NURS 3111 Exam 3 Ch 32 Questions With Complete
Solutions
1. Which activity should the nurse implement to decrease
shearing force on a client's stage II pressure injury?
a) Preventing the client from sliding in bed
b) Improving the client's hydration
c) Pulling the client up from under the arms
d) Lubricating the area with skin oil Correct Answers a)
Preventing the client from sliding in bed
Pg. 1055
Shearing force occurs when tissue layers move on one another,
causing vessels to stretch as they pass through the subcutaneous
tissue.
10. What type of dressing is occlusive or semi-occlusive, limits
exchange of oxygen between wound and environment, provides
minimal to moderate absorption of drainage, maintains a moist
wound environment, and may be left in place for three to seven
days, thus resulting in less interference with healing?
a) Hydrogel
b) Hydrocolloid
c) Alginate
d) Transparent film Correct Answers b) Hydrocolloid
Pg. 1073
,Hydrocolloids are occlusive or semi-occlusive dressings that
limit exchange of oxygen between wound and environment,
provide minimal to moderate absorption of drainage, maintain a
moist wound environment, and may be left in place for three to
seven days, thus resulting in less interference with healing.
Hydrogels maintain a moist wound environment and are best for
partial or full-thickness wounds. Alginates absorb exudate and
maintain a moist wound environment. They are best for wounds
with heavy exudate. Transparent films allow exchange of
oxygen between wound and environment. They are best for
small partial-thickness wounds with minimal drainage.
11. A medical-surgical nurse is assisting a wound care nurse
with the debridement of a client's coccyx wound. What is the
primary goal of this action?
a) Removing dead or infected tissue to promote wound healing
b) Stimulating the wound bed to promote the growth of
granulation tissue
c) Removing excess drainage and wet tissue to prevent
maceration of surrounding skin
d) Removing purulent drainage from the wound bed in order to
accurately assess it Correct Answers a) Removing dead or
infected tissue to promote wound healing
Pg. 1054
Debridement is the act of removing debris and devitalized tissue
in order to promote healing and reduce the risk of infection.
Debridement does not directly stimulate the wound bed, and the
goal is neither assessment nor the prevention of maceration.
, 12. The nurse is preparing to measure the depth of a client's
tunneled wound. Which implement should the nurse use to
measure the depth accurately?
a) An otic curette
b) A sterile tongue blade lubricated with water soluble gel
c) A sterile, flexible applicator moistened with saline
d) A small plastic ruler Correct Answers c) A sterile, flexible
applicator moistened with saline
Pg. 1107
A sterile, flexible applicator is the safest implement to use. A
small plastic ruler is not sterile. A sterile tongue blade lubricated
with water soluble gel is too large to use in a wound bed. An
otic curette is a surgical instrument designed for scraping or
debriding biological tissue or debris in a biopsy, excision, or
cleaning procedure and not flexible.
13. A nurse is cleaning the wound of a client who has been
injured by a gunshot. Which guideline is recommended for this
procedure?
a) Once the wound is cleaned, gently dry the wound bed with an
absorbent cloth
b) Use clean technique to clean the wound
c) Clean the wound in a circular pattern, beginning on the
perimeter of the wound
Solutions
1. Which activity should the nurse implement to decrease
shearing force on a client's stage II pressure injury?
a) Preventing the client from sliding in bed
b) Improving the client's hydration
c) Pulling the client up from under the arms
d) Lubricating the area with skin oil Correct Answers a)
Preventing the client from sliding in bed
Pg. 1055
Shearing force occurs when tissue layers move on one another,
causing vessels to stretch as they pass through the subcutaneous
tissue.
10. What type of dressing is occlusive or semi-occlusive, limits
exchange of oxygen between wound and environment, provides
minimal to moderate absorption of drainage, maintains a moist
wound environment, and may be left in place for three to seven
days, thus resulting in less interference with healing?
a) Hydrogel
b) Hydrocolloid
c) Alginate
d) Transparent film Correct Answers b) Hydrocolloid
Pg. 1073
,Hydrocolloids are occlusive or semi-occlusive dressings that
limit exchange of oxygen between wound and environment,
provide minimal to moderate absorption of drainage, maintain a
moist wound environment, and may be left in place for three to
seven days, thus resulting in less interference with healing.
Hydrogels maintain a moist wound environment and are best for
partial or full-thickness wounds. Alginates absorb exudate and
maintain a moist wound environment. They are best for wounds
with heavy exudate. Transparent films allow exchange of
oxygen between wound and environment. They are best for
small partial-thickness wounds with minimal drainage.
11. A medical-surgical nurse is assisting a wound care nurse
with the debridement of a client's coccyx wound. What is the
primary goal of this action?
a) Removing dead or infected tissue to promote wound healing
b) Stimulating the wound bed to promote the growth of
granulation tissue
c) Removing excess drainage and wet tissue to prevent
maceration of surrounding skin
d) Removing purulent drainage from the wound bed in order to
accurately assess it Correct Answers a) Removing dead or
infected tissue to promote wound healing
Pg. 1054
Debridement is the act of removing debris and devitalized tissue
in order to promote healing and reduce the risk of infection.
Debridement does not directly stimulate the wound bed, and the
goal is neither assessment nor the prevention of maceration.
, 12. The nurse is preparing to measure the depth of a client's
tunneled wound. Which implement should the nurse use to
measure the depth accurately?
a) An otic curette
b) A sterile tongue blade lubricated with water soluble gel
c) A sterile, flexible applicator moistened with saline
d) A small plastic ruler Correct Answers c) A sterile, flexible
applicator moistened with saline
Pg. 1107
A sterile, flexible applicator is the safest implement to use. A
small plastic ruler is not sterile. A sterile tongue blade lubricated
with water soluble gel is too large to use in a wound bed. An
otic curette is a surgical instrument designed for scraping or
debriding biological tissue or debris in a biopsy, excision, or
cleaning procedure and not flexible.
13. A nurse is cleaning the wound of a client who has been
injured by a gunshot. Which guideline is recommended for this
procedure?
a) Once the wound is cleaned, gently dry the wound bed with an
absorbent cloth
b) Use clean technique to clean the wound
c) Clean the wound in a circular pattern, beginning on the
perimeter of the wound
