NSG 3100 Exam 2 Wound Care Questions And Answers 1005 Solved

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection - ANSWER3. Breast biopsy Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A gastric resection would be included in the study. The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected - ANSWER2. Contaminated Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered, but minimal to no spillage has occurred. A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this clients care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving. - ANSWER1. Obtain ice packs to apply to the wounds. Rationale 1: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer - ANSWER1. Reactive hyperemia