Wound Care

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

A) Apply skin barrier only on the right side of the wound over the irritation
B) Apply skin barrier over the area of irritation to prevent further injury
C) Apply skin barrier only on the side of the wound without any irritation
D) Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation
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Terms in this set (53)
When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

A) Apply skin barrier only on the right side of the wound over the irritation
B) Apply skin barrier over the area of irritation to prevent further injury
C) Apply skin barrier only on the side of the wound without any irritation
D) Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation
D
A client with an abdominal wound requires frequent dressing changes because of large amounts of drainage. Which should the nurse use to secure this dressing?

A) Montgomery straps
B) Hypoallergenic tape
C) Abdominal binder
D) Transparent film dressing
A
What intervention should be performed by the nurse before applying Montgomery straps?

A) Apply a skin barrier to the site where the straps will be placed.
B) Initiate contact isolation precautions.
C) Assess client for additional pressure injuries.
D) Evaluate the complete blood count and electrolyte lab results.
A
What is the primary outcome the nurse expects when choosing Montgomery straps to secure a dressing?

A) The client experiences less pain and discomfort during care.
B) Wound care is accomplished without contamination of the wound.
C) The client's skin remains free from additional irritation or injury.
D) Wound assessment and care is performed more frequently.
C
A nurse is working with a client who requires frequent changes of a wound dressing. Which equipment would allow the nurse to change the dressing without having to use tape?

A) Gauze
B) Saline
C) Waterproof pad
D) Montgomery straps
D
The nurse is teaching a client the reasons for use of negative pressure wound therapy (NPWT). What should the nurse include in the teaching? Select all that apply.

A) It stimulates cell growth and growth of new blood vessels.
B) It promotes wound healing and wound closure.
C) It results in a reduction of bacteria in the wound.
D) It allows for earlier ambulation after surgery.
E) It provides a moist wound healing environment.
A, B, C, and E
In which client would negative pressure wound therapy be contraindicated?

A) Client with a wound with heavy drainage
B) Client with a moderately bleeding wound
C) Client with a slowly healing wound
D) Client with a wound that is failing to heal
B
The charge nurse is observing the new graduate nurse perform the dressing change for a client with negative pressure wound therapy. Which action by the graduate nurse will require the charge nurse to intervene?

A) The graduate nurse uses sterile scissors to cut the wound filler foam to the shape of the wound.
B) The graduate nurse tightly stretches the transparent adhesive dressing and applies it to the wound.
C) The graduate nurse counts and documents the number of wound filler placed in the wound.
D) The graduate nurse ensures that there is foam-to-foam contact inside the wound bed.
B
In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

A) Every 25 to 36 hours
B) Every 8 to 12 hours
C) Every 48 to 72 hours
D) Every 12 to 24 hours
C
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

A) Administer the prescribed analgesic.
B) Document the pain and vital signs
C) Notify the health care provider of the pain.
D) Assess the client's wound and vital signs.
D
Which action by the nurse is most appropriate when the sutures are difficult to remove because of crusted dried blood? A) Cut the crusted dried blood off using sterile scissors and tweezers. B) Use a sterile gauze and sterile saline to gently remove the crusted dried blood. C) Use a sterile alcohol prep to soak the sutures until they soften. D) Notify the health care provider of the findings and that the sutures cannot be removed.BWhat action will the nurse take to ensure a wound is ready for the sutures to be removed? A) Apply sterile saline to the suture site and assess the wound edges. B) Review the number of days the sutures have been in place. C) Apply gentle pressure to the incision and observe for dehiscence. D) Remove every other suture and assess the wound edges.DA nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options. 1) Grasp the knot with the forceps and pull the cut suture through the skin 2) Apply adhesive closure strips 3) Remove every other suture to be sure the wound edges are healed 4) Using the scissors, cut one side of the suture below the knot, close to the skin 5) Clean the incision using the wound cleanser and gauze 6) Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin564132The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? A) Apply a skin protectant to the incision site. B) Apply a skin protectant to the skin around the incision. C) Apply a transparent dressing over the incision site. D) Apply a sterile gauze sponge over the incision siteBWhich client is most likely to require that the sutures be left in place for an extended period of time? A client who: A) Has decreased urine output. B) Requires assistance with getting out of bed and ambulation. C) Uses the patient-controlled anesthesia (PCA) pump frequently. D) Has a current history of alcoholism.DWhat intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A) To ambulate using a cane or walker B) To splint the area when engaging in activity C) To remain in bed for the next 4 hours D) To turn the head away from the area whenever they coughBPlace in order, from first to last, the actions the nurse will perform when planning to remove surgical staples. Use all options. 1) Open the staple removal kit. 2) Firmly close the staple remover and remove every other staple. 3) Assess wound to see if the edges remain approximated. 4) Position the staple remover under the staple to be removed. 5) Remove the remaining staples.14235What should the nurse do with any surgical staples removed from a surgical incision? A) Wrap them up in a gauze sponge for disposal. B) Dispose of them in a sharps container. C) Dispose of them in a biohazard bag. D) Save them for the health care provider to observe on rounds.BWhen assessing a wound 2 hours after removing the surgical staples, the nurse notes that the wound edges have begun to pull apart. What action should the nurse take next? A) Re-staple the surgical incision. B) Notify the health care provider that the wound edges are coming apart. C) Call a rapid response. D) Apply a wet to dry saline dressing to the wound area.BWhat action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? A) Notify the health care provider of the dried blood and wait for a prescription to proceed. B) Apply moist saline compresses to loosen crusts before attempting to remove the staples. C) Apply a warm compress to the surgical staples and allow the dried blood to melt. D) Go ahead and remove the staples as they will pop up and out of the skin.BWhich client is a greatest risk of developing a pressure injury? A) 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness B) 25-year-old client on bed rest for 24 hours following a procedure C) 17-year-old client postoperative for fracture of the upper extremity D) 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistanceAWhich client would be at greatest risk for developing a pressure injury? A) Older adult client who has chronic obstructive pulmonary disease (COPD) B) Client who is delirious after taking pain medications C) Adult client who is comatose D) Adolescent client with a cast on the left legCThe nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? A) To promote moist wound healing and protect the wound from contamination and trauma. B) To fill the wound with saline to dissolve wound secretions. C) To prevent the dressing from sticking to the wound. D) To soften the dressing to prevent trauma to the wound bed.AWhen assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? A) Stage 2 pressure injury B) Unstageable, skin intact C) Deep tissue injury D) Stage 1 pressure injuryCThe nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? A) Remove the eschar by irrigating with sterile saline. B) Teach the client to reposition every 4 hours. C) Prescribe the client a high carbohydrate diet to promote healing. D) Teach the client ways to relieve the pressure on the heel.DPlace in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options. 1) Irrigate the wound bed 2) Open dressing materials 3) Time and date the dressing 4) Assess the wound bed 5) Put on clean gloves 6) Remove old dressing564213The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development? A) Pull the client up in the bed very gently. B) Keep the head of the bed elevated 35 degrees. C) Turn and reposition the client every 2 hours. D) Gently massage any reddened areas for several minutes.CThe nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? A) Deep tissue injury B) Unstageable, skin intact C) Stage 2 pressure injury D) Stage 1 pressure injuryDWhich assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. A) Drainage is foul smelling and green in color B) Skin around injury is red and warm to touch C) Full-thickness tissue loss D) No bone, tendon, or muscle visible. E) Visible subcutaneous fatC, D, and EThe nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: A) Has redness with partial thickness loss of dermis. B) Has black brown eschar covering the top. C) Has exposed bone, tendon, or muscle visible. D) Has bright red granulation tissue in the wound bed.BThe nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? A) Assure that the packing material is completely saturated when placed in the wound. B) Reduce the time interval between dressing changes. C) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. D) Use less packing material.BThe nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? A) Cleanse the area with an antimicrobial wipe prior to applying the new dressing. B) Use Montgomery straps instead of adhesive tape to hold the dressing in place. C) Use a skin barrier on the wound itself prior to applying a dressing. D) Cleanse the area with an alcohol wipe prior to applying the new dressing.BThe nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? A) Allow the wound to air dry. B) Notify the health care provider for further instructions. C) Replace the dressing with a smaller one. D) Replace the dressing with a larger one.DWhen removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? A) Sinus tract. B) Undermining. C) Dehiscence. D) Ecchymosis.CThe nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? A) Wipe the area with an alcohol wipe and pull the dressing from the skin. B) Soak the area with sterile water using gauze pads. C) Wipe the area with an antimicrobial swab and pull the dressing from the skin. D) Use small amounts of sterile saline to help loosen and remove the dressing.DThe nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? A) Measure the length, depth, and width of the wound. B) Allow the wound to air dry for 2 minutes. C) Pat the wound dry with a sterile gauze sponge. D) Position the client to promote drainage of the solution.CThe nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? A) Change the dressing using sterile technique B) Call a rapid response and stay with the client C) Notify the health care provider of the bleeding D) Reinforce the dressing and assess site frequentlyDThe nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? A) Tell the client that this is a life-threatening situation and that the health care provider will be called. B) Assess for pain, shortness of breath, and abdominal pressure. C) Leave the wound open and notify the health care provider. D) Place the client in a sitting position to reduce pressure on the abdomen.BAfter setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: A) Outside to center using a new gauze for each wipe. B) Side to side using a new gauze for each wipe. C) Top to the bottom using a new gauze for each wipe. D) Distal to proximal using a new gauze for each wipe.CThe nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? A) The client's comfort and effectiveness of pain medication B) Color of drainage on the wound dressings C) The client's temperature and pulses D) Any physical limitations the client may haveAThe nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? A) Position the client. B) Raise the bed to elbow height. C) Maintain a sterile field. D) Gather all necessary equipment.BThe nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate? A) Instill 50 mL of normal saline into the wound and loosely cover it with packing material. B) Fill the wound with sterile saline gel and cover with a large transparent dressing. C) Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing. D) Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.DThe nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? A) Gauze B) Waterproof pad C) Sterile basin D) Used wound dressingCWhen irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? A) Shake the bottle of irrigating solution before pouring. B) Pour the chilled irrigating solution into the irrigation container. C) Date and reuse leftover irrigation solution within 24 hours. D) Discard any irrigation solution remaining in the bottle.CThe nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? A) When the solution from the wound flows out clear B) When the solution from the wound flows out a pink color C) When the solution from the wound flows out a red color D) When all the irrigation solution is finishedAWhen irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? A) Positioning the client to face away from the sterile supplies B) Directing the flow of irrigating solution from the top of the wound C) Cleaning the tip of the syringe with an alcohol wipe after each use D) Keeping the tip of the syringe at least 1 in (2.5 cm) above the woundDThe nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? A) From the right side of the wound to the left side B) From the upper end of the wound to the lower end C) From the left side of the wound to the right side D) From the lower end of the wound to the upper endBThe nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next? A) Cleanse the wound with a nonantimicrobial cleanser B) Assess the drainage for amount, type, color, and odor. C) Open the culture tube and apply the swab to the wound bed. D) Dry the wound bed using a sterile sponge.AThe nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? A) Obtain a sterile wound culture B) Give ciprofloxacin 1gram IV every 12 hours C) Consult dietician to assist client with meal choices D) Assist client up to chair three times dailyAThe nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? A) Document the procedure. B) Clean the wound. C) Obtain the wound culture. D) Dress the wound.BWhen collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results? A) Back-and-forth motion B) Pushing motion C) Rolling motion D) Up-and-down motionCA nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. A) Touch the swab to the intact skin at the wound edges. B) Use the same swab for both wound sites. C) Place the swab in the culture tube when done. D) Tap the outside of the culture tube with the swab before placing it in the tube. E) Insert a swab into the wound. F) Press and rotate the swab several times over the wound surfaces.C, E, and FThe nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? A) Remove gloves and perform hand hygiene. B) Assess and clean the wound per orders. C) Identify the client using two client identifiers. D) Twist and break the seal on the culture tube.A