13 Wound Care Flashcards
(30 cards)
- A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?
A. Remove the dressing, inspect the wound, and reapply a new dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care provider arrives.
D. Wait until the health care provider orders the removal of the surgical dressing.
D. Wait until the health care provider orders the removal of the surgical dressing.
- Which wound would be allowed to heal by secondary intention?
A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife
B. Infected hysterectomy incision
- Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?
A. Taking the patient’s temperature
B. Applying clean gloves
C. Assessing the wound for drainage
D. Assessing the dressing for drainage
B. Applying clean gloves
- Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?
A. Assessing the site for signs of redness or swelling
B. Reporting the presence of wound odor
C. Removing a soiled outer dressing
D. Opening sterile dressings during the dressing change
B. Reporting the presence of wound odor
- The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?
A. Osteoarthritis
B. Glaucoma
C. Deafness
D. Diabetes mellitus
D. Diabetes mellitus
- Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?
A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment.
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, efficient manner.
B. Use appropriate personal protective equipment.
- The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?
A. Necrotic tissue
B. Presence of slough
C. Granulation tissue
D. Development of an infection
C. Granulation tissue
- Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?
B. Length and width
- How would the nurse safely apply an enzyme debridement ointment?
A. Daub ointment on dead tissue at the wound edges.
B. Put ointment on a tongue blade, and gently spread it on the center of the wound.
C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
D. Apply a gauze dressing to ensure contact with the ointment.
C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
- Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?
A. Reposition the patient at least every 2 hours.
B. Assess the patient’s bony prominences every shift.
C. Educate the family about the importance of healthy skin.
D. Assist the patient in the selection of high-protein foods.
A. Reposition the patient at least every 2 hours.
- A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
B. Use a distraction technique to divert the patient’s attention during the procedure.
C. Position the patient comfortably before the intervention.
D. Thoroughly explain the procedure to the patient.
A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
- Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?
A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment (PPE).
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, timely way.
B. Use appropriate personal protective equipment (PPE).
- What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?
A. Notify the surgeon of the bleeding.
B. Remove the dressing, and assess the wound.
C. Assess the patient for signs of shock.
D. Further assess the patient and the wound.
D. Further assess the patient and the wound.
- When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?
A. After performing hand hygiene at the start of the procedure
B. Before removing the inner dressing
C. After removing the original dressing materials and performing hand hygiene a second time
D. Just before cleansing the wound with sterile water
C. After removing the original dressing materials and performing hand hygiene a second time
- Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?
A. Cleansing the wound with sterile water
B. Blotting the incision with dry gauze
C. Wearing sterile gloves to cleanse the wound
D. Using a new gauze pad for each stroke while cleansing the wound
D. Using a new gauze pad for each stroke while cleansing the wound
. When irrigating a wound, how would the nurse know the right amount of pressure to apply?
A. Calculate the wound size.
B. Follow the general rule of keeping the pressure between 4 and 15 psi.
C. Keep the pressure strong enough to cause moderate pain.
D. Gentle enough that is does not create a splash off of the wound.
B. Follow the general rule of keeping the pressure between 4 and 15 psi.
- Which action should the nurse avoid before irrigating a patient’s foot wound?
A. Assess the patient for a history of allergies to tape and irrigating solution.
B. Review the provider’s orders for the type of irrigating solution to be used.
C. Assess the patient’s pain on a scale of 0 to 10.
D. Warm the irrigant to body temperature in the microwave.
D. Warm the irrigant to body temperature in the microwave.
- Which device is used for wound irrigation?
A. 19-gauge needle attached to a 10-mL syringe
B. 19-gauge needle attached to a 35-mL syringe
C. Sterile container held 30.5 cm (12 inches) above the wound
D. Foley irrigating syringe
B. 19-gauge needle attached to a 35-mL syringe
- Which imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient’s left heel is infected?
A. White blood cell count
B. Complete blood count
C. X-ray of left foot
D. Culture and sensitivity test
D. Culture and sensitivity test
- A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?
A. Drainage that was not present previously
B. Redness at the abdominal suture line
C. Granulation tissue in the wound bed
D. The patient reports less pain
A. Drainage that was not present previously
- The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?
A. Explain the purpose of the test to the patient.
B. Assess the level of the patient’s pain at the wound site.
C. Assess the patient for signs and symptoms of infection.
D. Review the order to determine the type of specimen to be collected.
D. Review the order to determine the type of specimen to be collected.
- Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?
A. Collect the specimen while wearing sterile gloves.
B. Collect the specimen after washing the wound with sterile water.
C. Collect the specimen before cleansing the wound.
D. Collect the specimen after administering prescribed pain medication.
A. Collect the specimen while wearing sterile gloves.
- Which question might the nurse ask the patient when an aerobic wound culture has been ordered?
A. “Do you have any pain at the wound site?”
B. “Have you ever collected a specimen from your wound before?”
C. “Have you had any trouble breathing?”
D. “Have your blood counts been high recently?”
A. “Do you have any pain at the wound site?”
- Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?
A. “Wear sterile gloves when holding the specimen.”
B. “Take this specimen to the lab immediately.”
C. “Borrow a specimen collection kit from another unit if we’re out of them.”
D. “Keep the specimen tube horizontal.”
B. “Take this specimen to the lab immediately.”
