Wound Care Questions and Answers Already Passed

Wound Care Questions and Answers Already Passed A nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. What would be the priority nursing assessment when inspecting the skin that is distal to the bandage? Circulatory Impairment A patient is assessed 30 minutes after a cholecystectomy (gallbladder removal), and 2 mL of drainage is noted in the Jackson-Pratt drainage system. After 3 hours the nurse notices that there has been no additional drainage and the patient is complaining of severe pain. What action should the nurse complete first? Check the drainage system for kinks The nurse is caring for a patient who has undergone an appendectomy. While inspecting the patient's wound dressing, the nurse finds that the gauze is bright red in color. What does the nurse infer from this observation? The patients sutures have ruptured. A nursing professor asks the student what is the purpose of the vacuum-assisted closure device. What response should the student give? It reduces edema and increases circulation A newly postoperative patient is transferred to the postanesthesia care unit (PACU). The nurse places the initials and time on the bandage. When the nurse reassesses the bandage, bleeding is evident. What should the nurse do next? Reinforce the bandage The nurse is caring for a patient who has undergone abdominal surgery. Following the daily assessment, the nurse finds that the patient has an internal hemorrhage. On the basis of which finding(s) did the nurse make such a conclusion? The patient has a rapid, thready pulse The patient has abdominal distention The patient has low blood pressure Which essential problems should be placed on the nursing care plan of a patient with a wound? Infection, Nutrition, Skin integrity A nurse has just finished placing the vacuum-assisted closure (VAC) device to a patient's wound. What amount of pressure should the nurse administer? 5 to 200 MM HG While caring for a patient, the nurse finds that the patient's wound dressing has become yellow in color. What parameter does the nurse assess further to diagnose the abnormality? Leukocyte Count Four hours after surgery, a patient rings the call bell. When the nurse arrives, the patient states that the wound is infected. When the nurse assesses the wound it is red, swollen, and warm to touch. Which statement would be the most appropriate response to the patient? The wound is not infected, normal healing is occurring. The nurse observes that a keloid has developed on a patient's skin at the site of injury. To what reason does the nurse attribute this formation? Overgrowth of collegen The nurse is instructed to use vacuum-assisted closure (VAC) for a patient with a chronic leg wound. What is the expected outcome of the therapy? Drop in bacterial count in the wound bed, increased tissue growth