Chapter 26 Wound Care

Chapter 26  Wound Care

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. When reassessing the patient’s wound, the nurse notes redness and swelling, but no drainage. This is indicative of the phase of healing called the
A.
Reconstruction phase.
B.
Remodeling phase.
C.
Inflammatory phase.
D.
Maturation phase.

____ 2. The nurse is providing care for a patient who has just had a bowel resection. The nurse understands that the patient’s wound will need to be closely monitored for infection because it falls under the classification of
A.
Open wounds.
B.
Closed wounds.
C.
Contusion wounds.
D.
Laceration wounds.

____ 3. The nurse applies several 4 × 4s around a patient’s wound with a large amount of drainage because
A.
The drainage must be kept close to the wound to promote healing.
B.
It allows fibroblasts to begin the granulation process.
C.
It lowers a patient’s risk for wound separation.
D.
Drainage in direct contact with the wound can cause infection.

____ 4. When assessing the patient’s wound, the nurse suspects that the wound most likely has been infected with Clostridia because
A.
A crackling sensation can be felt when palpating around the wound.
B.
The area surrounding the wound is bright red and draining serosanguineous material.
C.
The drainage from the wound has changed from serous to purulent.
D.
The wound is not as well-approximated as it appeared to be yesterday.

____ 5. When irrigating the patient’s wound with a syringe, the nurse directs the flow of solution from the superior area to the inferior area of the wound. The rationale for this action is to
A.
Slow the irrigation of the wound, thus eliminating patient discomfort.
B.
Assist the nurse in proceeding in an organized manner.
C.
Direct the flow of solution from the least contaminated area to the most contaminated area.
D.
Use gravity in increasing the force of the irrigation.

Chapter 26. Wound Care
Answer Section

MULTIPLE CHOICE

1. ANS: C

Feedback
A
During the reconstruction phase, scar tissue is developing.
B
During the remodeling phase, the wound is retracting and scar tissue is strengthening.
C
The first phase of healing is the inflammatory phase. During this phase, the nurse should expect to see warmth, edema, and redness around the wound. Chapter Objective: Explain the three phases of healing.
D
As in the remodeling phase, the wound is retracting and scar tissue is strengthening in the maturation phase.

PTS: 1 REF: Chapter: 26 | Page: 564 OBJ: Chapter Objective: 26-8
KEY: Content Area: Physiological Adaptation | Integrated Process: Nursing Process/Assessment | Client Need: Physiological Integrity/Physiological Adaptation, Basic Pathophysiology | Cognitive Level: Application

2. ANS: A

Feedback
A
Surgery results in a breach in skin integrity, which increases the risk of infection. Chapter Objective: Differentiate between clean, clean-contaminated, contaminated, infected, colonized, open, and closed wounds.
B
In a closed wound, the skin remains intact and less likely to develop complications, such as infection.
C
A contusion is a closed, discolored wound that was caused by blunt trauma.
D
A surgical wound is not a laceration. A laceration is due to accidental cutting or tearing of the skin.

PTS: 1 REF: Chapter: 26 | Page: 567 OBJ: Chapter Objective: 26-3
KEY: Content Area: Physiological Adaptation | Integrated Process: Nursing Process/Planning | Client Need: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems | Cognitive Level: Analysis

3. ANS: D

Feedback
A
Drainage left close to a wound can cause infection.
B
Excess drainage will interfere with granulation.
C
The purpose of using 4 × 4s is to prevent infection, which could contribute to wound separation.
D
The application of 4 × 4s will keep the drainage away from the skin, thereby decreasing the risk for infection. Chapter Objective: Discuss wound treatments and the nursing responsibilities for each.

PTS: 1 REF: Chapter: 26 | Page: 570 OBJ: Chapter Objective: 26-12
KEY: Content Area: Physiological Adaptation | Integrated Process: Nursing Process/Implementation | Client Need: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems | Cognitive Level: Analysis

4. ANS: A

Feedback
A
Crackling can be felt due to the gas created by the bacterium Clostridia. Chapter Objective: Describe possible complications of wound healing and appropriate nursing care for each.
B
A bright red wound can indicate a beginning wound infection, but serosanguineous drainage is typically a normal finding.
C
Purulent drainage indicates an infection but doesn’t necessarily indicate bacterium Clostridia.
D
A wound that appears to be less-approximated could indicate that an infection is present, but it is not specific for bacterium Clostridia.

PTS: 1 REF: Chapter: 26 | Page: 567 OBJ: Chapter Objective: 26-11
KEY: Content Area: Physiological Adaptation | Integrated Process: Nursing Process/Assessment | Client Need: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems | Cognitive Level: Application

5. ANS: C

Feedback
A
Utilizing a syringe for irrigation does not slow the irrigation but applies gentle pressure to wash away wound debris. Irrigating appropriately does eliminate patient discomfort.
B
Irrigating from the superior to inferior areas is organized, but the purpose is to prevent further contamination of the wound.
C
The purpose of irrigating from the superior to inferior areas is to direct the flow of solution from the least contaminated area to the most contaminated area. Objective: Discuss wound treatments and the nursing responsibilities for each.
D
The force of irrigation is controlled by using a 35-mL syringe with a 19-gauge angiocath attached.

PTS: 1 REF: Chapter: 26 | Page: 571 OBJ: Chapter Objective: 26-12
KEY: Content Area: Physiological Adaptation | Integrated Process: Nursing Process/Implementation | Client Need: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems | Cognitive Level: Analysis