Thirty-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?
Document the findings and continue to monitor the patient
Administer antipyretics, as ordered
Increase the frequency of assessment to every hour and notify the patient's primary care provider
Increase the frequency of wound care and contact the primary care provider for an antibiotic order
A 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?
Serous drainage is composed of the clear portion of the blood and serous membranes
Sanguineous drainage is composed of a large number of red blood cells and looks like blood
Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
Purulent drainage is composed of white blood cells, dead tissue and bacteria
Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
Serosanguineous drainage can be dark yellow or green depending on the causitive organism
A 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: ❌ 2: ❌ 3. ❌
A 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?
Pain
Impaired Skin Integrity
Disturbed Body Image
Disturbed Thought Processes
A patient is admitted with nonhealing surgical wound. Which nursing action is most effective inpreventing a wound infection?
Using sterile dressing supplies
Suggesting dietary supplements
Applying antibiotic ointment
Performing careful hand hygiene
A 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?
Hemostasis occurs immediately after the initial injury
A liquid call exudate is formed during the proliferation phase
White blood cells move to the wound in the inflammatory phase
Granulation tissue forms in the inflammatory phase
During the inflammatory phase, the patient has generalized body response
A scar forms during the proliferation phase
The 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?
Enhanced healing due to the presence of sugars and proteins
Delayed healing due ot dead tissue present in the wound
Decreased effectiveness of antibiotics against the bacteria
Impaired skin integrity due to overhydration of the cells of the wound
Delayed healing due to cells dehydrating and dying
Decreased effectiveness of the patient's normal immune process
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure?
Use standard precautions and transmission based precautions when indicated
Moisten sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution
Clean the wound in full or half circles beginning on the outside and working toward the center
Work outward from the incision in lines that are parallel to it from the dirty area to the clean area
Clean to at least one inch beyond the end of the new dressing if one is being applied
Clean to at least three inches beyond the wound if a new dressing is not being applied
A 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?
The patient takes time to think about her responses to questions
The patient's age of 86 years
Patient reports inability to control urine
A scheduled hip arthroplasty
Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL)
Patient reports increased pain in right hip when repositioning in bed or chair
A 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?
I can expect to have more discomfort in the area when the cold is applied
I should expect more drainage from the incision after the ice has been in place
I should see less swelling and redness with the cold treatment
My incision may bleed more when the ice is first applied
A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient?
The therapy is used to collect excess blood loss and prevent the formation of a scab
The therapy will prevent infection, ensuring that the wound heals with less scar tissue
The therapy provides a moist environment and stimulates blood flow to the wound
The therapy irrigates the wound to keep it free from debris and excess wound fluid
After 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:
Stage I
Stage II
Stage III
Stage IV
The 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?
Irrigate the wound
Provide the gentle cleansing of the wound
Debride the wound
Change the dressing frequently
A 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?
Keeping the head of the bed elevated as often as possible
Massaging over body prominences
Repositioning bed-bound patients every 4 hours
Using a mild cleansing agent when cleansing the skin
A nurse is measuring the depth of patient's puncture wound. Which technique is recommended?
Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down.
Draw the shape of the wound and describe how deep it appears in centimeters
Gently insert a sterile applicator into the wound and move it in a clockwise direction
Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker
A nurse is cleaning the wound of a gun shot victim. Which of the following is a recommended guideline for this procedure?
Clean the wound from the top to the bottom and from the center to the outside
Once the wound is cleaned, dry the area w/an absorbent cloth
Use clean technique to clean the wound
Clean the wound from the bottom to the top, and outside to center
The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing?
A client who is NPO following bowel surgery
An obese woman with a history of type 1 diabetes
A man with a sedentary lifestyle and long history of smoking
A client whose breast reconstruction surgery required numerous incisions
A 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?
Maintain the temperature of water at 100 degrees F
Keep the feet and torso uncovered
Encourage use of sitz bath for about an hours
Assess for rapid pulse and facial pallor
Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing?
Use a sterile applicator to apply any ointment that is ordered
Avoid touching the wound bed, whether with gloves or forceps
Use a new gauze for each wipe of the wound
Clean the wound from top to bottom
Clean from the outside of the wound to the center
A 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?
Help in controlling swelling
Increased blood flow
Resolution of inflammation
Relief of muscle stiffness
Which of the following actions should the nurse perform when applying negative pressure wound therapy?
Test the seal of the completed dressing by briefly attaching it to wall sunctioning
Increase the negative pressure setting until drainage is brisk
Irrigate the wound thoroughly using normal saline and clean technique
Cut foam to the shape of the wound and place it in the wound
A 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?
Wound pouching
Jackson-Pratt drain
Hemovac drain
Penrose drain
What observation should the nurse note about a client's open wound if the wound is healing by the third intention?
Wound edges are widely separated leading to complex reparative process
Wound edges are widely separated and brought together with closure material
Wound edges are directly next to each other
Wound edges are close to each other but require closure material
What type of dressing has the advantage of remaining in place for 3-7 days, resulting in less interference with wound healing?
Hydrogels
Hydrocolloid dressings
Transparent films
Alginates
The 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?
As soon as the infection clears, your surgeon will staple the wound close
If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention
Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal
Your wound will heal slowly as granulation tissue forms and fills the wound
