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NUR120 Exam #2

Terms in this set (30)

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?

a. Document the findings and continue to monitor the patient.

b. Administer antipyretics, as prescribed.

c. Increase the frequency of assessment to every hour and notify the patient's primary care provider.

d. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.
a. Document the findings and continue to monitor the patient.
A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply.

a. Serous drainage is composed of the clear portion of the blood and serous membranes.

b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.

c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding.

d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria.

e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor.

f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.
A,B,C,D
A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last.

a. Notify the health care provider of the situation.

b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.

c. Place the patient in the low Fowler's position.
C, B, A
A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?

a. Pain

b. Impaired Skin Integrity

c. Disturbed Body Image

d. Disturbed Thought Processes
c. disturbed body image
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?

a. Using sterile dressing supplies

b. Suggesting dietary supplements

c. Applying antibiotic ointment

d. Performing careful hand hygiene
d. performing careful hand hygiene
A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.

a. Hemostasis occurs immediately after the initial injury.

b. A liquid called exudate is formed during the proliferation phase.

c. White blood cells move to the wound in the inflammatory phase.

d. Granulation tissue forms in the inflammatory phase.

e. During the inflammatory phase, the patient has generalized body response.

f. A scar forms during the proliferation phase.
a, c, e
The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply.

a. Enhanced healing due to the presence of sugars and proteins

b. Delayed healing due to dead tissue present in the wound

c. Decreased effectiveness of antibiotics against the bacteria

d. Impaired skin integrity due to overhydration of the cells of the wound

e. Delayed healing due to cells dehydrating and dying

f. Decreased effectiveness of the patient's normal immune process
c, f
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply.

a. Use standard precautions or transmission-based precautions when indicated.

b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.

c. Clean the wound in full or half circles beginning on the outside and working toward the center.

d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area.

e. Clean to at least 1 in beyond the end of the new dressing if one is being applied.

f. Clean to at least 3 in beyond the wound if a new dressing is not being applied.
a, b, e
A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply.

a. The patient takes time to think about responses to questions.

b. The patient is 86 years old.

c. The patient reports inability to control urine.

d. The patient is scheduled for a hip arthroplasty.

e. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL).

f. The patient reports increased pain in right hip when repositioning in bed or chair.
b, c, d, f
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?

a. "I can expect to have more discomfort in the area where the cold is applied."

b. "I should expect more drainage from the incision after the ice has been in place."

c. "I should see less swelling and redness with the cold treatment."

d. "My incision may bleed more when the ice is first applied."
c. "I should see less swelling and redness with the cold treatment."
A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?

a. The therapy is used to collect excess blood loss and prevent the formation of a scab.

b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue.

c. The therapy provides a moist environment and stimulates blood flow to the wound.

d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.
c. The therapy provides a moist environment and stimulates blood flow to the wound.
After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as:
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
b. Stage 2
The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?

a. Irrigate the wound.

b. Provide gentle cleansing of the wound.

c. Debride the wound.

d. Change the dressing frequently.
b. Provide gentle cleansing of the wound.
A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury?

a. Keeping the head of the bed elevated as often as possible

b. Massaging over bony prominences

c. Repositioning bed-bound patients every 4 hours

d. Using a mild cleansing agent when cleansing the skin
d. Using a mild cleansing agent when cleansing the skin
A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended?

a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down.

b. Draw the shape of the wound and describe how deep it appears in centimeters.

c. Gently insert a sterile applicator into the wound and move it in a clockwise direction.

d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.
a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down.

***all rationales on pg 1126
Primary Intention
healing that occurs when a clean laceration or a surgical incision is closed primarily with sutures, Steri-Strips, or skin adhesive
Secondary Intention
-happens when a wound has a great deal of lost tissue, or is extensive and the edges can't be brought together --Doctors will leave the wound to heal naturally in these cases ! (e.g. pressure ulcer)
Tertiary Intention
-Healing by delayed primary closure, occurs when there is a need to delay the wound-closing process
-Often if a doctor fears that they may trap infectious germs in a wound by closing it
-The wound may need to drain or antibiotics may need to kick in before the wound is closed
name the PHASES OF WOUND HEALING and briefly describe
1. Inflammatory: The cleaning and healing of the area begin

2. Proliferative:
-Wound is stable
-Body begins to close the wound
-Creates new tissue
-Repairs any damaged blood vessels in the area

3. Remodeling:
-wound is mostly healed
-body is creating strong skin to replace
1. Inflammatory Phase of wound healing
-(1-5days)
-Controls bleeding
-Establish clean wound bed
-Clot dissolution
-Releases growth factors
-Release vasoactive substances
2. Proliferative Phase of wound healing
-(6-21 days)
-"Rebuilding Phase"
-Granulation - tissue fills the wound with vessels & connective tissue
-Epithelialization
-Contraction - wound edges pull together to reduce the size of the wound opening
3. Remodeling Phase of wound healing
-(3 wks - 2 yrs)

-Final phase of full thickness repair

-Replacing Connective Tissue - strength is acquired within 3 months
-Tissue may never be as strong as original skin (80% is optimal)

- Keloid scar - tissue extending beyond boundaries of the original wound bed
-Common in specific skin types
Factors affecting wound healing
-Tissue Perfusion
-Ischemia
-Environmental

-Nutritional Status
-Diet
-alcoholism/tobacco

-Disease
-type 2 diabetes, HTN, obesity, immunocompromised, cancer, HIV

-Medications
-Corticosteroids (skin heals w/ incomplete tissue
-ant-inflammatory drugs inhibit inflammation & proliferative process

-Age
-delayed inflammatory & proliferative response
-less collagen for collagen synthesis
- likely to have co-morbidities that neg. affect wound healing
-reduced macrophage functioning

elaborates from slides 22 and so on..
Dehiscence
a condition where a cut made during a surgical procedure separates or ruptures after it has been stitched back together
Evisceration
Rare, but occasionally happen in abdominal surgeries when wound dehisce happens and abdominal organs spill out of opening
Fistula
Abnormal passage/opening from one organ to vessel/organ
-internal organ to skin
-one organ to another
Wound Assessment
location
dimensions & depth
stage
status of wound bed
exudate (fluid how much etc)
status of surrounding skin (redness warmth?)
pain
how do you properly clean a wound
from LEAST contaminated area to the MOST contaminated area
TOP to BOTTOM
INNER to OUTTER
with each wipe a new gauze should be used
how to obtain a wound culture
put on sterile gloves
ROLL the culturette into ONE area ONLY!
If more than one area is to be cultures you use a NEW CULTURETTE for each area
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