Olivia McRitchie
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NCLEX (Medical-Surgical) Nursing Test sobre Exemplar 21.4: Wound Healing, creado por Olivia McRitchie el 27/03/2018.

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Olivia McRitchie
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Exemplar 21.4: Wound Healing

Pregunta 1 de 12

1

Which of the following patients would be at risk for impaired wound healing?

Selecciona una o más de las siguientes respuestas posibles:

  • A patient diagnosed with hemophilia who underwent a gall bladder removal surgery.

  • An HIV positive patient with a pressure ulcer.

  • An immunocompetent patient whose wound opened and intestines came out following GI surgery.

  • A patient who is on prophylactic heparin following surgery.

Explicación

Pregunta 2 de 12

1

Which of the following patients would NOT be at risk for impaired wound healing?

Selecciona una o más de las siguientes respuestas posibles:

  • A vegan dietitian who engages in regular exercise.

  • An obese client that doesn't drink or smoke.

  • An office worker that smokes 1/2 a pack of cigarettes every day.

  • A patient who is taking risperidone for schizophrenia, but is otherwise physically healthy.

  • A patient taking steroids for systemic lupus erythematosus.

  • A patient on chemotherapy for liver cancer.

Explicación

Pregunta 3 de 12

1

Which of the following describes a patient with serous exudate?

Selecciona una de las siguientes respuestas posibles:

  • Patient has mild inflammation and clear, thin, watery discharge following a burn.

  • Patient has a thick, green discharge following dehiscence of a surgical wound.

  • Patient has bright red discharge in a stage III pressure ulcer.

  • Patient has a clear discharge with hints of blood following a surgery to correct a fracture.

Explicación

Pregunta 4 de 12

1

Which of the following describes a purulent exudate?

Selecciona una o más de las siguientes respuestas posibles:

  • Thick and milky/opaque

  • Thick and tinged with blue, green, or yellow.

  • Thin and milky/opaque

  • Thick and clear or straw colored.

  • Thick, milky, and tinged with some red.

Explicación

Pregunta 5 de 12

1

Which of the following describes a patient with sanguineous exudate?

Selecciona una de las siguientes respuestas posibles:

  • Patient has bright red drainage in a stage III pressure ulcer.

  • Patient has a straw colored draining in a burn.

  • Patient has thick, green-tinged drainage in a stage III pressure ulcer.

  • Patient has a thick, milky, pink-tinged drainage in a new gunshot wound.

Explicación

Pregunta 6 de 12

1

Efforts for wound healing should focus on promoting healing and preventing infection, unless life threatening complications arise.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 7 de 12

1

Rellena los espacios en blanco para completar el texto.

is a procedure in which the wound is flushed with saline solution, topical anesthetic is applied, and the necrotic tissue is grabbed with forceps and cut away with scalpel. It's appropriate for wounds with large amounts of infected or necrotic tissue.

is a procedure in which incisions are made along a damaged area to the release the pressure, and the swelling of the tissue causes the incisions to spread. The spreading incisions expose the underlying tissue and structures. This procedure is appropriate for full-thickness wounds that encircle or nearly encircle a body part and have formed eschar (such as burns).

Explicación

Pregunta 8 de 12

1

Which of the following pharamacologic therapies are NOT appropriate for a normally healing wound?

Selecciona una de las siguientes respuestas posibles:

  • Antibacterial ointment

  • Prophylactic antibiotics

  • Analgesics

  • Growth factors

Explicación

Pregunta 9 de 12

7

Rellena los espacios en blanco para completar el texto.

In wounds that are healing correctly, prevention measures; bandages or hosiery; and diets high in protein, carbs, and vitamins may promote healing.

All of the following are procedures used for wounds that are not healing correctly:

is a process in which negative pressure is used to remove excess fluid from the wound, thus improving oxygenation and blood flow to the area and promoting formation of granulation tissue. Similarly, therapy improves oxygenation in nonhealing wounds.

may be an appropriate regenerative cellular therapy This type of therapy introduces rapidly regenerating cells into the wound to promote healing.

may also be appropriate in some cases. In these procedures, either the client's own skin or a donor's skin is placed into the wound to promote healing.

is a procedure in which maggots are placed on the wound to digest damage tissue. This may be used in nonhealing wounds with necrotic tissue or slough.

Explicación

Pregunta 10 de 12

1

You are a nurse in the ER. The patient you are assessing has just gotten into a car crash. You were informed by the paramedic that the most extensive damage is on her skull, her torso, and her arms. Which of the following statements made by the nurse shows that he/she knows how to properly assess the new wounds on this patient?

Selecciona una o más de las siguientes respuestas posibles:

  • "I will measure the length, width, and depth of the laceration on her cheek."

  • "I will assess the amount of blood coming from her wounds."

  • "I will inspect her wounds for broken glass, shards of metal, and shreds of clothing."

  • "I will inspect her for bone fractures, chest and brain hemorrhaging, and spinal cord injuries,.

  • "I will check her immunization record for her last tetanus shot."

  • "I will take photographs of the damage for the purpose of future assessment."

  • "I will assess the amount of drainage coming from the wound."

  • "I will check for undermining of the wound."

Explicación

Pregunta 11 de 12

1

Your patient who experienced damage on her skull, torso, and arms from a car crash has pulled through and is in in the intensive care unit. You are still caring for her. Which of the following statements made by you, the nurse, shows that you know how to assess her newly sutured wounds?

Selecciona una o más de las siguientes respuestas posibles:

  • "I will assess the her wounds' appearance and size."

  • "I will estimate the amount of wound drainage by assessing the degree to which the wound dressing is saturated."

  • "I will assess the presence of swelling and drainage."

  • "I will check the status of the drains and tubes."

  • "I will document the description of the drainage."

  • "I will document the amount of dressing I used, as well as the type of dressing I used."

  • "I will inspect the wound for bleeding."

  • "I will administer a tetanus shot."

Explicación

Pregunta 12 de 12

1

Which of the following interventions are appropriate for a client with a healing wound?

Selecciona una o más de las siguientes respuestas posibles:

  • Dressing the wound with dry dressings.

  • Have the client take in at least 2,500 mL of fluid per day,

  • Ensuring that the client receives sufficient proteins; vitamins C, A, B, and B5; and zinc.

  • Consulting with a registered dietitian.

  • Positioning the client to keep pressure off the wound.

  • Keep the client immobile,

Explicación

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