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Showing 10 questions, Sign in for moreA nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?
Explanation
Correct answer: C) Increased pain and tenderness
Rationale: Increased pain and tenderness of the wound site may indicate an infection, as the inflammatory response is triggered by the presence of microorganisms. The nurse should obtain a wound culture and notify the provider of the suspected infection.
Incorrect options:
A) Serous drainage - This is a normal finding for a healing wound, as serous fluid is clear and watery and contains plasma and white blood cells. It does not indicate an infection unless it is cloudy, foul-smelling, or purulent.
B) Reddened periwound skin - This is a normal finding for a healing wound, as the increased blood flow to the area promotes oxygen and nutrient delivery to the wound site. It does not indicate an infection unless the redness is spreading, warm, or accompanied by other signs of inflammation.
D) Granulation tissue formation - This is a normal finding for a healing wound, as granulation tissue is new connective tissue that fills the wound bed and supports epithelialization. It does not indicate an infection unless it is pale, friable, or necrotic.
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?
Explanation
Correct answer: A) Eschar
Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.
Incorrect options:
B) Slough - This is dead tissue that is yellow, tan, gray, green, or brown and has a moist, stringy, or mucinous appearance. It may be loosely attached or firmly adherent to the wound bed. It should be removed to promote wound healing.
C) Fibrin - This is a protein involved in blood clotting that forms a mesh-like structure to seal the wound and stop bleeding. It may appear as a yellowish-white film on the wound surface. It should not be confused with slough or pus.
D) Exudate - This is fluid that leaks out of blood vessels into the surrounding tissues due to inflammation or injury. It may have different characteristics depending on the type and stage of the wound. It should be managed to maintain a moist but not wet wound environment.
A nurse is planning care for a client who has a surgical incision with staples. Which intervention should the nurse include in the plan to prevent wound dehiscence?
Explanation
Correct answer: B) Instruct the client to splint the incision when coughing
Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.
Incorrect options:
A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.
C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.
D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.
A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is 4 cm in length, 3 cm in width, and 2 cm in depth. The wound bed is 80% granulation tissue and 20% slough. Which type of dressing should the nurse use for this wound?
Explanation
Correct answer: C) Alginate
Rationale: Alginate is a type of dressing that is derived from seaweed and forms a gel-like substance when in contact with wound exudate. It is highly absorbent and can handle moderate to large amounts of drainage. It also provides a moist wound environment and supports autolytic debridement of slough and eschar. It is suitable for wounds with depth, such as stage 3 or 4 pressure ulcers.
Incorrect options:
A) Hydrocolloid - This is a type of dressing that has an adhesive outer layer and an inner layer that forms a gel when in contact with wound fluid. It is occlusive and waterproof and provides a moist wound environment. It is suitable for wounds with minimal to moderate drainage, such as stage 2 pressure ulcers or partial-thickness burns. It is not recommended for wounds with depth, as it may cause maceration of the surrounding skin.
B) Hydrogel - This is a type of dressing that consists of water or glycerin-based gels that are available in sheets, gauze, or impregnated into other types of dressings. It provides moisture to dry wounds and facilitates autolytic debridement. It is suitable for wounds with minimal drainage, such as stage 2 pressure ulcers or partial-thickness burns. It is not recommended for wounds with moderate to large amounts of drainage, as it may cause maceration or leakage.
D) Transparent film - This is a type of dressing that consists of a thin sheet of polyurethane with an adhesive coating that allows the exchange of oxygen and moisture vapor but not bacteria or water. It provides a moist wound environment and facilitates autolytic debridement. It is suitable for wounds with minimal drainage, such as stage 1 pressure ulcers or superficial abrasions. It is not recommended for wounds with depth or moderate to large amounts of drainage, as it may cause maceration or leakage.
A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?
Explanation
Correct answer: B) Obtain a wound culture and sensitivity
Rationale: The nurse should first obtain a wound culture and sensitivity to identify the causative organism and the appropriate antibiotic therapy for the client's wound infection. The nurse should use sterile technique and collect the specimen from the wound bed after cleansing the wound with normal saline.
Incorrect options:
A) Apply compression bandages to the affected leg - Compression therapy is indicated for clients with venous leg ulcers to improve venous return and reduce edema, but it is not the first priority in this case. The nurse should first address the infection before applying compression bandages.
C) Administer prescribed analgesics and antipyretics - Administering analgesics and antipyretics may help to relieve the client's pain and fever, but it does not treat the underlying cause of the infection. The nurse should first obtain a wound culture and sensitivity before administering medications.
D) Elevate the affected leg above the level of the heart - Elevating the affected leg may help to reduce edema and improve blood flow, but it does not address the infection. The nurse should first obtain a wound culture and sensitivity before elevating the leg.
A nurse is caring for a client who has a stage 3 pressure ulcer on the sacrum. Which type of dressing should the nurse use to promote moist wound healing?
Explanation
Correct answer: A) Hydrocolloid
Rationale: Hydrocolloid dressings are occlusive and adhesive, forming a gel-like substance over the wound bed that maintains a moist environment and facilitates autolytic debridement. They are suitable for stage 3 pressure ulcers, as they protect the wound from contamination and reduce pain and trauma during dressing changes.
Incorrect options:
B) Transparent film - This type of dressing is semi-permeable and allows oxygen exchange, but does not absorb exudate or provide cushioning. It is suitable for stage 1 pressure ulcers, as it protects the skin from friction and moisture.
C) Calcium alginate - This type of dressing is highly absorbent and forms a gel-like substance when in contact with wound exudate. It is suitable for stage 4 pressure ulcers with heavy drainage, as it fills the dead space and promotes hemostasis.
D) Gauze - This type of dressing is inexpensive and readily available, but it can adhere to the wound bed and cause pain and bleeding during removal. It is suitable for stage 4 pressure ulcers with minimal drainage, as it provides mechanical debridement.
A client is admitted to the hospital with a burn injury that covers 30% of the total body surface area (TBSA). The client's weight is 70 kg. Using the Parkland formula, how much fluid should the client receive in the first 24 hours after the injury?
Explanation
Correct answer: D) 16,800 mL
Rationale: The Parkland formula is used to calculate the fluid resuscitation for burn clients. It states that the client should receive 4 mL of lactated Ringer's solution per kg of body weight per percentage of TBSA burned in the first 24 hours after the injury. Half of this amount should be given in the first 8 hours, and the remaining half should be given in the next 16 hours. Therefore, for this client, the calculation is as follows:
4 mL x 70 kg x 30% = 8,400 mL in the first 24 hours
8,400 mL / 2 = 4,200 mL in the first 8 hours
8,400 mL - 4,200 mL = 4,200 mL in the next 16 hours
Incorrect options:
A) 2,100 mL - This is half of the amount that should be given in the first 8 hours.
B) 4,200 mL - This is the amount that should be given in the first 8 hours or in the next 16 hours.
C) 8,400 mL - This is half of the amount that should be given in the first 24 hours.
A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?
Explanation
Correct answer: C) Moistening the new dressing with sterile water before wringing it out and applying it to the wound
Rationale: Wet-to-dry dressings are used for mechanical debridement of necrotic tissue from chronic wounds. The new dressing should be moistened with sterile water (not saline, as saline can cause sodium crystals to form on the wound bed and impair healing), wrung out to remove excess moisture (to prevent maceration of surrounding skin), and loosely packed into the wound (to allow contact with necrotic tissue). The old dressing should be removed dry (not soaked, as soaking can rehydrate necrotic tissue and reduce debridement).
Incorrect options:
A) Soaking the old dressing with sterile saline before removing it - This can rehydrate necrotic tissue and reduce debridement.
B) Applying antibiotic ointment to the new dressing before placing it on the wound - This can interfere with debridement and increase the risk of infection and resistance.
D) Covering the new dressing with an occlusive secondary dressing to prevent evaporation - This can create a moist environment that promotes bacterial growth and infection.
A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?
Explanation
Correct answer: A) Autograft
Rationale: An autograft is a type of skin graft that uses the client's own skin as the donor site. This is the preferred type of graft, as it has the lowest risk of rejection and infection, and provides the best cosmetic and functional results.
Incorrect options:
B) Allograft - This is a type of skin graft that uses human skin from a cadaver or a living donor as the donor site. This type of graft is used as a temporary measure to cover large wounds until an autograft is available.
C) Xenograft - This is a type of skin graft that uses animal skin, usually from pigs, as the donor site. This type of graft is also used as a temporary measure to protect wounds from infection and fluid loss until an autograft is available.
D) Mesh graft - This is a type of skin graft that involves making small slits in the donor skin to create a mesh-like pattern. This allows the graft to cover a larger area and conform to irregular surfaces. This type of graft can be either an autograft or an allograft.
A nurse is assessing a client who has a wound on the abdomen. The nurse observes that the wound edges are approximated, there is minimal drainage, and granulation tissue is visible. How should the nurse document this wound?
Explanation
Correct answer: C) Primary intention wound
Rationale: A primary intention wound is one that heals by epithelialization, with minimal tissue loss and scarring. The wound edges are approximated (closed), either naturally or by surgical means, and there is minimal drainage and inflammation. Granulation tissue is the new connective tissue that forms on the wound bed, indicating healing.
Incorrect options:
A) Partial-thickness wound - This is a wound that involves damage to the epidermis and part of the dermis, such as an abrasion or a blister. It heals by regeneration, with minimal scarring.
B) Full-thickness wound - This is a wound that involves damage to the epidermis, dermis, and underlying structures, such as a pressure ulcer or a surgical incision. It heals by granulation, contraction, and epithelialization, with significant scarring.
D) Secondary intention wound - This is a wound that heals by granulation, contraction, and epithelialization, with significant tissue loss and scarring. The wound edges are not approximated (open), either due to infection, trauma, or chronicity, and there is copious drainage and inflammation.
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