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1. A patient with a chronic wound is not eating well and shows signs of delayed
healing. What nursing intervention should be prioritized?
Encourage the patient to keep the wound exposed to air.
Administer steroids to enhance healing.
Increase the frequency of dressing changes.
Assess and improve the patient's nutritional intake.
2. After an initial skin assessment, the nurse documents the presence of a
reddened area that is a 1 cm blister According to recognized staging systems,
this pressure injury would be classified as:
Stage 1 dark maroon wound, skin intact
Stage 4 blanchable reddened area, 2 cm
Stage 3 wound base with red granulation tissue
Stage 2 with 1cm blister noted
3. A patient who underwent major abdominal surgery reports increased
drainage from the surgical site. As a nurse, what should be your immediate
action?
Assess the wound for signs of dehiscence and notify the physician.
Apply a new dressing without further assessment.
Administer pain medication to the patient.
Encourage the patient to cough to clear their lungs.
,4. Describe the significance of using a pressure reducing support surface in the
prevention of pressure injuries.
A pressure reducing support surface helps to distribute weight
evenly and reduce pressure on bony prominences, thereby
preventing skin breakdown.
A pressure reducing support surface increases the risk of skin
irritation.
A pressure reducing support surface is primarily used for comfort and
does not affect pressure injury prevention.
A pressure reducing support surface is only necessary for patients
with existing wounds.
5. 5 days ago a diabetic patient had an exploratory laparotomy. Patient history
indicates a BMI of 32 and smokes 1 pack a day. Based on this information, the
nurse knows she needs to be alert for what?
Hemorrhage
Development of blood clot
Wound dehiscence
Development of fistula
6. What is a common complication that a nurse should monitor for in a
postoperative patient with diabetes and obesity?
wound dehiscence
seroma
infection
hematoma
, 7. Which of the following signs is commonly associated with internal
hemorrhage? Select all that apply.
swelling of the affected body part, normal white blood cell count,
increased pulse
elevated white blood cell count, purulent drainage and tenderness at
wound site
increased blood pressure and decreased pulse, normal drainage from
a surgical drain
distention or swelling of the affected body part, decreased blood
pressure and increased pulse, change in the type and amount of
drainage from a surgical drain
8. Describe the conditions necessary for healing by primary intention to occur.
Healing by primary intention occurs only in cases of severe tissue loss
and contamination.
Healing by primary intention occurs when the edges of a clean
surgical incision are sutured together, with minimal or no tissue loss
and no contamination by microorganisms.
Healing by primary intention requires the use of topical antibiotics on
the wound.
Healing by primary intention is only applicable to chronic wounds.
9. If a caregiver fails to wring out excess solution from the gauze before
packing a wound, what potential issue could arise?
The dressing will adhere better to the wound.
There will be no impact on the wound healing process.
The wound will heal faster due to increased moisture.