Chapter 09 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 09 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

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

Correct Answer: 3

Rationale 1: Tertiary intention combines primary and secondary intention, often requiring the wound to be left open for a period of time, such as a few days.

Rationale 2: Primary intention healing occurs when the wound is closed and heals without interruption.

Rationale 3: This wound has dehisced, which means that it has not healed as expected and the suture line is opened. This may occur because of stretching of the skin, poor skin integrity, or because the wound is infection. Dehisced sternal wounds are allowed to heal by second intention.

Rationale 4: Future surgical debridement may be necessary if the wound does not heal, but this is not an expected part of the plan of care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-2

 

Question 2

Type: MCSA

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.”

Correct Answer: 3

Rationale 1: Pulsatile lavage is not a form of autolytic debridement.

Rationale 2: Whirlpool tubs are not used for pulsatile lavage. Whirlpool treatments increase risk of cross contamination of the wound.

Rationale 3: Pulsatile lavage is used to clean materials out of the wound bed.

Rationale 4: Pulsatile lavage is not used to inject medications into the wound.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-5

 

Question 3

Type: MCSA

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

Correct Answer: 4

Rationale 1: Hydrocolloid dressings are used on moderate to heavily exudating wounds. This wound is dry.

Rationale 2: Wet-to-dry dressings are used for wounds that are healing by second intention.

Rationale 3: Alginate dressings are used to absorb secretions and form a covering for the wound bed. This wound bed is dry.

Rationale 4: The patient’s wound is healing by primary intention. Dry, sterile dressings are the standard for wounds healing by this method, offering protection from contamination and the absorption of the minimal amount of exudate expected.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-5

 

Question 4

Type: MCMA

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?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

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.

Correct Answer: 1,2,4

Rationale 1: Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also associated with significantly higher infection rates.

Rationale 2: Peripheral artery disease decreases oxygenation of the tissues, increasing risk of complications.

Rationale 3: The presence of osteoarthritis is related to overuse of the joint and is not a significant risk factor for problems healing.

Rationale 4: Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is a factor in healing problems.

Rationale 5: Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues, leading to difficulties with healing.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-3