C HAPTER 38: P ROVIDING W OUND C ARE AND
T REATING P RESSURE U LCERS
Williams: deWit's Fundamental Con cepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. Because the patient with an abdominal dressing requires frequent dressing
changes, the abdomen is beginning to show skin irritation from repeated
tape removal. The nurse would change the dressing procedure in order to
use:
a. paper tape.
b. Montgomery straps.
c. Karaya paste.
d. elastic adhesive tape.
ANS: B
Montgomery straps allow the dressing to be changed without constantl y
appl ying and removing tape.
DIF: Cognitive Level: Anal ysis REF: p. 770 OBJ:
Clinical Practice #1 TOP: Securing Dressings KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
,2. A nurse caring for a patient with a Stage I pressure ulcer would most
appropriatel y select:
a. nonocclusive dressing.
b. exudate absorbing dressing.
c. hydrocolloid dressing .
d. thin film dressing.
ANS: D
Thin film dressings are used on Stage I ulcers to protect them from
shearing forces and to keep them moist.
DIF: Cognitive Level: Application REF: p. 769 OBJ:
Clinical Practice #2 TOP: Treatment of Ulcers KEY:
Nursing Pro cess Step: Implementation MSC: NCLEX:
Physiological Integrity: Reduction of Risk
3. A patient has a pooling of blood under unbroken skin of the hip after a
fall. The nurse should document that this patient has a(n):
a. abrasion.
b. laceration.
c. hematoma.
d. avulsion.
ANS: C
A hematoma is a pooling of blood under unbroken skin. An abrasion is
a scraping away of skin tissue. A laceration is a torn, ragged, or
mangled wound, and a contusion is a bruise.
, DIF: Cognitive Level: Comprehension REF: p. 765
OBJ: Theory #1 TOP: Documentation KEY: Nursing
Process Step: Assessment MSC: NCLEX: Physiological
Integrit y: Physiological Adaptation
4. The nurse is performing a dry sterile dressing change for an abdominal
wound. The nurse should use a swab to clean:
a. from the outer abd omen toward the wound.
b. in a circular motion around the wound circling to the outside.
c. from the left to the right across the wound.
d. directl y over the wound.
ANS: B
A circular motion around the wound toward the outside keeps the
wound area cleanest.
DIF: Cognitive Level: Application REF: p. 776|Skill 38-1
OBJ: Clinical Practice #1 TOP: Wound Cleaning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Safe, Effective Care Environment: Safet y and Infection
Control
5. A patient is due for a wound dres sing change for a horizontal lower
abdominal incision. In which direction should the nurse pull to remove the
tape from the old dressing?
a. From left to right across the abdomen
b. From right to left across the abdomen
c. From the top of the wound to the bottom
T REATING P RESSURE U LCERS
Williams: deWit's Fundamental Con cepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. Because the patient with an abdominal dressing requires frequent dressing
changes, the abdomen is beginning to show skin irritation from repeated
tape removal. The nurse would change the dressing procedure in order to
use:
a. paper tape.
b. Montgomery straps.
c. Karaya paste.
d. elastic adhesive tape.
ANS: B
Montgomery straps allow the dressing to be changed without constantl y
appl ying and removing tape.
DIF: Cognitive Level: Anal ysis REF: p. 770 OBJ:
Clinical Practice #1 TOP: Securing Dressings KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
,2. A nurse caring for a patient with a Stage I pressure ulcer would most
appropriatel y select:
a. nonocclusive dressing.
b. exudate absorbing dressing.
c. hydrocolloid dressing .
d. thin film dressing.
ANS: D
Thin film dressings are used on Stage I ulcers to protect them from
shearing forces and to keep them moist.
DIF: Cognitive Level: Application REF: p. 769 OBJ:
Clinical Practice #2 TOP: Treatment of Ulcers KEY:
Nursing Pro cess Step: Implementation MSC: NCLEX:
Physiological Integrity: Reduction of Risk
3. A patient has a pooling of blood under unbroken skin of the hip after a
fall. The nurse should document that this patient has a(n):
a. abrasion.
b. laceration.
c. hematoma.
d. avulsion.
ANS: C
A hematoma is a pooling of blood under unbroken skin. An abrasion is
a scraping away of skin tissue. A laceration is a torn, ragged, or
mangled wound, and a contusion is a bruise.
, DIF: Cognitive Level: Comprehension REF: p. 765
OBJ: Theory #1 TOP: Documentation KEY: Nursing
Process Step: Assessment MSC: NCLEX: Physiological
Integrit y: Physiological Adaptation
4. The nurse is performing a dry sterile dressing change for an abdominal
wound. The nurse should use a swab to clean:
a. from the outer abd omen toward the wound.
b. in a circular motion around the wound circling to the outside.
c. from the left to the right across the wound.
d. directl y over the wound.
ANS: B
A circular motion around the wound toward the outside keeps the
wound area cleanest.
DIF: Cognitive Level: Application REF: p. 776|Skill 38-1
OBJ: Clinical Practice #1 TOP: Wound Cleaning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Safe, Effective Care Environment: Safet y and Infection
Control
5. A patient is due for a wound dres sing change for a horizontal lower
abdominal incision. In which direction should the nurse pull to remove the
tape from the old dressing?
a. From left to right across the abdomen
b. From right to left across the abdomen
c. From the top of the wound to the bottom
