NCLEX Questions - Wound Care well answered to pass

NCLEX Questions - Wound Care well answered to passA nurse is assessing a patient's skin and notes a 3 cm shallow crater on the patient's buttocks. The patient winces when the area is palpated. How should the nurse stage this wound? A. stage 1 pressure ulcer B. stage 2 pressure ulcer C. stage 3 pressure ulcer D. stage 4 pressure ulcer B. Stage 2 pressure ulcer Which of the following are functions of dressings? (select all that apply) A. promote hemostasis B. keep wound bed dry C. wound debridement D. prevent contamination E. increase circulation A. promote hemostasis C. wound debridement D. prevent contamination We don't want to keep the wound bed dry and dressings don't increase circulation Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical debridement)? (select all that apply) A. 24 year old with an open infected wound from a spider bite B. 7 year old with an abrasion on bilateral knees C. 50 year old with a post operative knee replacement incision D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound A. 24 year old with an open, infected wound from a spider bite. D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound. The nurse is caring for a patient who had knee replacement surgery 5 days go. The patient's knee appears red and warm to the touch and patient is requesting increased pain medication. What complication should the nurse be concerned about? A. nothing, this is expected post operatively B. patient is becoming dependent on pain medication C. post operative wound dehiscence D. post operative wound infection D. post operative wound infection Keyword-RED AND WARM...this is a sign of an infection! Which of the following may indicate internal hemorrhage? (select all that apply) A. distention or swelling of the affected body part. B. elevated WBC C. decrease in blood pressure and increase in pulse D. change in the type and amount of drainage. A. Distention or swelling of effected body part C. decrease in blood pressure and increase in pulse When educating a patient about wound healing the nurse should include what in the teaching? A. inadequate nutrition delays wound healing and increases risk of infection. B. chronic wounds heal better in a dry, open environment so leave them open to air. C. fat tissue heals more rapidly because there is less vascularization. D. long term steroid use diminishes the inflammatory response and speeds up wound healing A. inadequate nutrition delays wound healing and increases risk of infection What strategies should be included in pressure ulcer prevention (select all that apply) A. use moisture barrier ointment with incontinence B. reposition immobile patients every 4 hours C. when patient in side lying position ensure HOB <30 degrees D. place patient on pressure reducing support surface E. maintain bed at 45 degree angle F. massage reddened bony prominences G. oral nutrition supplement should be used when undernourished. A. use moisture barrier ointment with incontinence C. when patient in side lying position ensure HOB <30 degrees D. place patient on pressure reducing support surface G. oral nutrition supplement should be used when undernourished. Why does a wound bed need to stay moist? A. to support healing by enabling granulation tissue to grow. B. to prevent excessive fluid loss from the body C. to determine if the area has reactive hyperemia D. to decrease patient discomfort A. to support healing by enabling granulation tissue to grow. Which of the following characteristics are most likely that of a stage 4 pressure ulcer? A. eschar B. blister C. shallow crater D. nonblanchable redness A. eschar (dead skin finally falling off) What evaluation criteria are included in the Braden Risk assessment? (select all that apply) A. sensory perception B. medications C. mobility D. friction and shear E. mental status F. moisture A. sensory perception C. mobility D. friction and shear F. moisture What term refers to pale, red and watery drainage from a wound? A. serous B. sanguineous C. serosanguineous D. purulent C. serosanguineous serous - CLEAR, watery, plasma sanguineous - bright red, active bleeding purulent - thick, yellow, green, tan or brown (pus) A nurse is caring for a patient with a pressure ulcer. What type of healing process will occur with this wound? A. primary intention B. secondary intention C. tertiary intention B. secondary intention A patient has a new abdominal wound. The wound has stopped bleeding and clots are beginning to form. What phase of healing is identified? A. remodeling phase B. proliferative phase C. inflammatory phase D. hemostasis phase D. hemostasis phase Keyword- STOP BLEEDING and CLOTS Hemo-blood Stasis-stop The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is NPO (nothing by mouth) following bowel surgery an obese woman with a history of type 1 diabetes DIABETES IMPACTS WOUND-HEALING The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Pasta salad Fish Banana Green beans Fish The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Allow the wound and intestinal contents to remain open to air. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry. Apply saline solution-moistened gauze over the protruding area. The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who lifts himself up on the elbows a client who lies on wrinkled sheets a client who must remain on the back for long periods of time a client sitting in a chair who slides down A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. Fingers with quick capillary refill Warm hand Decreased radial pulse Cyanosis No finger numbness or tingling Fingers with quick capillary refill Warm hand No finger numbness or tingling A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Carefully pick the crusts off the sutures with the forceps before removing them. Do not attempt to remove the sutures because the wound needs more time to heal. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.