Wound Care: Techniques for Preventing Infection and Promoting Healing, Exams of Nursing

Download Wound Care: Techniques for Preventing Infection and Promoting Healing and more Exams Nursing in PDF only on Docsity! NURSING CLINICALS Sterile Wound Care Review Exam Q & A 2024 1. Which of the following is the most common cause of impairment of tissue integrity? a) Infection b) Physical trauma c) Nutritional imbalances d) Altered circulation **b) Physical trauma** Rationale: Physical trauma (e.g., car accidents, sports injuries, cuts, blunt trauma, etc.) is the most common cause of impairment or a break in tissue integrity. Other causes can be related to thermal factors (e.g., burns, frostbites), chemical injury (e.g., adverse reactions to drugs), infection, nutritional imbalances, fluid imbalances, and altered circulation (e.g., pressure injuries). 2. What is the goal of wound hygiene (e.g., cleansing, irrigation, and debridement)? a) To reduce the contaminant burden without causing further tissue damage or introducing more contaminants b) To stimulate the inflammatory response and promote granulation tissue formation c) To remove all necrotic tissue and foreign bodies from the wound bed d) To create a moist environment that facilitates wound healing **a) To reduce the contaminant burden without causing further tissue damage or introducing more contaminants** Rationale: Wound hygiene, including thorough examination of the wound and surrounding tissues, promotes uncomplicated healing of traumatic skin wounds and is required prior to wound closure. Wound healing is impaired by various factors (e.g., bacterial contamination, foreign bodies, wound ischemia, host factors). All traumatic wounds are assumed to be contaminated. The goal of wound hygiene is to reduce the contaminant burden without causing further tissue damage or introducing more contaminants. 8. What is the function of a drain in wound management? a) To collect excess fluid and blood from the wound site b) To reduce pressure and tension on the wound edges c) To prevent infection and promote healing d) All of the above **d) All of the above** Rationale: A drain is a device that is inserted into or near a wound to collect excess fluid and blood from the wound site. This helps reduce pressure and tension on the wound edges, which can cause dehiscence or necrosis. It also prevents infection and promotes healing by removing potential sources of bacterial growth and inflammation. 9. Which of the following is a factor that affects burn wound healing? a) Depth of burn injury b) Location of burn injury c) Extent of burn injury d) All of the above **d) All of the above** Rationale: Burn wound healing is influenced by several factors, such as depth, location, and extent of burn injury. Depth of burn injury determines the degree of tissue damage and the potential for regeneration. Location of burn injury affects the functional and cosmetic outcomes, as well as the risk of complications (e.g., inhalation injury, infection, contractures). Extent of burn injury affects the systemic response and the need for fluid resuscitation and nutritional support. 10. What is the most common method for assessing the extent of burn injury? a) Rule of nines b) Lund and Browder chart c) Total body surface area (TBSA) d) All of the above **d) All of the above** Rationale: The most common method for assessing the extent of burn injury is to estimate the percentage of total body surface area (TBSA) involved. This can be done using various tools, such as the rule of nines, which divides the body into regions that approximate 9% or multiples of 9% of TBSA, or the Lund and Browder chart, which adjusts for age- related variations in body proportions. These methods help guide fluid resuscitation and determine the need for referral to a burn center. 11. What is the first step in emergency burn management? a) Stop the burning process b) Assess airway, breathing, and circulation (ABCs) c) Administer analgesics for pain relief d) Apply cool water or saline to the burn site **a) Stop the burning process** Rationale: The first step in emergency burn management is to stop the burning process by removing any source of heat (e.g., clothing, jewelry, chemicals), extinguishing any flames, and cooling down any hot surfaces. This prevents further tissue damage and reduces pain and inflammation. The next step is to assess airway, breathing, and circulation (ABCs), followed by administering analgesics for pain relief and applying cool water or saline to the burn site. 12. What is the purpose of wound cleaning and dressing in burn management? a) To remove necrotic tissue and debris from the burn site b) To prevent infection and promote healing c) To assess wound depth and monitor healing progress d) All of the above **d) All of the above** Rationale: Wound cleaning and dressing are essential components of burn management. They help remove necrotic tissue and debris from the burn site, which can impair healing and increase infection risk. They also prevent infection and promote healing by creating a moist environment that facilitates epithelialization and granulation tissue formation. They also allow for assessment of wound depth and monitoring of healing progress by observing changes in color, texture, sensation, and exudate. 1. Which of the following is NOT considered a sterile technique for wound care? A. Using sterile gloves B. Cleaning the wound with sterile saline solution C. Covering the wound with a clean, dry bandage D. Applying antibiotic ointment to the wound Answer: C. Covering the wound with a clean, dry bandage Rationale: A clean, dry bandage is not considered a sterile technique as it can introduce microorganisms to the wound. 2. When performing a sterile dressing change, which of the following steps should be performed first? A. Remove the old dressing B. Wash your hands C. Put on sterile gloves D. Cleanse the wound with sterile saline solution Answer: B. Wash your hands Rationale: Proper hand hygiene is essential before performing any sterile procedure to prevent the introduction of pathogens. 3. Which of the following statements is true about sterile wound dressings? A. Sterile dressings should be changed every 24 hours B. It is acceptable to reuse sterile dressings as long as they appear clean C. Sterile dressings should be applied directly to an open wound D. Sterile dressings should be kept sealed in their packaging until ready to use Answer: D. Sterile dressings should be kept sealed in their packaging until ready to use Rationale: Sterile dressings should remain sealed in their packaging until Answer: B. Irrigating the wound with sterile saline solution Rationale: Irrigating the wound with sterile saline solution helps to remove debris and pathogens from the wound without causing trauma to the tissue. 11. Which of the following actions is NOT recommended when performing sterile wound care on a surgical incision? A. Removing the sutures or staples before applying a new dressing B. Checking for signs of infection around the incision site C. Documenting the appearance of the incision and any drainage D. Applying a sterile dressing over the incision site Answer: A. Removing the sutures or staples before applying a new dressing Rationale: Sutures or staples should not be removed without healthcare provider direction to prevent wound dehiscence or infection. 12. Which of the following statements is true regarding the use of sterile gloves during wound care? A. Sterile gloves are only necessary if the wound is visibly contaminated B. Sterile gloves should be worn when handling sterile dressings and supplies C. Non-sterile gloves can be used in place of sterile gloves in a pinch D. Sterile gloves should be reused if they appear clean and undamaged Answer: B. Sterile gloves should be worn when handling sterile dressings and supplies Rationale: Sterile gloves help maintain asepsis during wound care procedures and protect both the patient and healthcare provider from contamination. 13. Which of the following techniques is recommended for preventing the spread of infection during sterile wound care procedures? A. Using hand sanitizer instead of washing hands with soap and water B. Keeping all supplies and equipment uncovered and within reach C. Avoiding touch contamination by using sterile technique D. Reusing dressings and supplies if they appear clean Answer: C. Avoiding touch contamination by using sterile technique Rationale: Using sterile technique helps prevent the introduction of pathogens and reduces the risk of infection during wound care procedures. 14. Which of the following actions is NOT recommended when applying a sterile dressing to a wound? A. Changing the dressing daily to promote wound healing B. Making sure the dressing is secure and does not restrict circulation C. Covering the wound with a dressing that allows for proper ventilation D. Documenting the appearance of the wound and any drainage Answer: A. Changing the dressing daily to promote wound healing Rationale: The frequency of dressing changes should be based on clinical judgement and the healthcare provider's recommendations, not automatically changed daily. 15. Which of the following interventions is appropriate when managing a wound with moderate serosanguinous drainage? A. Applying a dry dressing over the wound B. Changing the dressing only when it becomes visibly soiled C. Adding a layer of antibiotic ointment to the dressing D. Using a non-adherent dressing to protect the wound Answer: D. Using a non-adherent dressing to protect the wound Rationale: Non-adherent dressings help protect the wound from trauma and adhere to the wound bed, reducing the risk of maceration and infection. Question: Which of the following statements best describes the purpose of sterile wound care? a) To prevent infection and promote healing b) To reduce pain and discomfort for the patient c) To expedite the formation of scar tissue d) To minimize the visibility of the wound Answer: a) To prevent infection and promote healing Rationale: The primary goal of sterile wound care is to prevent infection and facilitate the healing process by creating an optimal environment for tissue repair. Question: When performing sterile wound care, which of the following is an essential step to maintain asepsis? a) Wearing gloves only during wound dressing changes b) Cleaning the wound with tap water c) Using sterile gloves and sterile instruments d) Allowing multiple healthcare providers to access the wound Answer: c) Using sterile gloves and sterile instruments Rationale: Maintaining asepsis during wound care necessitates the use of sterile gloves and instruments to minimize the risk of introducing harmful microorganisms to the wound site. Question: Which of the following wounds would require the use of a sterile dressing? a) Superficial abrasion b) Surgical incision c) Minor laceration d) Insect bite Answer: b) Surgical incision Rationale: Surgical incisions are at a higher risk of infection due to their deeper nature, making it crucial to apply sterile dressings to minimize the risk of contamination. Question: What precaution should be taken when irrigating a wound during sterile wound care? a) Using tap water for irrigation b) Applying gentle pressure to the syringe when irrigating c) Allowing the wound to air dry after irrigation d) Using a non-sterile syringe for irrigation Answer: b) Applying gentle pressure to the syringe when irrigating Rationale: Gentle pressure helps to effectively cleanse the wound Question: What should the nurse prioritize when managing a wound with excessive exudate? a) Increasing the frequency of dressing changes b) Using a dressing with high absorbency c) Applying an occlusive dressing d) Allowing the wound to air dry Answer: b) Using a dressing with high absorbency Rationale: Using a dressing with high absorbency helps to effectively manage excessive exudate, maintaining a moist wound environment conducive to healing. Question: Which of the following factors can impair wound healing and should be addressed during wound assessment? a) Presence of granulation tissue b) Adequate blood supply to the wound site c) Inadequate nutrition and hydration d) Absence of pain or discomfort Answer: c) Inadequate nutrition and hydration Rationale: Adequate nutrition and hydration are essential for supporting the body's healing processes, and their absence can impede wound healing. Question: What is the significance of documenting wound assessment findings accurately and consistently? a) To fulfill regulatory requirements only b) To monitor the progression of wound healing c) To satisfy the preferences of healthcare providers d) To avoid liability in case of complications Answer: b) To monitor the progression of wound healing Rationale: Accurate and consistent documentation of wound assessment findings enables healthcare providers to track the healing trajectory of the wound and make informed clinical decisions. Question: When educating a patient about self-care for a healing wound, which instruction is essential to promote optimal outcomes? a) Avoiding inspection of the wound until the next healthcare visit b) Keeping the wound dry at all times c) Practicing proper hand hygiene before and after wound care d) Applying over-the-counter antibiotic ointment liberally to the wound Answer: c) Practicing proper hand hygiene before and after wound care Rationale: Proper hand hygiene reduces the risk of introducing harmful microorganisms to the wound, supporting the healing process and preventing infection. Question: Which of the following statements best describes the role of the nurse in promoting patient safety during sterile wound care? a) Minimizing patient involvement in the wound care process b) Engaging in multitasking to expedite the dressing change c) Communicating effectively with the patient throughout the procedure d) Delegating wound care tasks to unlicensed assistive personnel Answer: c) Communicating effectively with the patient throughout the procedure Rationale: Effective communication with the patient fosters a collaborative approach to wound care, promotes patient understanding, and enhances overall safety and outcomes.