Question 1

When is healing by primary intention expected?

Accepted Answer

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 
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

Question 2

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?

Accepted Answer

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. 
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.

Question 3

What is an appropriate technique for the nurse to implement for drainage evacuation?

Accepted Answer

A) Replace the Hemovac drain fully expanded. 
B) Attach the drainage tubing to the patient's gown. 
C) Tilt the evacuator of the Hemovac away from the plug. 
D) Complete the dressing change before the drainage evacuation. 
A) Replace the Hemovac drain fully expanded. 
B) Attach the drainage tubing to the patient's gown. 
C) Tilt the evacuator of the Hemovac away from the plug. 
D) Complete the dressing change before the drainage evacuation.

Question 4

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?

Accepted Answer

A) Place a safety pin on the part of the drain outside the body. 
B) Replace the cap immediately after emptying. 
C) Pin the drainage tubing to the patient's gown. 
D) Place the Hemovac on a flat surface. 
A) Place a safety pin on the part of the drain outside the body. 
B) Replace the cap immediately after emptying. 
C) Pin the drainage tubing to the patient's gown. 
D) Place the Hemovac on a flat surface.

Question 5

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

Accepted Answer

A) Decrease scar formation. 
B) Remove debris from the wound. 
C) Improve circulation from the wound. 
D) Decrease irritation from wound drainage. 
A) Decrease scar formation. 
B) Remove debris from the wound. 
C) Improve circulation from the wound. 
D) Decrease irritation from wound drainage.

Question 6

You are irrigating a wound and are trying to make sure you get the wound adequately cleansed.Which of the following should you avoid?

Accepted Answer

A) Inserting the tip of a soft catheter into a deep wound 
B) Using a 19-gauge angiocatheter 
C) Pushing the tip inside a deep wound that has a small opening 
D) Using a large syringe 
A) Inserting the tip of a soft catheter into a deep wound 
B) Using a 19-gauge angiocatheter 
C) Pushing the tip inside a deep wound that has a small opening 
D) Using a large syringe

Question 7

The nurse is educating a patient about his role in wound healing.Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level?

Accepted Answer

A) Age 
B) Smoking 
C) Underlying cardiopulmonary conditions 
D) Hemoglobin 
A) Age 
B) Smoking 
C) Underlying cardiopulmonary conditions 
D) Hemoglobin

Question 8

You are explaining negative-pressure wound therapy (NPWT) to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

Accepted Answer

A) NPWT optimizes blood flow. 
B) NPWT will remove wound fluid. 
C) NPWT will maintain a moist environment. 
D) NPWT will apply positive pressure to the wound. 
A) NPWT optimizes blood flow. 
B) NPWT will remove wound fluid. 
C) NPWT will maintain a moist environment. 
D) NPWT will apply positive pressure to the wound.

Question 9

The nurse is changing a surgical dressing and is cleansing the wound.She knows that:

Accepted Answer

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. 
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.

Question 10

You are explaining wound healing to your patient.You are trying to explain the healing process in a full-thickness wound.Which of the following phases should you include in your explanation? (Select all that apply.)

Accepted Answer

A) Hemostasis 
B) Inflammation 
C) Proliferation 
D) Maturation 
E) None of above 
A) Hemostasis 
B) Inflammation 
C) Proliferation 
D) Maturation 
E) None of above

Question 11

How does the skin defend the body? (Select all that apply.)

Accepted Answer

A) Skin serves as a sensory organ for pain. 
B) Skin serves as a sensory organ for touch. 
C) Skin serves as a sensory organ for temperature. 
D) Skin has an acid pH. 
E) None of above 
A) Skin serves as a sensory organ for pain. 
B) Skin serves as a sensory organ for touch. 
C) Skin serves as a sensory organ for temperature. 
D) Skin has an acid pH. 
E) None of above

Question 12

When should a nurse consider culturing a wound?

Accepted Answer

A) When the tissue is clean and dry 
B) When exudate is not present 
C) When the patient is afebrile 
D) When the surrounding area shows inflammation 
A) When the tissue is clean and dry 
B) When exudate is not present 
C) When the patient is afebrile 
D) When the surrounding area shows inflammation

Question 13

The physician reports that he is expecting that the patient's wound will have an output of close to 500 mL per day.The nurse anticipates placement of which of the following?

Accepted Answer

A) Dry sterile dressing 
B) Jackson-Pratt (JP) drain 
C) Hemovac drain 
D) No drain 
A) Dry sterile dressing 
B) Jackson-Pratt (JP) drain 
C) Hemovac drain 
D) No drain

Question 14

Physiologically, wound healing occurs in the same way for all patients, with some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all.The latter group includes which of the following cells? (Select all that apply.)

Accepted Answer

A) Liver cells 
B) Skin cells 
C) Renal tubules 
D) Central nervous system neurons 
A) Liver cells 
B) Skin cells 
C) Renal tubules 
D) Central nervous system neurons

Question 15

For absorption of heavy exudate from a wound, a nurse selects which of the following dressings?

Accepted Answer

A) Alginates 
B) Hydrogel 
C) Hydrocolloid 
D) Transparent film 
A) Alginates 
B) Hydrogel 
C) Hydrocolloid 
D) Transparent film

Exam 38: Wound Care and Irrigations

When is healing by primary intention expected?

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?

What is an appropriate technique for the nurse to implement for drainage evacuation?

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?

The nurse prepares to irrigate the patient's wound.What is the primary reason for this procedure?

You are irrigating a wound and are trying to make sure you get the wound adequately cleansed.Which of the following should you avoid?

The nurse is educating a patient about his role in wound healing.Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level?

You are explaining negative-pressure wound therapy (NPWT) to a patient.Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.)

The nurse is changing a surgical dressing and is cleansing the wound.She knows that:

You are explaining wound healing to your patient.You are trying to explain the healing process in a full-thickness wound.Which of the following phases should you include in your explanation? (Select all that apply.)

How does the skin defend the body? (Select all that apply.)

When should a nurse consider culturing a wound?

The physician reports that he is expecting that the patient's wound will have an output of close to 500 mL per day.The nurse anticipates placement of which of the following?

Physiologically, wound healing occurs in the same way for all patients, with some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all.The latter group includes which of the following cells? (Select all that apply.)

For absorption of heavy exudate from a wound, a nurse selects which of the following dressings?

Using Evidence in Nursing Practice

Admitting, Transfer, and Discharge

Communication

Documentation and Informatics

Vital Signs

Health Assessment

Medical Asepsis

Sterile Technique

Safe Patient Handling, Transfer, and Positioning

Exercise and Ambulation

Orthopedic Measures

Support Surfaces and Special Beds

Safety and Quality Improvement

Disaster Preparedness

Pain Assessment and Basic Comfort Measures

Palliative Care

Personal Hygiene and Bed Making

Pressure Ulcer Care

Care of the Eye and Ear

Safe Medication Preparation

Oral and Topical Medications

Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Closed Chest Drainage Systems

Emergency Measures for Life Support

Intravenous and Vascular Access Therapy

Blood Transfusions

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Dressings, Bandages, and Binders

Therapeutic Use of Heat and Cold

Home Care Safety

Home Care Teaching

Specimen Collection

Diagnostic Procedures

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