Chapter 24: Wound Care and Irrigation

Chapter 24: Wound Care and Irrigation

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse assesses several preoperative patients for potential postoperative referrals to the wound care team. Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing?

a.	Eight weeks postpartum from live vaginal birth in for tubal ligation
b.	Older than 70 years, coronary artery disease, and hypertension
c.	Six-week course of chemotherapy for a cancerous tumor
d.	Chronic obstructive lung disease on long-term prednisone therapy

 

 

ANS:  A

The patient with the lowest risk of delayed wound healing is the patient scheduled for a tubal ligation because she is likely to be 40 years old or younger, decreasing the risk for chronic disease. She is likely to have generally good health as evidenced by a live vaginal birth. The older patient with coronary artery disease and hypertension has atherosclerotic lesions in the heart aggravated by high blood pressure. The patient is likely to have atherosclerotic lesions in other vessels because atherosclerosis is a nonselective disease; thus the patient is at risk for delayed healing because of the potential for impaired tissue perfusion. Radiation therapy increases the risk of postradiation scarring and fibrosis which increases the risk of delayed healing. The patient taking prednisone is at high risk for delayed healing because glucocorticoids suppress inflammation and the immune system.

 

DIF:    Cognitive Level: Analyze                REF:   Page 643| Page 645-646

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Evaluation

 

2. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on the fourth postoperative day?

a.	The tympanic temperature is 39.5° C at 8 AM and noon.
b.	The incision is slightly reddened and swollen without drainage.
c.	The skin is spongy and warm around the incision.
d.	The patient’s pain has been increasing gradually.

 

 

ANS:  B

By the fourth postoperative day the patient’s surgical incision is expected to have slight redness and swelling but no drainage, indicating a physiological, expected, inflammatory response to tissue injury. Tympanic temperature of 39.5° C is febrile and warrants further investigation to rule out infection. Spongy, warm skin around the wound area can indicate infection and requires follow-up. Increasing pain can indicate that the wound status is deteriorating and needs to be assessed.

 

DIF:    Cognitive Level: Apply                   REF:   Page 643

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Evaluation

 

3. The nurse prepares to assess the patient’s wound after removing the dressing. Which does the nurse implement to promote infection control?

a.	Scrubs the drain insertion site in a back-and-forth manner
b.	Cleans the incision from wound edges toward the center
c.	Applies clean gloves after removing the old dressing; inspects the wound
d.	Dons sterile gloves, removes the dressing, and inspects the wound

 

 

ANS:  C

First the nurse applies clean gloves, and then removes soiled dressings and examines dressings for quality of drainage (color, consistency), presence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). The nurse discards dressings in a waterproof biohazard bag, removes and discards gloves, performs hand hygiene, and applies clean gloves. Then the nurse inspects the wound and determines the type of wound healing (e.g., primary or secondary intention). The wound is cleansed from the cleanest to the dirtiest area to avoid contamination of the cleaner area. The nurse does not need to put on sterile gloves to remove the dressing but does need to change gloves before inspecting the wound.

 

DIF:    Cognitive Level: Apply                   REF:   Page 645

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

4. The nurse teaches a patient about self-care of two Jackson-Pratt drains after breast surgery. What does the nurse include in patient teaching?

a.	Empty the drain every 2 hours and measure the contents.
b.	Maintain a small, steady amount of tension on the drain tubing.
c.	Record the amount removed from each drain separately.
d.	Keep the collection end of the drain lower than the patient’s waist.

 

 

ANS:  C

Since the patient has two Jackson-Pratt drains, the amount removed from each drain should be recorded separately to allow the healthcare provider to know their effectiveness and when they can be removed. The bulb should be emptied when it is approximately two-thirds full, and a household device should be used to measure the contents as precisely as possible. The nurse instructs the patient to avoid putting tension on the tubing and to keep the bulb below the insertion site. Waist level is probably as low as the tubing can reach and still allow slack in the tubing.

 

DIF:    Cognitive Level: Apply                   REF:   Page 649| Page 652

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

5. The nurse teaches a patient about Steri-Strips after suture removal. What information does the nurse include in patient teaching?

a.	They provide a skin barrier.
b.	They provide gentle support.
c.	They prevent scarring of the wound.
d.	They collect additional drainage.

 

 

ANS:  B

Steri-Strips provide continued support to the incision after sutures or staples are removed. The nurse instructs the patient to expect the Steri-Strips to curl up and eventually fall off the skin and instructs the patient not to remove them. Steri-Strips do not provide a barrier since they are not applied continuously along the incision. The method of skin closure, site, and patient status determine the level of scarring. Steri-Strips are able to absorb only a few drops of drainage.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 653| Page 655

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation