Chapter 38 Providing Wound Care and Treating Pressure Ulcers

Chapter 38  Providing Wound Care and Treating Pressure Ulcers

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse clarifies that the first stage of wound healing is:
a.
proliferation.
b.
maturation.
c.
reconstruction.
d.
inflammation.

ANS: D
Inflammation is the first stage of wound healing, followed by the proliferation, maturation, and reconstruction stages.

DIF: Cognitive Level: Knowledge REF: p. 761 OBJ: Theory #1
TOP: Inflammatory Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:
a.
fourth intention.
b.
third intention.
c.
second intention.
d.
first intention.

ANS: D
A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first, or primary, intention. Wounds that are not closed heal by either second (secondary) or third (tertiary) intention.

DIF: Cognitive Level: Comprehension REF: p. 762 OBJ: Theory #1
TOP: Wound Healing Stages KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse gives an example of a wound that heals by second (secondary) intention as a:
a.
laceration with edges that do not approximate.
b.
surgical incision closed with staples.
c.
chest wound left open for a closed system.
d.
puncture wound sutured with silk suture.

ANS: A
A secondary intention healing occurs when there is a jagged wound whose edges do not approximate.

DIF: Cognitive Level: Comprehension REF: p. 762 OBJ: Theory #1
TOP: Wound Types KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse’s most helpful response would be that swelling indicates that:
a.
an infection is in progress at the wound site.
b.
vessels have dilated and allowed plasma to leak into the wound site.
c.
he has lain in one position for such a long time that swelling has occurred.
d.
there is probably a deeper injury than what appears on the surface.

ANS: B
As part of the healing process, histamines and prostaglandins have caused small vessels to dilate and leak plasma and electrolytes into the wound site causing swelling, which causes the wound to become reddened and swollen as the phagocytosis cleans up the microorganisms.

DIF: Cognitive Level: Application REF: p. 761 OBJ: Theory #3
TOP: Swelling and Inflammation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse warns the patient that one of the patient’s habits has caused the reduction of functional hemoglobin, which limits the hemoglobin’s oxygen carrying ability. To improve this situation, the nurse suggests that the patient quit:
a.
drinking.
b.
using marijuana.
c.
smoking cigarettes.
d.
eating excessive fats.

ANS: C
Smoking reduces the functional hemoglobin which, in turn, reduces the amount of oxygen carried to the cells of the body.

DIF: Cognitive Level: Analysis REF: p. 762 OBJ: Theory #2
TOP: Smoking KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation