Test
Chapter 31: Skin Integrity and Wound Care
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Preguntas del test (25)
1Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?
- ADocument the findings and continue to monitor the patient
- BAdminister antipyretics, as ordered
- CIncrease the frequency of assessment to every hour and notify the patient's primary care provider
- DIncrease the frequency of wound care and contact the primary care provider for an antibiotic order
2A nurse caring for patients in PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage?
- ASerous drainage is composed of the clear portion of the blood and serous membranes
- BSanguineous drainage is composed of a large number of red blood cells and looks like blood
- CBright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
- DPurulent drainage is composed of white blood cells, dead tissue and bacteria
- EPurulent drainage is thin, cloudy, and watery and may have a musty or foul odor
- FSerosanguineous drainage can be dark yellow or green depending on the causitive organism
3A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions?
1: [blank_start]Notify the physician of the situation[blank_end]
2: [blank_start]Cover exposed tissue w/sterile towels[blank_end]
3. [blank_start]Place patient in low Fowler's position[blank_end]- ANotify the physician of the situation
- BCover exposed tissue w/sterile towels
- CPlace patient in low Fowler's position
4A patient age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now". Based on this statement, what nursing diagnosis would be most appropriate?
- APain
- BImpaired Skin Integrity
- CDisturbed Body Image
- DDisturbed Thought Processes
5A patient is admitted with nonhealing surgical wound. Which nursing action is most effective inpreventing a wound infection?
- AUsing sterile dressing supplies
- BSuggesting dietary supplements
- CApplying antibiotic ointment
- DPerforming careful hand hygiene
6A nurse who is changing dressing of postoperative patient in the hospital documents various phases of wound healing on the patient charts. Which statement accurately describe these stages?
- AHemostasis occurs immediately after the initial injury
- BA liquid call exudate is formed during the proliferation phase
- CWhite blood cells move to the wound in the inflammatory phase
- DGranulation tissue forms in the inflammatory phase
- EDuring the inflammatory phase, the patient has generalized body response
- FA scar forms during the proliferation phase
7The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound?
- AEnhanced healing due to the presence of sugars and proteins
- BDelayed healing due ot dead tissue present in the wound
- CDecreased effectiveness of antibiotics against the bacteria
- DImpaired skin integrity due to overhydration of the cells of the wound
- EDelayed healing due to cells dehydrating and dying
- FDecreased effectiveness of the patient's normal immune process
8The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure?
- AUse standard precautions and transmission based precautions when indicated
- BMoisten sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution
- CClean the wound in full or half circles beginning on the outside and working toward the center
- DWork outward from the incision in lines that are parallel to it from the dirty area to the clean area
- EClean to at least one inch beyond the end of the new dressing if one is being applied
- FClean to at least three inches beyond the wound if a new dressing is not being applied
9A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (his replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient?
- AThe patient takes time to think about her responses to questions
- BThe patient's age of 86 years
- CPatient reports inability to control urine
- DA scheduled hip arthroplasty
- ELab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL)
- FPatient reports increased pain in right hip when repositioning in bed or chair
10A nurse is explaining to a patient the anticipated effect of the application of cold to an injured are. What response indicates that the patient understand the explanation?
- AI can expect to have more discomfort in the area when the cold is applied
- BI should expect more drainage from the incision after the ice has been in place
- CI should see less swelling and redness with the cold treatment
- DMy incision may bleed more when the ice is first applied
11A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient?
- AThe therapy is used to collect excess blood loss and prevent the formation of a scab
- BThe therapy will prevent infection, ensuring that the wound heals with less scar tissue
- CThe therapy provides a moist environment and stimulates blood flow to the wound
- DThe therapy irrigates the wound to keep it free from debris and excess wound fluid
12After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as:
- AStage I
- BStage II
- CStage III
- DStage IV
13The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red". What would be the priority nursing intervention for this type of wound?
- AIrrigate the wound
- BProvide the gentle cleansing of the wound
- CDebride the wound
- DChange the dressing frequently
14A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long-term facility. Which action would be a priority in preventing a patient from developing a pressure ulcer?
- AKeeping the head of the bed elevated as often as possible
- BMassaging over body prominences
- CRepositioning bed-bound patients every 4 hours
- DUsing a mild cleansing agent when cleansing the skin
15A nurse is measuring the depth of patient's puncture wound. Which technique is recommended?
- AMoisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down.
- BDraw the shape of the wound and describe how deep it appears in centimeters
- CGently insert a sterile applicator into the wound and move it in a clockwise direction
- DInsert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker
16A nurse is cleaning the wound of a gun shot victim. Which of the following is a recommended guideline for this procedure?
- AClean the wound from the top to the bottom and from the center to the outside
- BOnce the wound is cleaned, dry the area w/an absorbent cloth
- CUse clean technique to clean the wound
- DClean the wound from the bottom to the top, and outside to center
17The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing?
- AA client who is NPO following bowel surgery
- BAn obese woman with a history of type 1 diabetes
- CA man with a sedentary lifestyle and long history of smoking
- DA client whose breast reconstruction surgery required numerous incisions
18A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do?
- AMaintain the temperature of water at 100 degrees F
- BKeep the feet and torso uncovered
- CEncourage use of sitz bath for about an hours
- DAssess for rapid pulse and facial pallor
19Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing?
- AUse a sterile applicator to apply any ointment that is ordered
- BAvoid touching the wound bed, whether with gloves or forceps
- CUse a new gauze for each wipe of the wound
- DClean the wound from top to bottom
- EClean from the outside of the wound to the center
20A home care nurse is visiting a client as part of a regular visit. The client's daughter falls and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress based on the understanding that cold achieves which effect?
- AHelp in controlling swelling
- BIncreased blood flow
- CResolution of inflammation
- DRelief of muscle stiffness
21Which of the following actions should the nurse perform when applying negative pressure wound therapy?
- ATest the seal of the completed dressing by briefly attaching it to wall sunctioning
- BIncrease the negative pressure setting until drainage is brisk
- CIrrigate the wound thoroughly using normal saline and clean technique
- DCut foam to the shape of the wound and place it in the wound
22A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?
- AWound pouching
- BJackson-Pratt drain
- CHemovac drain
- DPenrose drain
23What observation should the nurse note about a client's open wound if the wound is healing by the third intention?
- AWound edges are widely separated leading to complex reparative process
- BWound edges are widely separated and brought together with closure material
- CWound edges are directly next to each other
- DWound edges are close to each other but require closure material
24What type of dressing has the advantage of remaining in place for 3-7 days, resulting in less interference with wound healing?
- AHydrogels
- BHydrocolloid dressings
- CTransparent films
- DAlginates
25The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?
- AAs soon as the infection clears, your surgeon will staple the wound close
- BIf less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention
- CYour surgeon may not have been skilled enough to close such a large wound, but it will eventually heal
- DYour wound will heal slowly as granulation tissue forms and fills the wound
Información
- Descripción
- Unit VII: Promoting Healthy Physiologic Responses Chapter 31: Skin Integrity and Wound Care
- Autor
- Alexandra Bozan
- Idioma
- English
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- 1.816
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