43

Pregunta
A wound with little tissue loss, such as a surgical incision and the edges of the wound approximate and there is only a slight chance of infection, heals by
Respuesta
  • First intention
  • Second intention
  • Third intention

Pregunta 44

Pregunta
A wound with tissue loss, such as a decubitus ulcer or severe laceration typically heals by
Respuesta
  • First intention
  • Second intention
  • Third intention

Pregunta 45

Pregunta
This type of healing is known as delayed or secondary closure, occurs when there is delayed suturing of a wound. Such wounds are sutured after granulation tissue has began to form.
Respuesta
  • first intention
  • second intention
  • third intention

Pregunta 46

Pregunta
If internal hemorrhage is extensive, hypovolemic shock occurs resulting in:
Respuesta
  • decreased blood pressure
  • increased blood pressure
  • increased respiration's
  • rapid thready pulse
  • bradycardia
  • restlessness
  • diaphoresis
  • cold clammy skin
  • elevated temperature

Pregunta 47

Pregunta
A localized infection called an [blank_start]abscess[blank_end] is an accumulation of pus made up of debris from phagocytosis when microorganisms have been present.
Respuesta
  • abscess
  • hematoma
  • cellulitis
  • fistula

Pregunta 48

Pregunta
This is an inflammation of the tissue surrounding the initial wound, with redness and induration.
Image:
Cellulitis (binary/octet-stream)
Respuesta
  • Cellulitis
  • Fistula
  • Exudate
  • Abscess

Pregunta 49

Pregunta
This is a abnormal passage or communication usually formed between two internal organs or leading from an internal organ to the surface of the body.
Respuesta
  • Cellulitis
  • Fistula
  • Exudate
  • Abscess

Pregunta 50

Pregunta
The best way to prevent wound infection is to maintain strict asepsis when performing wound care.
Respuesta
  • True
  • False

Pregunta 51

Pregunta
[blank_start]Dehiscense[blank_end] is the spontaneous opening of an incision, an abdominal wound often involves separation of the layers beneath the skin as well.
Image:
Dehiscense (binary/octet-stream)
Respuesta
  • Dehiscense
  • Evisceration
  • Sinus
  • Laceration

Pregunta 52

Pregunta
This is the protrusion of an internal organ through the incision.
Image:
Evisceration (binary/octet-stream)
Respuesta
  • Dehiscense
  • Evisceration
  • Fistula
  • Laceration

Pregunta 53

Pregunta
The greatest risk for wound dehiscence is on how many postoperative days, before extensive collagen build up.
Respuesta
  • 4-5
  • 2-3
  • 5-6
  • 10-15

Pregunta 54

Pregunta
If dehiscence occurs which steps should be taken
Respuesta
  • lay the patient in supine
  • lay the patient in semi-fowlers
  • place a large sterile dressing
  • push the contents back in
  • towels soaked in normal saline
  • make patients NPO immediately

Pregunta 55

Pregunta
There are three basic wound types: red, yellow and black. the type of wound indicates the type of dressing needed. This wound is clean and ready to heal.
Respuesta
  • Red wound
  • Yellow wound
  • Black wound

Pregunta 56

Pregunta
There are three basic wound types: red, yellow and black. the type of wound indicates the type of dressing needed. This wound has a layer of fibrous debris or exudate. Sloughing may cause drainage and needs to be frequently cleansed and should have a dressing that will absorb the drainage and debride the surface mechanically. These wounds often become infected.
Respuesta
  • Red wounds
  • Yellow wounds
  • Black wounds

Pregunta 57

Pregunta
There are three basic wound types: red, yellow and black. the type of wound indicates the type of dressing needed. These wounds need debridement of the eschar to heal.
Respuesta
  • Red wounds
  • Yellow wounds
  • Black wounds

Pregunta 58

Pregunta
This type of drain is a flat rubber tube, often a safety pin is placed external end of the drain to prevent it from slipping into the wound.
Image:
Penrose (binary/octet-stream)
Respuesta
  • Penrose
  • Hemovac
  • Jackson Pratt or Jp

Pregunta 59

Pregunta
A plastic drainage tubes can be connected to a drainage system that is compressed and closed to create suction, this device contains springs and can hold up to 500 mL of drainage.
Image:
Hemovac (binary/octet-stream)
Respuesta
  • Penrose
  • Hemovac
  • Jackson Pratt or JP

Pregunta 60

Pregunta
A plastic drainage tube can be connected to a drainage system that is compressed and closed, applying slight suction to the drainage tube to help evacuate wound fluids. You must compress the bulb of this device and it holds about 100 mL of drainage.
Image:
Jp Drain (binary/octet-stream)
Respuesta
  • Penrose
  • Hemovac
  • Jackson Pratt or JP

Pregunta 61

Pregunta
A transparent film dressing, such as [blank_start]Opsite[blank_end], allows you assess the wound without removing the dressing, these are often used to cover intravenous catheter sites.
Respuesta
  • Opsite

Pregunta 62

Pregunta
When taping a dressing to your patient you should tape the dressing [blank_start]across the joint or crease[blank_end] to get correct a adhesion.
Respuesta
  • across the joint or crease
  • up and down along the edges of bandage

Pregunta 63

Pregunta
Wound cleansing should be performed by [blank_start]warm[blank_end] isotonic saline.
Respuesta
  • warm
  • cool

Pregunta 64

Pregunta
Surgical wounds and open wounds dressing require [blank_start]sterile[blank_end] technique.
Respuesta
  • sterile
  • nonsterile

Pregunta 65

Pregunta
If the wound is infected, the dressing may be changed how often?
Respuesta
  • 12-24 hours
  • 8-12 hours
  • 48-72 hours
  • 3 times a week

Pregunta 66

Pregunta
Sometimes a wet to dry dressing may also be applied to help he sloughing of necrotic tissue by what
Respuesta
  • Mechanical debridement
  • Chemical debridement
  • Sharp debridement
  • Autolytic debridement

Pregunta 67

Pregunta
You do not have to have a physicians order to remove sutures or staples.
Respuesta
  • True
  • False

Pregunta 68

Pregunta
Some therapeutic effect of heat application could be
Respuesta
  • Vasodilation
  • Vasoconstriction
  • Reduced blood viscosity
  • Reduced muscle tension
  • Increased blood viscosity
  • Increased tissue metabolism
  • Increased capillary permeability
  • Decreased muscle tension

Pregunta 69

Pregunta
Some therapeutic effects of cold application.
Respuesta
  • Vasoconstriction
  • Vasodilation
  • Local anesthesia
  • Reduced cellular metabolism
  • Increased blood viscosity
  • Reduced blood viscosity
  • Decreased muscle tension
  • Reduced muscle tension

Pregunta 70

Pregunta
Cold therapy is applied for a maximum of how long each time
Respuesta
  • 5 minutes
  • 10 minutes
  • 20 minutes
  • 30 minutes
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