ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers, Exams of Nursing

Download ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers and more Exams Nursing in PDF only on Docsity! ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers A wound - correct answer Is a result of injury to the skin A pressure ulcer is caused by - correct answer Unrelieved pressure that results in ischemia and damage to the underlying tissue Suspected deep tissue injury - correct answer Discolored but intact skin caused by damage to underlying tissue Stage I Pressure Ulcer - correct answer Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, which may feel warm or cool to touch. The tissue is swollen and congested, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Stage II Pressure Ulcer - correct answer Partial- thickness skin loss involving the epidermis and the dermis. The ulcer ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers is visible and superficial and may appear as an abrasion, blister, or shallow cavity. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage III Pressure Ulcer - correct answer Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may reach, but not extend thorough the fascia below. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common Stage IV Pressure Ulcer - correct answer Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers Drainage and infection are common - correct answer Stage III Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures - correct answer Stage IV be sinus tracts, deep pockets of infection, tunneling, undermining, eschar, or slough. - correct answer Stage IV Eschar - correct answer Black scab-like material Slough - correct answer Tan, yellow, or green scab like material. The Stages of Wound Healing - correct answer 1. Inflammatory stage 2. Proliferative stage 3. The maturation or remodeling stage. ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers The inflammatory stage - correct answer occurs in the first 3 days after the initial trauma Control bleeding with clot formation - correct answer The inflammatory stage Deliver oxygen, WBC, and nutrients to the area via the blood supply - correct answer The inflammatory stage The proliferative stage - correct answer lasts the next 3 to 24 days Replacing lost tissue with connective or granulated tissue - correct answer The proliferative stage Contraction of the wound's edges - correct answer The proliferative stage Resurfacing of new epithelial cells - correct answer The proliferative stage ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers Maturation or remodeling stage i - correct answer strengthening of the collagen scar and the restoration of a more normal appearance. It can take more than 1 year to complete, depending on the extent of the original wound. Primary intention - correct answer Little or no tissue loss Edges are approximated, as with a surgical incision • Heals rapidly • Low risk of infection • Minimal or no scarring Secondary intention - correct answer • Loss of tissue • Wound edges widely separated, as with pressure ulcers and stab wounds • Increased risk of infection • Scarring ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers Spontaneous opening of a previously closed wound - correct answer Tertiary intention Risk of infection - correct answer Tertiary intention Extensive drainage and tissue debris - correct answer Tertiary intention Closes later - correct answer Tertiary intention Long healing time - correct answer Tertiary intention Serous drainage - correct answer is the portion of the blood (serum) that is watery and clear or slightly yellow in appearance. Sanguineous drainage - correct answer contains serum and red blood cells. It is thick and appears reddish ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers Serosanguineous drainage - correct answer contains both serum and blood. It is watery and appears blood streaked or blood tinged. Purulent drainage - correct answer is the result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color reflects the type of organism present (green may indicate a pseudomonas infection). lack of protein puts the client at greater risk for - correct answer delayed wound healing and infection Woven gauze (sponges) - correct answer Absorb exudate from the wound Nonadherent material - correct answer Does not adhere to the wound bed ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers Self-adhesive, transparent film - correct answer A temporary "second skin" ideal for small, superficial wounds Hydrocolloid - correct answer An occlusive dressing that swells in the presence of exudate Used to maintain a granulating wound bed - correct answer Hydrocolloid May be left in place up to 5 days - correct answer Hydrocolloid May be used on infected, deep wounds - correct answer Hydrogel (Aquasorb) Provides a moist wound bed - correct answer Hydrogel (Aquasorb) Dehiscence - correct answer is a partial or total rupture (separation) of a sutured wound ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers • Provide nutritional supplements as prescribed. • Administer analgesics as prescribed. • Administer antimicrobials (topical and/or systemic) as prescribed. Unstageable - correct answer • Eschar should cover wound as protective barrier. • Provide nutritional supplements as prescribed. • Administer analgesics as prescribed. • Administer antimicrobials (topical and/or systemic) as prescribed. 1. An adolescent client who has diabetes mellitus is recovering from an appendectomy. This is the third postoperative day. The client has been prescribed a regular diet and is tolerating it well. He has ambulated successfully around the unit with the help of his parents and is requesting pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after medication is given. ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers His incision is approximated and free of redness with scant serous drainage noted on the dressing. What type of healing process should the nurse expect this wound to be undergoing? Explain. - correct answer This wound is healing by primary intentions because it is a surgical incision. 2. Which of the following diagnostic tests is relevant for assessing the risk of developing a pressure ulcer for an older adult client who has no major health issues? A. Serum albumin B. WBCs C. RBCs D. Serum potassium - correct answer Serum albumin would provide information regarding the adequacy of protein intake. Inadequate protein poses a great risk for altered skin integrity and ineffective healing. The other options are not indicative of this finding. 3. Which of the following findings may negatively impact wound healing? (Select all that apply.) ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers 1. Type 2 diabetes mellitus 2. Strict vegetarian 3. Cigarette smoker 4. Long-term use of glucocorticosteroids 5. Family history of pressure ulcers - correct answer 1,2,3,4. Diabetes mellitus negatively impacts the immune response. A strict vegetarian may not have adequate protein intake, which would negatively impact wound healing, as would smoking (because it impairs oxygenation) and the use of glucocorticosteroids (because they depress the immune response). A family history is not indicative of developing pressure ulcers. 4. Which of the following term describes wound drainage that is thick and yellow? A. Serous ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers 8. What placed this client at risk for a wound dehiscence/evisceration? - correct answer Age Obesity Abdominal surgery 6 days ago Recent vomiting An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.) A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care - correct answer B, C ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - correct answer A, B, C A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.) A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - correct answer A, E ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management Questions And Answers A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with his hips and knees bent. E. Offer the client a warm beverage, such as herbal tea. - correct answer A, D A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing.