Introduction > Medical Surgical
Exam Review
Wound Care and Bleeding Control
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is caring for a client who has a deep laceration on the forearm. The nurse notices that the wound is oozing dark red blood. What type of bleeding is this?
Explanation
Choice A Reason: Arterial bleeding is bright red and spurts from a wound, not dark red and oozing.
Choice B Reason: Venous bleeding is characterized by a steady flow of dark red blood from a wound, which matches the description in the question.
Choice C Reason: Capillary bleeding is slow and oozes from a wound, but it is usually lighter in color than venous bleeding.
Choice D Reason: Hemorrhagic bleeding is severe and life-threatening, and it can be arterial or venous, but it is not a specific type of bleeding.
A nurse is teaching a group of students about wound care and bleeding control. Which of the following statements should the nurse include in the teaching? (Select all that apply.)
Explanation
Choice A Reason: Alcohol should not be used to clean a wound, as it can damage healthy tissue and delay healing. Soap and water or saline solution are preferred.
Choice B Reason: The frequency of dressing changes depends on the type and condition of the wound, but it should not be done more often than necessary, as it can disrupt healing and increase the risk of infection.
Choice C Reason: Applying direct pressure to a wound with a clean cloth or bandage is the most effective way to stop the bleeding, as it compresses the blood vessels and prevents further blood loss.
Choice D Reason: Elevating the injured part above the level of the heart can help reduce blood loss by gravity, as it lowers the blood pressure in the injured area and reduces blood flow.
Choice E Reason: Using a tourniquet as the first option to control bleeding is not recommended, as it can cause tissue damage and necrosis by cutting off blood supply to the limb. It should only be used as a last resort when other methods fail, and it should be loosened every 10 minutes to check for signs of circulation.
A nurse is assessing a client who has an infected wound on the leg. The nurse observes that the wound has yellow-green drainage, foul odor, and increased pain. The nurse asks the client how they feel about their wound. Which of the following statements by the client indicates a need for further intervention?
Explanation
Choice A Reason: Worrying about wound healing is a normal reaction, but it does not indicate a need for further intervention, unless it affects the client's mood or coping skills.
Choice B Reason: Feeling embarrassed by how a wound looks and smells is also a normal reaction, but it does not indicate a need for further intervention, unless it affects the client's self-esteem or social interactions.
Choice C Reason: Taking antibiotics as prescribed by a doctor is an appropriate action for an infected wound, as it helps prevent or treat bacterial infection.
Choice D Reason: Cleaning a wound with hydrogen peroxide every day can harm healthy tissue and delay healing, as well as increase the risk of infection by altering the pH balance of the wound environment. This indicates a need for further intervention by the nurse.
A nurse is preparing to dress a wound on a client's abdomen. The nurse notices that the wound edges are approximated, the wound bed is pink, and there is no drainage or signs of infection. The nurse selects a transparent film dressing for the wound. What is the rationale for this choice?
Explanation
Choice A Reason: A transparent film dressing protects the wound from contamination and allows oxygen to reach the wound, which promotes healing. This is the rationale for this choice.
Choice B Reason: A transparent film dressing does not absorb any drainage, so it is not suitable for wounds that are wet or exudative. A hydrocolloid or foam dressing would be more appropriate for these types of wounds, as they absorb excess drainage and provide a moist environment for healing.
Choice C Reason: A transparent film dressing does not debride any necrotic tissue, so it is not suitable for wounds that are infected or have slough or eschar. A hydrogel or enzymatic dressing would be more appropriate for these types of wounds, as they debride necrotic tissue and stimulate granulation tissue formation.
Choice D Reason: A transparent film dressing does not compress the wound, so it is not suitable for wounds that are bleeding or have edema. A gauze or elastic bandage would be more appropriate for these types of wounds, as they compress the wound and prevent bleeding and edema.
A nurse is caring for a client who has a gunshot wound on the chest. The nurse observes that the client's breathing is rapid and shallow, the pulse is weak and thready, and the blood pressure is low. The nurse suspects that the client has developed a tension pneumothorax. What should the nurse do first?
Explanation
Choice A Reason: Administering oxygen via nasal cannula may help improve oxygenation, but it does not address the underlying cause of tension pneumothorax, which is increased pressure in the chest cavity.
Choice B Reason: Inserting a chest tube in the affected side may help drain air and fluid from the pleural space and restore lung expansion, but it requires sterile equipment and preparation, which may delay treatment.
Choice C Reason: Performing needle decompression in the second intercostal space at the midclavicular line on the affected side can release the trapped air and relieve the pressure in the chest cavity, which can improve ventilation and circulation. This is a rapid and effective intervention that can be done with minimal equipment and preparation.
Choice D Reason: Applying an occlusive dressing over the wound may help prevent air from entering or escaping from the pleural space, but it does not remove any existing air that has already caused tension pneumothorax.
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