Wound care BSN 205
A contaminated or traumatic wound may show signs of infection within 24 hours. A
surgical wound infection usually develops postoperatively within 14 days. - answerFalse
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. - answerTrue
This is the correct definition of healing by primary intention.
Which of the following may indicate internal hemorrhage? (Select all that apply.) -
answer-Distention or swelling of the affected body part
-A decreased blood pressure and increased pulse.
-A change in the type and amount of drainage from a surgical drain.
Which of the following patients has the least risk for developing a wound infection? -
answerA 30-year-old woman who had an episiotomy with childbirth.
When teaching a patient about wound healing, what should the nurse tell the patient? -
answerInadequate nutrition delays wound healing and increases risk of infection.
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? - answerThe patient is demonstrating signs of a postoperative wound
infection.
The nurse is caring for a patient after major abdominal surgery. Which of the following
demonstrates correct understanding of wound dehiscence? - answerThe nurse should
be alert for an increase in serosanguineous drainage from the wound.
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: - answerIs at
greater risk for infection.
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: - answerWound dehiscence.
, Which of the following are common sites for the development of pressure injuries?
(Select all that apply.) - answer-Heels.
-Sacrum.
-Lateral malleoli.
-Trochanters.
- Ischial tuberosities.
Identify contributing factors to pressure injury formation. (Select all that apply.) - answer-
Malnutrition.
-Decreased sensory perception/mobility.
-Anemia
-Excessive sweating
Identify prevention strategies for pressure injuries. (Select all that apply.) - answer-
When the patient is in the side-lying position in bed, use the 30-degree lateral position.
-Place patient on a pressure-reducing support surface
-Oral supplements should be instituted if the patient is found to be undernourished.
The nurse is observing the patient's wife perform treatment of her husband's pressure
injury. Which action, if made by the patient's wife, indicates that further instruction is
needed? - answerShe performs hand hygiene and removes the old dressing and begins
to clean the injury with soap and water.
A family member calls the nurse to ask for advice regarding their mother who has
developed a "bedsore" on her right heel. The family member describes the pressure
injury as "a blister that has now popped and you can see redness." Based on this
description, at what stage would the nurse classify this pressure injury? - answerStage
2.
The patient asks the nurse what the purpose is for his Hemovac drain. What is the
nurse's best response? - answer"To provide suction to remove and collect drainage
from your wound to help it heal."
A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if
made by the patient, indicates further teaching is required? - answerIf drainage
suddenly stops, it means the drain is ready to be removed."
When should wound drainage be cultured? - answerWhen there is a change in color,
amount, or odor of drainage.
The nurse is teaching a patient how to empty his Hemovac drain. Which action of the
patient indicates that further instruction is needed? The patient: - answerempties the
Hemovac drain, replaces the plug, and records the amount of drainage.
Because a patient has a Penrose drain, the nurse inspects the patient's skin and
changes the dressing by placing a drainage sponge around the drain. What is the
A contaminated or traumatic wound may show signs of infection within 24 hours. A
surgical wound infection usually develops postoperatively within 14 days. - answerFalse
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. - answerTrue
This is the correct definition of healing by primary intention.
Which of the following may indicate internal hemorrhage? (Select all that apply.) -
answer-Distention or swelling of the affected body part
-A decreased blood pressure and increased pulse.
-A change in the type and amount of drainage from a surgical drain.
Which of the following patients has the least risk for developing a wound infection? -
answerA 30-year-old woman who had an episiotomy with childbirth.
When teaching a patient about wound healing, what should the nurse tell the patient? -
answerInadequate nutrition delays wound healing and increases risk of infection.
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? - answerThe patient is demonstrating signs of a postoperative wound
infection.
The nurse is caring for a patient after major abdominal surgery. Which of the following
demonstrates correct understanding of wound dehiscence? - answerThe nurse should
be alert for an increase in serosanguineous drainage from the wound.
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: - answerIs at
greater risk for infection.
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: - answerWound dehiscence.
, Which of the following are common sites for the development of pressure injuries?
(Select all that apply.) - answer-Heels.
-Sacrum.
-Lateral malleoli.
-Trochanters.
- Ischial tuberosities.
Identify contributing factors to pressure injury formation. (Select all that apply.) - answer-
Malnutrition.
-Decreased sensory perception/mobility.
-Anemia
-Excessive sweating
Identify prevention strategies for pressure injuries. (Select all that apply.) - answer-
When the patient is in the side-lying position in bed, use the 30-degree lateral position.
-Place patient on a pressure-reducing support surface
-Oral supplements should be instituted if the patient is found to be undernourished.
The nurse is observing the patient's wife perform treatment of her husband's pressure
injury. Which action, if made by the patient's wife, indicates that further instruction is
needed? - answerShe performs hand hygiene and removes the old dressing and begins
to clean the injury with soap and water.
A family member calls the nurse to ask for advice regarding their mother who has
developed a "bedsore" on her right heel. The family member describes the pressure
injury as "a blister that has now popped and you can see redness." Based on this
description, at what stage would the nurse classify this pressure injury? - answerStage
2.
The patient asks the nurse what the purpose is for his Hemovac drain. What is the
nurse's best response? - answer"To provide suction to remove and collect drainage
from your wound to help it heal."
A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if
made by the patient, indicates further teaching is required? - answerIf drainage
suddenly stops, it means the drain is ready to be removed."
When should wound drainage be cultured? - answerWhen there is a change in color,
amount, or odor of drainage.
The nurse is teaching a patient how to empty his Hemovac drain. Which action of the
patient indicates that further instruction is needed? The patient: - answerempties the
Hemovac drain, replaces the plug, and records the amount of drainage.
Because a patient has a Penrose drain, the nurse inspects the patient's skin and
changes the dressing by placing a drainage sponge around the drain. What is the
