SOLVED

Chapter 9 Question 1 Assessment of the patient’s sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner? 1. Tertiary intention 2. Primary intention 3. Secondary intention 4. Recurrent surgical debridement Question 2 A patient is to receive pulsatile lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment? 1. “This treatment is a form of autolytic debridement to remove dead tissue from your heel.” 2. “Your foot will be submersed in a whirlpool tub for this treatment.” 3. “This treatment will help cleanse the wound bed.” 4. “This treatment will inject medications into the deep crevices of your wound.” Question 3 The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound? 1. Hydrocolloid dressing 2. Wet-to-dry dressing 3. Alginate dressing 4. Dry, sterile dressing Question 4 A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patient’s risk of complications with wound healing? 1. The patient smokes eight cigarettes a day. 2. The patient has peripheral artery disease. 3. The patient has osteoarthritis in his knees. 4. The patient’s average blood sugar measurements are over 200mcg/dL. 5. The patient lost some blood during the injury but the loss was not excessive. Question 5 There is dead tissue throughout the patient’s nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal? 1. Diet analysis for protein adequacy 2. Keeping the wound covered to increase oxygen to the wound bed 3. Debridement of devitalized tissue 4. Introduction of air into the wound for drying Question 6 The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated? 1. Encourage the patient to ingest more fluids. 2. Assess for pain and warmth. 3. Cover the wound with a sterile dry dressing. 4. Dress the wound as prescribed. Question 7 The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important? 1. Wear gloves at all times. 2. Administer antibiotics as prescribed. 3. Assess patients for infection risk upon admission. 4. Follow hand washing protocols. Question 8 A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the health care provider about possible necrotizing fasciitis (NF)? 1. Blood pressure is 140/90 mm Hg. 2. The patient reports recently taking steroids for a severe ear infection. 3. The patient works in an elementary school. 4. The patient reports pain as a 9 on the 1 to 10 pain scale. 5. The patient’s body mass index is 31. Question 9 A male patient tells the nurse that he has “excruciating pain” in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patient’s perineum below the scrotal sac. What nursing intervention is priority? 1. Have the wound further evaluated for possible Fournier’s gangrene. 2. Apply ice to the region. 3. Give the patient prn acetaminophen. 4. Place a scrotal support on the patient. Question 10 A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient’s wound? 1. Irrigating the wound twice daily before applying dry dressing 2. Caring for a split thickness skin graft 3. Applying wet-to-dry dressings 4. Caring for a suture line created by surgical closure of the wound