Chapter 38 Wound Care and Irrigations

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Chapter 38  Wound Care and Irrigations

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

MULTIPLE CHOICE

1. When is healing by primary intention expected?
a.
When the wound is left open and is allowed to heal
b.
When a surgical wound is left open for 3 to 5 days
c.
When connective tissue development is evident
d.
When the edges of a clean incision remain close together

ANS: D
Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 922
OBJ: Differentiate between primary and secondary intention wound healing.
TOP: Primary Intention KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

2. The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed?
a.
Change the dressing so she can assess the wound.
b.
Administer an analgesic 30 to 45 minutes before a dressing change.
c.
Culture the wound if wound exudate is present.
d.
Administer an analgesic 30 minutes after a dressing change.

ANS: B
To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth.

DIF: Cognitive Level: Application REF: Text reference: p. 922
OBJ: Perform a wound assessment. TOP: Medicating the Patient Before Dressing Changes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system?
a.
Decreases the amount of angiogenesis
b.
Reduces mechanical stretch of tissue
c.
Dressing should not need to be changed for 48 hours
d.
Helps create a dry environment

ANS: C
The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels), and that this stimulates the production of new blood vessels via mechanical stretch of the tissue. The dressing placed into the wound maintains a moist environment to facilitate healing. A suction device is placed over the dressing, and the dressing, suction, and wound area are covered with a transparent dressing, which provides the air-tight seal necessary for negative-pressure wound therapy (NPWT).

DIF: Cognitive Level: Application REF: Text reference: p. 923
OBJ: Perform a wound assessment. TOP: Negative-Pressure Wound Therapy (NPWT)
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

4. The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock. How should the nurse proceed?
a.
Use irrigation pressures of less than 4 psi.
b.
Cleanse in a direction from most contaminated to least contaminated.
c.
Irrigate so that the solution flows from least contaminated to most contaminated.
d.
Irrigate with clean irrigation solution only.

ANS: C
When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.

DIF: Cognitive Level: Application REF: Text reference: p. 923
OBJ: Perform wound irrigation. TOP: Irrigation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

5. The nurse is changing a surgical dressing and is cleansing the wound. She knows that:
a.
the incision line should be cleansed last.
b.
she should start at one end of the incision line and swab the entire length.
c.
she should start at the center of the incision line and swab toward one end.
d.
she should work in a circular motion around the incision line.

ANS: C
The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke.

DIF: Cognitive Level: Application REF: Text reference: p. 923
OBJ: Explain factors that impair or promote normal wound healing.
TOP: Cleansing an Incision KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

 

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