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Ch. 40 Wound Care and Irrigations

Terms in this set (5)

While removing the patient's staples, the nurse notices that the incision starts to open larger than the width of two staples. Which action should the nurse initially take?

Place several Steri-Strip to close the open area.

Remove one more staple to see whether the open area enlarges.

Notify the health care provider of the opening in the wound.

Palpate the edges of the wound.
Place several Steri-Strip to close the open area. - Correct

Remove one more staple to see whether the open area enlarges.

Notify the health care provider of the opening in the wound.

Palpate the edges of the wound.
A patient needs to have his abdominal wound irrigated. Which part of the procedure may the nurse delegate to nursing assistive personnel (NAP)?

Documenting the description of the wound

Packing the wound with sterile gauze pads

Taping the dressing once the wound is covered

Performing wound irrigation
Documenting the description of the wound

Packing the wound with sterile gauze pads

Taping the dressing once the wound is covered -Correct

Performing wound irrigation
The patient asks the nurse why he has a drain in his abdomen after surgery. Which response by the nurse is most accurate?

"The drain removes abdominal fluids to reduce stress on the suture line."

"You have a drain to prevent any swelling of the surgical area."

"The drain allows the antibiotics that were instilled in the wound to drain."

"The drain removes fluid from the surgical area to promote healing."
"The drain removes abdominal fluids to reduce stress on the suture line."

"You have a drain to prevent any swelling of the surgical area."

"The drain allows the antibiotics that were instilled in the wound to drain."

"The drain removes fluid from the surgical area to promote healing." - Correct
A patient with a large abdominal incision is being discharged. Which statement by the patient indicates that teaching by the nurse has been effective?

"Now that my incision is without staples, it is healed and strong."

"As long as I don't have pain, I can do just about anything I want."

"I don't have to worry about further drainage, now that the staples are out."

"I need to avoid lifting anything heavy for at least several weeks."
"Now that my incision is without staples, it is healed and strong."

"As long as I don't have pain, I can do just about anything I want."

"I don't have to worry about further drainage, now that the staples are out."

"I need to avoid lifting anything heavy for at least several weeks." - Correct
An older diabetic patient with a lot of abdominal fat underwent abdominal surgery 4 days ago involving an 8-inch vertical incision. The nurse would be most concerned if which observation of the incision was made?

The incision line is slightly pink and elevated where the staples are located.

Serosanguineous drainage has increased since 2 days ago.

The incision line has a light crust on it.

The patient's pain level has changed from "5" yesterday to "2" today.
The incision line is slightly pink and elevated where the staples are located.

Serosanguineous drainage has increased since 2 days ago. - Correct

The incision line has a light crust on it.

The patient's pain level has changed from "5" yesterday to "2" today.
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