Best Practices for Wound Care and Management, Exams of General Surgery

Download Best Practices for Wound Care and Management and more Exams General Surgery in PDF only on Docsity! Chapter 22 Which approach is the most appropriate way to cleanse the wound and surrounding area for a sterile dry dressing change? 1. Use a sterile swab to soak up any drainage; then apply a clean dressing. 2. Using an aseptic swab, start on the side of the wound closest to you and apply one stroke per swab. 3. Using an aseptic swab, start from the incision outward, applying one stroke per swab; then allow to air-dry. 4. Using an aseptic swab, start at the top of the incision, using the same swab until dirty; then get a clean swab. - ANS: 3 In classifying wounds, which classification results from the presence of gastrointestinal (GI) products? 1. Dirty 2. Clean 3. Contaminated 4. Clean-contaminated - ANS: 3 If a patient with an abdominal incision and discomfort begins to cough, which intervention is the most appropriate? 1. Roll the patient to the left side. 2. Offer the patient a drink of water. 3. Sit the patient up in a semi-Fowler's position. 4. Apply a pillow to the incision with slight pressure. - ANS: 4 For removing staples from a surgical incision, which intervention is most appropriate? 1. Remove all the staples. If the edges pull apart, apply Steri-Strips. 2. Remove every other staple; then wait several days to remove the rest. 3. Remove the middle staples first; then proceed to the outer edges and apply the dressing. 4. Remove every other staple first and replace with Steri-Strips while ensuring that the incision remains closed. - ANS: 4 What amount of pressure would the nurse administer when placing a vacuum-assist closure (VAC) device to a patient's wound? 1 5 to 200 mm Hg 2 201 to 300 mm Hg 3 301 to 400 mm Hg 4 401 to 500 mm Hg - ANS: 1 The nurse is caring for a patient who has undergone an appendectomy. The nurse observes that the patient has difficulty coughing. Which suggestion given by the nurse would help the patient to cough effectively during this recovery period? 1 "Gargle with warm saline every 2 to 3 hours." 2 Edges closely approximated 2 No edema or tenderness noted 3 Foul odorous purulent drainage 4 Absence of exudate or discharge - ANS: 3 Which method should be used to remove a bandage when the gauze becomes stuck to the wound bed? 1. Allow the patient to remove the gauze. 2. Quickly pull the gauze from the wound. 3. Moisten the gauze with sterile normal saline. 4. Have the patient moisten the gauze in the shower. - ANS: 3 Which dietary tray would be ordered for a patient to provide adequate nutrition that will promote wound healing? 1 Baked potato, peach cobbler, and milk 2 Fried chicken, baked French fries, and chocolate milk 3 Baked fish, legumes, spinach, strawberries, and decaffeinated tea 4 Hot ham and cheese sandwich, baked French fries, peaches, and milk - ANS: 3 A postsurgery patient with an abdominal incision has been complaining of discomfort because of coughing. Which technique should the nurse instruct a patient to use when coughing? 1. Instruct the patient to lay supine, take a deep breath, and cough forcibly. 2. Ask the patient to lean forward, place head to the knees, and cough softly. 3. Tell the patient to place the palms of the hands or a pillow over the incision and cough. 4. Have the patient assume the prone position and use the mattress to cushion the wound. - ANS: 3 A bandage is applied to the left upper arm of a patient. Further assessment upon the patient's arm distal to the bandage reveals that it is cool to touch, the pulse is diminished, and the arm appears slightly blue. Which intervention should the nurse perform immediately? 1. Tighten the bandage. 2. Readjust the bandage immediately. 3. Place the arm in a sling for support. 4. Perform passive range-of-motion exercises. - ANS: 2 Which information is essential to be documented in the chart after a dressing change? Select all that apply. 1 Patient's response 2 Patient's medication 3 Status of the wound 4 Level of consciousness 5 Location of the wound 6 Type of dressing applied - ANS: 1, 3, 5, 6 Which factor would cause a keloid on the patient's skin at the site of injury? 1 Shortening of muscle tissue 2 Overgrowth of collagen 3 Impaired blood flow 4 Reduction in skin capillaries - ANS: 2 Which intervention is essential for the nurse to implement to prevent a problem with skin integrity for an elderly patient who needs dressing changes three times a day? 1. Reinforcing the bandage with paper tape 2. Vigorously scrubbing the skin on the wound 3. Applying bandages extra tightly over the wound 4. Using tape with a heavy adhesive to secure dressing - ANS: 1 After a wound irrigation, which intervention should the nurse do to ensure that a transparent dressing will adhere to the wound? Instruct the patient to lie in Sims position. Correct4 Place a warm, moist sterile dressing over the area. - Which conclusion can the nurse make when assessing a patient's wound with scar tissue that is thin and pale in color? Incorrect1 Possibility of keloid formation 2 Risk of wound separation 3 Overgrowth of collagen Correct4 Complete healing of the wound - Which action will decrease tissue trauma to the skin surrounding a wound? 1 Removing the bandage slowly Correct2 Using the thumb to retract skin away from the tape 3 Applying petroleum jelly on the skin around the wound 4 Soaking the skin with alcohol before removing the bandage - ANS: 2 A nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. Which assessment would be the priority when inspecting the skin that is distal to the bandage? 1 Bacteria 2 Inflammation Incorrect3 Impaired skin integrity Correct4 Circulatory impairment - Five days after surgery, a patient calls the nurse and states that the wound is bleeding. After assessing the wound of the patient, the nurse notes that there is no drainage on the bandage at that time. Which other sign may indicate that the patient's wound is bleeding? 1 Even respirations Correct2 Rapid thready pulse 3 Increased urinary output Incorrect4 Increased blood pressure - Five days after a patient's abdominal operation, the nurse observes an increase in the flow of serosanguineous drainage into the wound dressing. Which immediate risk to the patient will the nurse assess? Correct1 Dehiscence Incorrect2 Hematoma 3 Internal hemorrhage 4 Sloughing - A patient's lab reports indicate reduced bone marrow function and a decreased white blood cell count. Which type of medication does the nurse suspect the patient was most likely taking? 1 Antibiotic 2 Antihistaminic Correct3 Chemotherapy 4 Antiinflammatory - When orders are written to remove sutures in 22 days, which type of sutures does the nurse suspect the patient has been given? Incorrect1 Blanket 2 Separate Correct3 Retention 4