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167 terms

Health Assessment II Week 2

Module 2
STUDY
PLAY
You are preparing a sterile field. You open the sterile commercial kit by pulling the outermost flap toward your body, followed by opening the remaining flaps. You touch only the outer edge of the sterile field with your hands. You add sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. You pour normal saline from a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did you perform incorrectly?
Open the outermost flap and pouring out a sterile solution
The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following techniques are incorrect and should not be included in the review?
Place the drape so the top half is over the top half of the work surface
The nurse if preparing a sterile field. Which of the following would be considered contamination of the field?
Some of the sterile normal saline spills onto the sterile barrier; Non-sterile items are added to the sterile field; The nurse prepares the sterile field and leaves the room to get more sterile supplies
The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time?
The nurse asks the patient if he has ambulated in the hall today
One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is a cause for concern?
Temp 102.5 F
The nurse is applying sterile gloves. Which series of steps would require correction?
Hold the gloved hands at sides of body, below waist level, until beginning the sterile procedure
Which of the following is a correct description of glove removal?
You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle.
Which of the following are symptoms of latex allergy?
Skin redness, Itching, Edema, Difficulty breathing
An elderly patient is admitted for back surgery. She states that she has an allergy to latex. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy?
History of multiple surgeries as a child and occupation
The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction?
Once sterile gloves are applied, the inside of the glove is still considered sterile
The patient reports an allergy to latex. What alterations should be made in the patient's care?
Use latex-free or synthetic gloves when gloves are necessary; avoid items that contain latex in the care of the patient
You have prepared a sterile field and have added the necessary sterile items to the field. You have applied sterile gloves and are waiting to assist the physician in performing a surgical procedure. You keep the sterile field in view and hold your hands down at your sides, away from your clothing. While waiting, you instruct the patient to avoid touching the sterile field and for the need to lie still. Which action made by you is incorrect?
Holding your gloved hands at your sides
You (a student nurse) have opened a sterile drape and added a sterile receptacle to the field. You apply sterile gloves. You next add sterile solution to the receptacle. As you replace the cap on the bottle of solution, you realize that the outside of the bottle is nonsterile. What action should you take?
Remove the gloves, perform hand hygiene without leaving the sterile field, and apply a new pair of sterile gloves
When are sterile gloves necessary?
When performing a sterile procedure
To apply sterile gloves, you have applied the first sterile glove on your right hand. Where should you pick up the remaining glove?
Underneath the second glove's cuff
The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following should be included in the discussion?
When preparing a sterile field, unwrap the commercial tray by beginning with the outermost flap and unfolding it in the direction away from the sterile kit toward the top of what will be the sterile field; If there is any question or doubt of an item's sterility, the item is considered to be nonsterile; When using a sterile drape, position the bottom half of the sterile drape over the top of the intended sterile field
During change of shift report the nurse states that a patient has early renal failure and that your should be alert to this when administering medications. Why would this be a concern?
The kidneys assist in the detoxification of drug metabolites
Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized?
An elderly female carries her urinary drainage bag like a purse under her arm as she ambulates; As a patient is being transferred in a wheelchair, he places the drainage bag in his lap; The NAP places a patient's drainage bag on a lowered side rail or on the floor
Which of the following are true regarding the impact of aging related to urinary elimination?
Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone; The elderly are at increased risk of UTI because of retained urine in the bladder
The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed?
The nurse may use clean technique to insert an indwelling catheter
A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is your best response?
What medications are you taking and when?
A 68 year old female patient is admitted for knee-replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The physician has ordered an indwelling Foley catheter to be inserted preoperatively. Which catheter should you choose?
14 French, 5 mL ballon, latex catheter
A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding the anchoring of the catheter would be most accurate?
It is important to anchor the catheter tubing to minimize the risk for urethral trauma, bladder spasms from traction, and to prevent accidental dislodgement
The nursing assistive personnel (NAP) reports leakage around a patient's urinary catheter. What action should the nurse take first?
Attempt to reinflate the ballon
The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient's vital signs with the following results: Temperature 98.4°F, pulse 54, respirations 20 and blood pressure 160/100. The patient's head of the bed is elevated. What action should the nurse take next?
Check for any kinks in catheter tubing
The nursing assistive personnel (NAP) is assisting the nurse to insert a Foley catheter on a male patient. In which position should the NAP place the patient?
Supine with legs slightly abducted
Which of the following actions associated with Foley catheterization could cause a potential problem?
Keeping the foreskin retracted after catheterization
A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The physician has ordered that the patient be catheterized. Which of the following would be an appropriate size catheter for this patient?
16 French 5mL ballon
As part of catheter insertion assessment, where should you palpate?
Above the symphysis pubis
You are inserting an indwelling Foley catheter in a male patient. You have asked the patient to bear down as if to void, and you slowly insert the catheter through the urethral meatus. You advance the catheter and meet resistance. What is your best initial action at this time?
Ask the patient to take slow deep breaths while you insert the catheter slowly
After catheter insertion and urine return, patient continues to complain of discomfort
A spasm, bladder infection, or injury to the urinary tract could cause
If the catheter is in the urethra but outside of the bladder or the catheter is in the vagina rather than the urethra then there would be
a lack of urine
An enlarge prostate could cause the nurse to be
unable to advance catheter into the bladder
You have a sterile urinary catheter and sterile gloves. Choose the remaining equipment you will need to insert a straight urethral catheter
Sterile cotton balls, antiseptic solution, Water soluble lubricant, sterile forceps
Identify the reasons why a patient with an indwelling catheter may have less than 30 mL per hour of urine in the collection bag
The catheter has slipped out of the bladder; The patient is severely dehydrated; The patient's kidneys are damaged or injured
Reasons for lack of urine after inserting a straight catheter include
The catheter is outside of the bladder; The catheter is inserted in the vagina rather than in the urethra of a female patient
A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique?
The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to locate the urethra with the same catheter; The nurse lubricates the catheter and places it back into the sterile tray when it recoils and touches the bed; After the nurse cleans the labia, the labia becomes slippery and closes as the nurse attempts to obtain a clear view of the urethra
A nurse inserting an indwelling Foley catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take?
Advance the catheter another 1-2 inches and inflate balloon
The nurse has inserted a catheter 7.5 cm in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time?
Leave the catheter in vagina as a landmark and insert another sterile catheter
The nurse is catheterizing a male patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon the patient complains of pain and resistance is felt. What is the nurse's best action?
Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to reinflate
Which of the following would be inappropriate to delegate to NAP?
Foley catheter insertion
Which of the following could be considered negligence?
A condom catheter is removed every 3 days
During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse's best action?
Obtain another adhesive strip from condom catheter kit
The nurse is assessing the patient's condom catheter. Which of the following most likely indicates the condom catheter should be removed?
Redness and/ or excoriation of the penis
The NAP is applying a condom catheter to the patient. The patient asks, "What is the purpose of the skin preparation solution?" The NAP correctly responds:
The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied
You are teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following would you include in the teaching?
It is relatively safe and noninvasive; It is a convenient method of draining urine; It is used for male patients who are incontinent; It carries less risk of developing a UTI than an indwelling catheter
The nurse is caring for a patient who is unable to get out of bed. During the nurse's routine assessment, the nurse notices that urine seems to be pooling in the space at the end and around the condom catheter. The NAP comes to you complaining that the patient's condom catheter has fallen off for the second time today, requiring changing of bed linens. Which is an appropriate response from the nurse?
Let's check the condom catheter size. Perhaps there is one that will fit better
T/F - Obtaining a urine sample from an indwelling catheter requires sterile technique
True
T/F - After a patient has had a Foley catheter for 1 week, a urine specimen may be obtained from the bedside drainage bag
False
T/F - Obtaining a sterile urine sample for testing by using a straight catheter can be delegated to NAP
False
You are to collect a sterile urine specimen for culture and sensitivity from your patient's indwelling Foley catheter. Choose the supplies that you will need to carry out the procedure.
Clean gloves, Alcohol or disinfectant swab, 5mL Luer Lock syringe, Catheter clamp or elastic band, Sterile specimen container, Completed laboratory requisition, Completed ID label
You are informing your patient that his physician has ordered a urine test for culture and sensitivity that you will obtain from his indwelling Foley catheter. Which statement(s), if made by the patient, indicate that further instruction is needed?
1)That's ok; you can just get a sample out of my urinary drainage bag 2)I think my catheter comes apart from the tubing that goes to the collection bad. We can take it apart and hold a cup at the end of the catheter until you get enough urine for the test 3)After you clamp my tubing, I'm probably going to need some pain medication 4)You will have to insert a new catheter to get a sterile specimen
What is the recommended amount of time to leave the catheter clamped when obtaining a urine specimen from an indwelling catheter?
30 mins
Step 1 for collecting a urine sample from an indwelling catheter
Clamp the drainage tubing below the sampling port of the catheter for 30 minutes. Apply gloves, cleanse the sampling port with a disinfectant swab, and allow to dry
Step 2 for collecting a urine sample from an indwelling catheter
Insert a 21-gauge, 1-inch needle attached to a 3- or 20-mL syringe into the center of the sampling port, or a 3- or 20- mL leurlok syringe to a needleless port. Draw the correct amount of urine into the syringe (3 mL or 20 mL).
Step 3 for collecting a urine sample from an indwelling catheter
Transfer the urine to the appropriate container. Place the lid on the container. Unclamp the catheter. Discard the gloves and used supplies; perform hand hygiene; attach the identification label to the container and complete the requisition; send the sample to the lab in a biohazard bag.
Step 4 for collecting a urine sample from an indwelling catheter
Document the collection of the specimen
When obtaining a sterile urinary catheter specimen, the sterile specimen container should be opened and the lid:
Place with the inside up
Which of the following actions, if made by the nurse, could be considered negligence?
Obtaining the urine sample at 1030 and transporting it to the lab at 1115
The nurse is reviewing urinary catheter care with a newly hired NAP. Which statement made by the NAP indicates further instruction is needed?
The bedside drainage bag should only be emptied when it is full
The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves?
The NAP stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing.
Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter?
The patient's urine appears cloudy with a foul odor
A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for you to give the patient?
This is a normal occurrence after having a catheter in place for more than several days
If a patient's indwelling catheter is removed by 0900, the patient should be due to void by
1500-1700 (3:00-5:00PM)
Identify the indicators of a UTI
Fever, Complaints of pain, Abdominal pressure and discomfort, cloudiness of the urine
Which of the following steps should you take before removing fluid from the balloon in a Foley catheter
Attach a 10mL syringe or larger to the balloon port and allow the water to passively fill the syringe; Gently aspirate the syringe plunger if water remains in the balloon
A male patient with back and lower abdominal injuries from a motor vehicle accident is unable to void. His physician has requested the insertion of a catheter to determine the amount of residual urine and possibly to assist him with voiding. What type of urinary catheter should the nurse anticipate using?
A foley catheter
Which of the following requires strict surgical asepsis?
Insertion of a Foley catheter
The nurse is catheterizing a male patient. Which of the following demonstrates correct understanding of the procedure?
1)The patient is placed in a supine position with legs slightly abducted 2)The nurse cleans the urethral meatus using a circular motion from the meatus down to the base of glans 3)The nurse applies sterile gloves before opening the antiseptic solution and lubricant
The nurse is caring for a Hindu patient. Which of the following would be important nursing measures when inserting a urinary catheter?
1)The nurse provides privacy during catheter insertion 2)The nurse is of the same gender as the patient 3)The nurse avoids putting soiled linens on the bedside table
Identify procedures that may be delegated to NAP
Application of a condom catheter; Collection of a sterile urine sample; care of an indwelling catheter
16 French 5mL Foley catheter inserted, tolerated well, output of 875 mL clear yellow urine, pain free, urine specimen sent to the lab
Document the procedure
Urine output from Foley catheter is less than 30 mL per hour
Ensure tubing/catheter is kink free then assess patient for renal failure or severe dehydration
Foley catheter removed at 10 AM
Patient is due to void between 4:00PM and 6:00PM
Catheter leaks after insertion
Consider catheter too small, balloon deflated, or catheter has slipped out of bladder
Patient is an incontinent male who empties his bladder fully
Apply condom catheter
Patient has a spinal cord injury
Assess bladder frequently and monitor output closely
Patient needs a single sterile urine specimen
Insert a straight catheter
Patient with indwelling catheter develops fever, elevated pulse, lower abdominal pain, cloudy, foul-smelling urine
Notify physician
Difficulty inserting catheter with a male patient
Consider prostate enlargement, may require coude catheter
patient is going to have major abdominal surgery
Insert indwelling catheter
Male/Female: Abducts legs during positioning
Male
M/F - Wipe from the clitoris toward the anus
Female
M/F: Gently retract foreskin, exposing urinary meatus
Male
M/F: Advance the catheter to bifurcation of drainage and balloon port
Male
M/F: Gently retract the labia and expose the urinary meatus
Female
M/F: Lubricate catheter 2.5-5 cm (1-2 inches)
Female
M/F: Wipe around the urethral meatus in a circular motion
Male
m/f: Advance the catheter 2.5-5 cm (1-2 inches)
Female
M/F: lubricate the catheter 12.5-17.5 cm (5-7 inches)
Male
m/f: position with knees flexed with slight external rotation of the hips
Female
The nurse is assisting the NAP to remove a Foley catheter. The nurse should intervene if which of the following actions is noted
The NAP cleans the perineal area, hands the patient their call light and removes gloves
The nurse has received an order to insert a Foley catheter in a 24 y/o female patient. Which catheter would be most appropriate for this patient?
14 French 5mL balloon
A patient who is 48 hours post Foley insertion is running a low-grade fever and complains of lower abdominal discomfort, and his urine appears cloudy. The NAP states that his urine had a foul odor when his drainage bag was emptied. Which of the following would be an appropriate nursing action?
Assess the patient for back or flank pain; obtain a physician's order then obtain a sterile urine specimen for culture and sensitivity
When teaching a patient about wound healing, the nurse should tell the patient:
Inadequate nutrition delays wound healing and increases risk of infection
The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse is noticing?
The patient is demonstrating signs of postoperative wound infection
The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding in regard to wound dehiscence?
The nurse should be alert for an increase in serosanguineous drainage from the wound
T/F - A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days
False
T/F - Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms
True
Which of the following may indicate internal hemorrhage?
Distention or swelling of the affected body part; A decreased blood pressure and increased pulse; A change in the type and amount of drainage from a surgical drain
Which of the following patients have risk factors for developing a wound infection?
1)An 80 y/o M who has a burn 2)A 17 y/o patient who has a metal fragment lodged in his thigh 3)A patient receiving chemotherapy who has a surgical incision 4)A patient with peripheral vascular disease and an ulcer on the heel
Abnormal passage between 2 organs, chronic drainage is a sign of
A fistula
Increase white blood cell count, fever, and purulent drainage is a sign of
infection
Hypotension, tachycardia, and hematoma formation is a sign of
hemorrhage
Protrusion of visceral organs through a wound opening is a sign of
Evisceration
Partial or total separation of wound layers; patient states that it feels like something has given way is a sign of
dehiscence
Clear, watery plasma
serous
Bright red: indicates active bleeding
sanguineous
Thick, yellow, green, tan, or brown
purulent
Pale, red, watery
serosanguineous
An excessive amount of bright blood drainage accumulates over a short time (eg 4 hours)
Report to the surgeon. Keep the patient NPO because it may be necessary to return to surgery for suturing of a bleeding vessel Drainage that is bright red in large may indicate hemorrhage
Pain can result from manipulation of the drainage device or accumulation of drainage within the wound. Infection accompanied by inflammation and edema may increase pain
Report unrelieved increasing pain to the physician
Drainage containers expand rapidly
Check all connections for leakage. Tape or otherwise eliminate leaks in the system
Drainage system is empty although wound drainage is present
position the tubing to enhance gravity flow and eliminate kinks or pressure on the tubing. Gently "milk" the tubing to release any clots that may block tubing
Fever, elevated WBC, redness, swelling, and increasing pain
Collect diagnostic specimen for culture and sensitivity. Assess for additional indications of infection
Wound infection develops, as evidenced by unexpected purulence or foul odor
report the findings to the physician
The patient complains "It feels like the drain is pulling on my surgical site". What is the nurse's best action?
Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site
The patient asks the nurse what the purpose is for Hemovac drain. The nurse's best response is
to provide constant suction to remove and collect drainage from your wound to help it heal
A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required?
if drainage suddenly stops, it means the drain is ready to be removed
When should wound drainage be cultured?
when there is a change in color amount or odor of drainage
The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed?
The patient empties the Hemovac drain, replaces the plug, and records the amount of drainage
Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by using drainage sponges. What is the rationale for doing this?
Because drainage can be irritating to the skin and may cause skin breakdown
Which of the following is inappropriate to delegate to nursing assistive personnel?
Assessment of wound drainage
Which of the following are functions of dressings?
To promote hemostais, Wound debridement, to prevent contamination
Which the following patients would be expected to benefit from a moist to dry dressing?
A 24 y/o patient with an open and infected wound from a spider bite; A 30 y/o who had a large cyst removed and now has some necrotic tissue present in the crater type wound
The nurse is observing the patient's wife perform the moist-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed?
Pack the wound tightly; Leaves contact or primary dressing dripping moist
A patient with a vaccuum assisted closure continues to complain of pain. What measures may be taken?
switch to the white polyvinyl alcohol (PVA) soft foam; decrease the pressure setting; administer pain medication
Wound appears inflamed and tender, drainage is evident, and/or an odor is present
Monitor patient for signs of infection, for example, fever, increased WBC, purulent drainage. Notify MD. Obtain wound cultures as ordered
Patient or caregiver is unable to perform dressing change
Provide additional teaching and support. Obtain services of home care agency as needed
Wound drainage increases requiring frequent dressing changes
Notify MD, who may consider drain placement or alternate dressing method
Patient reports a sensation that "something has given way under the dressing"
Observe wound for increased drainage or dehiscence or evisceration. Cover wound with sterile moist dressing. Instruct patient to lie still. Notify MD
Wound bleeds during dressing change
Observe color and amount of drainage. If excessive, you may need to apply direct pressure. Obtain vital signs. Notify MD of findings
During a sterile dressing change, when are gloves changed?
After the old dressing is removed and before cleansing the wound
A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient?
Make sure that you have a margin of 1-1.5 inches around the wound and that the skin is thoroughly dry before applying the dressing
A patient asks the nurse why the Montgomery ties are being used instead of regular tape. The nurse's best response is:
"Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes."
How can the nurse determine that negative pressure is being achieved with a wound V.A.C.?
The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure.
Which of the following is a correct sequence for changing a gauze dressing?
Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing.
A patient has a 4-day-old postoperative incision. Which would be a normal finding when changing the dressing?
Small amount of serous drainage
Which of the following are common sites for the development of pressure ulcers?
Heels, Sacrum, Lateral malleoli, Trochanters, Ischial tuberosities
Identify contributing factors to pressure ulcer formation
malnutrition, decreased sensory perception/mobility, stress, anemia, excessive sweating
Identify prevention strategies for pressure ulcers
Use a moisture barrier ointment, applied after each incontinent episode; When the patient is in the side-lying position in bed, use the 30 degree lateral position; place patient on a pressure-reducing support surface; oral supplements should be instituted if the patient is found to be malnourished
The nurse is observing the patient's wife perform treatment of her husband's pressure ulcer. Which action, if made by the patient's wife, indicates that further instruction is needed?
She performs hand hygiene and removes the old dressing and begins to clean the ulcer with soap and water
To save on cost, the nurse may use clean gloves for changing the dressing on which of the following
chronic pressure ulcer
The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states the patient has a hematoma on the right knee. The nurse knows to expect to see:
a localized collection of blood underneath the tissues that often takes on a bluish discoloration
The nurse observes all wounds closely, particularly surgical wounds, in which the risk of hemorrhage is greatest
during the first 24 - 48 hours after surgery
The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection
2-3 days after surgery
A patient with lung cancer received radiation therapy to reduce the size of the tumor prior to a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient's chest cavity and an opening on the patient's back. The nurse is aware the patient is at increased risk for:
fluid and electrolyte imbalance
Which of the following is an example of healing by secondary intention?
A full thickness pressure ulcer, a dog bite, a burn
It is suspected that a patient is developing a wound infection. Which data, if present by the patient, would support this conclusion?
yellow tinged drainage, temp 100.3F, increased complaints of pain at wound site, WBC 13,000mm, foul odor noted from previous dressing
Which of the following lab results or measurements indicated a risk for impaired wound healing?
A BMI 35 (elevated), FSBG 215(elevated), serum albumin 2.9 (decreased), hemoglobin 10 g/dl (decreased)
Identify the functions of dressings
maintaining a moist environment, control of bleeding and drainage, protection from outside contaminants and further tissue injury, increased patient comfort
Which of the folllowing regarding removal of the old dressing on a surgical incision are accurate?
If the dressing is over a hairy area, remove tape in the direction of hair growth; use caution to avoid tension on any drains that are present
Which of the following are methods of wound debridement?
whirlpool and moist-to-dry dressing
You are teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should you include in the teaching?
Turning patients at least every 2 hours; use of pillow bridging when needed; positioning the patient in the 30 degree lateral position; using a turn sheet to reposition patients
Nonstick, has a shiny appearance and wicks drainage to the center layer
Tefla gauze
The layer of dressing in contact with the wound
primary dressing
Least irritating material
dry gauze
How is the vacuum reestablished after emptying a drain such as a Jackson-Pratt drain or Hemovac?
by compressing the drain reservoir
A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?
Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top
A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?
Montgomery ties
Why does a wound bed need to stay moist?
to support healing by enabling granulation tissue to grow
A nurse is applying a wound V.A.C. dressing independently for the first time. What action, if made by the nurse, indicates that further instruction is needed in performing this procedure?
The nurse applies new gloves, irrigates the wound with normal saline, and then gently blots it dry. The nurse measures the wound, removes and discards gloves, and applies a new pair of gloves. The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas.
The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?
"You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling."
The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?
Apply sterile saline-soaked towels to the area
Which of the following may indicate an increased risk for wound dehiscence?
There is an increase in serosanguineous drainage from the wound
Which of the following patients is at greatest risk for developing a wound infection?
A diabetic obese patient who smokes
The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding?
1)The nurse instructs the NAP to empty the drain every 8 hours or when it is 2/3 full and document the amount as output on the intake and output record. 2)The nurse ensures the drainage device appears deflated after it is emptied