NURS 258 Final Exam (Combination of previous sets, and
some magic notes) Questions With Complete Solutions
Dehiscence & Evisceration
dehiscence: opening up of a surgical incision
evisceration: protrusion of an internal organ through incision
-increase in drainage
-pt reports it feels like it is coming apart
Clean Closed Wound
assess that the wound and dressing is clean, dry, and intact
(CDI)
Assessment of Open Wound
Location, REED (Redness of surrounding skin,
Edema/induration, Ecchymosis, Discharge/drainage),
Assessment of Drainage
amount, color/consistency (serous: clear, sanguinous: red,
sersanguinous: pink, purulent: pus), odor, size/shape (length,
width, depth, description of wound bed (red, yellow, black)),
temperature, tenderness/pain, approximation, stage of pressure
ulcer, photograph
Documentation of a Wound
-dressing: location, secure/nonsecure attachment, drainage
-drainage devices: location, patency, drainage
-assessment of wound
,-action: type of dressing change
-response: how pt tolerated it
Pressure Injuries
-turning at least q2h
-shearing forces at work with ill pts
-any part of the body can develop a pressure wound
-look for nonblanching
-open wound
-pressure injuries can heal: chemical debriding (elase), sharps
debriding, gelfoam into wound, wet-dry dressings, sugar
solutions, peroxide flushing, heat lamp therapies
Basics in Wound Care
increase nutrition, decrease pressure at the site, increase
mobility, decrease infections, increase moisture of skin
Materials for Dry Wound Care
4x4 gauze pads, drain sponges (have slit and circle to go around
the drain), ABD pads (often used in the abdominal area), telfa
(non-adherent pad, clear)
Materials for Wet/Moist Wound Care
saline-soaked gauze pads, saline-soaked gauze packing strips,
secure with more gauze then rolled gauze or tape
Wound Drainage Devices
wound VAC, jackson-pratt drain, hemovac, penrose drain
Staple Removal
,start at second staple. two prongs underneath, one on top.
depress handle. remove every other staple, clean, then apply
steri strips where the staple was (do not use tension or pull steri
strips)
Suture Removal
cut on side of knot closest to the skin, pull the thread up and
over the wound
Obtaining a Wound Culture
swab from margin to margin in a zig-zag pattern, rotating the
swab as you go.
obtain before antibiotics
Principles of Surgical Asepsis
-a sterile object remains sterile only when touched by another
sterile object
-only sterile object may be placed on the sterile field
-a sterile object or filed out of the range of vision or an object
held below a person's waist is contaminated
-sterile object or field becomes contaminated by prolonged air
exposure
-when a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
-fluid flows in direction of gravity
-the edges of a sterile field or container are considered to be
contaminated
, 7 Rights of Med Administration
right patient, right drug, right dose, right time, right route, right
reason and right documentation
Polyuria
Excessive urine production, usually 2500-3000 ml/day
Oliguria
Diminished urine output, typically <500 ml/24 hours
Anuria
Technically no urine output; <100 ml/24 hours
Dysuria
Painful or difficult urination
Nocturia
Excessive urination at night
Hematuria
Presence of blood in urine
Pyuria
Presence of pus in urine
Urgency
Sudden and compelling need to urinate
Frequency
The need to urinate often
some magic notes) Questions With Complete Solutions
Dehiscence & Evisceration
dehiscence: opening up of a surgical incision
evisceration: protrusion of an internal organ through incision
-increase in drainage
-pt reports it feels like it is coming apart
Clean Closed Wound
assess that the wound and dressing is clean, dry, and intact
(CDI)
Assessment of Open Wound
Location, REED (Redness of surrounding skin,
Edema/induration, Ecchymosis, Discharge/drainage),
Assessment of Drainage
amount, color/consistency (serous: clear, sanguinous: red,
sersanguinous: pink, purulent: pus), odor, size/shape (length,
width, depth, description of wound bed (red, yellow, black)),
temperature, tenderness/pain, approximation, stage of pressure
ulcer, photograph
Documentation of a Wound
-dressing: location, secure/nonsecure attachment, drainage
-drainage devices: location, patency, drainage
-assessment of wound
,-action: type of dressing change
-response: how pt tolerated it
Pressure Injuries
-turning at least q2h
-shearing forces at work with ill pts
-any part of the body can develop a pressure wound
-look for nonblanching
-open wound
-pressure injuries can heal: chemical debriding (elase), sharps
debriding, gelfoam into wound, wet-dry dressings, sugar
solutions, peroxide flushing, heat lamp therapies
Basics in Wound Care
increase nutrition, decrease pressure at the site, increase
mobility, decrease infections, increase moisture of skin
Materials for Dry Wound Care
4x4 gauze pads, drain sponges (have slit and circle to go around
the drain), ABD pads (often used in the abdominal area), telfa
(non-adherent pad, clear)
Materials for Wet/Moist Wound Care
saline-soaked gauze pads, saline-soaked gauze packing strips,
secure with more gauze then rolled gauze or tape
Wound Drainage Devices
wound VAC, jackson-pratt drain, hemovac, penrose drain
Staple Removal
,start at second staple. two prongs underneath, one on top.
depress handle. remove every other staple, clean, then apply
steri strips where the staple was (do not use tension or pull steri
strips)
Suture Removal
cut on side of knot closest to the skin, pull the thread up and
over the wound
Obtaining a Wound Culture
swab from margin to margin in a zig-zag pattern, rotating the
swab as you go.
obtain before antibiotics
Principles of Surgical Asepsis
-a sterile object remains sterile only when touched by another
sterile object
-only sterile object may be placed on the sterile field
-a sterile object or filed out of the range of vision or an object
held below a person's waist is contaminated
-sterile object or field becomes contaminated by prolonged air
exposure
-when a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
-fluid flows in direction of gravity
-the edges of a sterile field or container are considered to be
contaminated
, 7 Rights of Med Administration
right patient, right drug, right dose, right time, right route, right
reason and right documentation
Polyuria
Excessive urine production, usually 2500-3000 ml/day
Oliguria
Diminished urine output, typically <500 ml/24 hours
Anuria
Technically no urine output; <100 ml/24 hours
Dysuria
Painful or difficult urination
Nocturia
Excessive urination at night
Hematuria
Presence of blood in urine
Pyuria
Presence of pus in urine
Urgency
Sudden and compelling need to urinate
Frequency
The need to urinate often
