BSN 205-10 Wound Care
T/F A contaminated or traumatic wound may show signs of infection within 24 hours. A
surgical wound infection usually develops postoperatively within 14 days.
True
False - answerF
A contaminated or traumatic wound may show signs of infection early, within 2 to 3
days. A surgical wound infection usually develops postoperatively within 4 to 5 days.
Healing by primary intention is expected when the edges of a clean surgical incision are
sutured or stapled together, tissue loss is minimal or absent, and the wound is
uncontaminated by microorganisms.
True
False - answerT
Which of the following may indicate internal hemorrhage? (Select all that apply.)
A. Distention or swelling of the affected body part.
B. An elevated white blood cell count.
C. A decreased blood pressure and increased pulse.
D. A change in the type and amount of drainage from a surgical drain.
E. Purulent drainage and tenderness at wound site. - answerACD
Which of the following patients has the least risk for developing a wound infection?
An 80-year-old man who has a burn.
A 17-year-old patient who has a metal fragment lodged in his thigh.
A 30-year-old woman who had an episiotomy with childbirth.
A patient receiving chemotherapy who has a surgical incision.
A patient with peripheral vascular disease and an ulcer on the heel - answerA 30-year-
old woman who had an episiotomy with childbirth.
The chances of wound infection are greater when the wound contains dead or necrotic
tissue (as with a burn), there are foreign bodies in or near the wound, and the blood
supply and local tissue defenses are reduced or the patient is immunocompromised.
When teaching a patient about wound healing, what should the nurse tell the patient?
Inadequate nutrition delays wound healing and increases risk of infection.
Chronic wounds heal more efficiently in a dry, open environment, so leave them open to
air when possible.
,Long-term steroid therapy diminishes the inflammatory response and speeds wound
healing.
Fat tissue heals more readily because there is less vascularization. - answerInadequate
nutrition delays wound healing and increases risk of infection.
Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—
delays tissue repair and increases risk for infection. Both full-thickness wounds and
partial-thickness wounds heal more efficiently in a moist, protected environment. Long-
term steroid therapy may diminish the inflammatory response and reduce the healing
potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which
decreases transport of nutrients and cellular elements required for healing.
The nurse is caring for a patient who had knee replacement surgery 5 days ago. The
patient's knee appears red and is very warm to the touch. The patient requests pain
medication. Which of the following would be a correct explanation of what the nurse has
assessed?
These are expected findings for this postoperative period.
The patient is becoming dependent on pain medication.
The nurse should observe the patient more closely for wound dehiscence.
The patient is demonstrating signs of a postoperative wound infection. - answerThe
patient is demonstrating signs of a postoperative wound infection.
The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection
include fever, tenderness and pain at the wound site, and an elevated white blood cell
count, and the edges of the wound may appear inflamed. If drainage is present, it is
odorous and purulent, which causes a yellow, green, or brown color, depending on the
causative organism.
The nurse is caring for a patient after major abdominal surgery. Which of the following
demonstrates correct understanding of wound dehiscence?
The nurse should be alert for an increase in serosanguineous drainage from the wound.
Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery.
The nurse should administer cough suppressant to prevent wound dehiscence.
The condition is an emergency that requires surgical repair. - answerThe nurse should
be alert for an increase in serosanguineous drainage from the wound.
An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence
most commonly occurs before collagen formation (3 to 11 days after injury). To prevent
dehiscence, place a folded thin blanket or pillow over an abdominal wound when the
patient is coughing. This provides a splint to the area, supporting the healing tissue
when coughing increases the intra-abdominal pressure. Evisceration is an emergency
that requires surgical repair. Dehiscence does not necessarily indicate surgery is
necessary.
, The nurse reports that a patient has a wound on his abdomen that is healing by
secondary intention. The nurse understands this means the patient:
has a drain.
Is at greater risk for infection.
Is at greater risk for wound dehiscence.
Is healing naturally. - answerIs at greater risk for infection.
Healing by secondary intention indicates the patient has a wound where there is tissue
loss and the wound edges are not well approximated. There is greater opportunity for
development of infection without the protective epidermal barrier and longer healing
time.
A postoperative diabetic patient had an exploratory laparotomy (incision in the
abdomen) 5 days ago. The patient's history indicates obesity with a body mass index
(BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands
the patient should be observed for:
Developing a blood clot.
Developing a fistula.
Wound dehiscence.
Hemorrhage. - answerWound dehiscence.
This patient is at risk for poor wound healing as a result of the chronic illness of
diabetes, being obese (BMI > 30), and smoking. Fatty tissue has a poor blood supply
for healing and smoking increases the patient's likelihood of coughing. The nurse should
observe for an increase in serosanguineous drainage, an indication of potential
dehiscence. The nurse should teach the patient to splint the abdomen with a pillow
when coughing as a sudden strain on the incision could lead to dehiscence.
Which of the following are common sites for the development of pressure injuries?
(Select all that apply.)
A. Sternum.
B. Heels.
C. Sacrum.
D. Lateral malleoli.
E. Trochanters.
F. Ischial tuberosities. - answerBCDEF
Identify contributing factors to pressure injury formation. (Select all that apply.)
A. Malnutrition.
B. Middle age.
C. Decreased sensory perception/mobility.
D. Anemia.
E. Excessive sweating.
F. Ethnic background. - answerACDE
T/F A contaminated or traumatic wound may show signs of infection within 24 hours. A
surgical wound infection usually develops postoperatively within 14 days.
True
False - answerF
A contaminated or traumatic wound may show signs of infection early, within 2 to 3
days. A surgical wound infection usually develops postoperatively within 4 to 5 days.
Healing by primary intention is expected when the edges of a clean surgical incision are
sutured or stapled together, tissue loss is minimal or absent, and the wound is
uncontaminated by microorganisms.
True
False - answerT
Which of the following may indicate internal hemorrhage? (Select all that apply.)
A. Distention or swelling of the affected body part.
B. An elevated white blood cell count.
C. A decreased blood pressure and increased pulse.
D. A change in the type and amount of drainage from a surgical drain.
E. Purulent drainage and tenderness at wound site. - answerACD
Which of the following patients has the least risk for developing a wound infection?
An 80-year-old man who has a burn.
A 17-year-old patient who has a metal fragment lodged in his thigh.
A 30-year-old woman who had an episiotomy with childbirth.
A patient receiving chemotherapy who has a surgical incision.
A patient with peripheral vascular disease and an ulcer on the heel - answerA 30-year-
old woman who had an episiotomy with childbirth.
The chances of wound infection are greater when the wound contains dead or necrotic
tissue (as with a burn), there are foreign bodies in or near the wound, and the blood
supply and local tissue defenses are reduced or the patient is immunocompromised.
When teaching a patient about wound healing, what should the nurse tell the patient?
Inadequate nutrition delays wound healing and increases risk of infection.
Chronic wounds heal more efficiently in a dry, open environment, so leave them open to
air when possible.
,Long-term steroid therapy diminishes the inflammatory response and speeds wound
healing.
Fat tissue heals more readily because there is less vascularization. - answerInadequate
nutrition delays wound healing and increases risk of infection.
Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—
delays tissue repair and increases risk for infection. Both full-thickness wounds and
partial-thickness wounds heal more efficiently in a moist, protected environment. Long-
term steroid therapy may diminish the inflammatory response and reduce the healing
potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which
decreases transport of nutrients and cellular elements required for healing.
The nurse is caring for a patient who had knee replacement surgery 5 days ago. The
patient's knee appears red and is very warm to the touch. The patient requests pain
medication. Which of the following would be a correct explanation of what the nurse has
assessed?
These are expected findings for this postoperative period.
The patient is becoming dependent on pain medication.
The nurse should observe the patient more closely for wound dehiscence.
The patient is demonstrating signs of a postoperative wound infection. - answerThe
patient is demonstrating signs of a postoperative wound infection.
The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection
include fever, tenderness and pain at the wound site, and an elevated white blood cell
count, and the edges of the wound may appear inflamed. If drainage is present, it is
odorous and purulent, which causes a yellow, green, or brown color, depending on the
causative organism.
The nurse is caring for a patient after major abdominal surgery. Which of the following
demonstrates correct understanding of wound dehiscence?
The nurse should be alert for an increase in serosanguineous drainage from the wound.
Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery.
The nurse should administer cough suppressant to prevent wound dehiscence.
The condition is an emergency that requires surgical repair. - answerThe nurse should
be alert for an increase in serosanguineous drainage from the wound.
An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence
most commonly occurs before collagen formation (3 to 11 days after injury). To prevent
dehiscence, place a folded thin blanket or pillow over an abdominal wound when the
patient is coughing. This provides a splint to the area, supporting the healing tissue
when coughing increases the intra-abdominal pressure. Evisceration is an emergency
that requires surgical repair. Dehiscence does not necessarily indicate surgery is
necessary.
, The nurse reports that a patient has a wound on his abdomen that is healing by
secondary intention. The nurse understands this means the patient:
has a drain.
Is at greater risk for infection.
Is at greater risk for wound dehiscence.
Is healing naturally. - answerIs at greater risk for infection.
Healing by secondary intention indicates the patient has a wound where there is tissue
loss and the wound edges are not well approximated. There is greater opportunity for
development of infection without the protective epidermal barrier and longer healing
time.
A postoperative diabetic patient had an exploratory laparotomy (incision in the
abdomen) 5 days ago. The patient's history indicates obesity with a body mass index
(BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands
the patient should be observed for:
Developing a blood clot.
Developing a fistula.
Wound dehiscence.
Hemorrhage. - answerWound dehiscence.
This patient is at risk for poor wound healing as a result of the chronic illness of
diabetes, being obese (BMI > 30), and smoking. Fatty tissue has a poor blood supply
for healing and smoking increases the patient's likelihood of coughing. The nurse should
observe for an increase in serosanguineous drainage, an indication of potential
dehiscence. The nurse should teach the patient to splint the abdomen with a pillow
when coughing as a sudden strain on the incision could lead to dehiscence.
Which of the following are common sites for the development of pressure injuries?
(Select all that apply.)
A. Sternum.
B. Heels.
C. Sacrum.
D. Lateral malleoli.
E. Trochanters.
F. Ischial tuberosities. - answerBCDEF
Identify contributing factors to pressure injury formation. (Select all that apply.)
A. Malnutrition.
B. Middle age.
C. Decreased sensory perception/mobility.
D. Anemia.
E. Excessive sweating.
F. Ethnic background. - answerACDE
