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20 Cards in this Set

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Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage will the nurse document?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B
There are three phases of wound healing. The nurse observes granulation tissue in a client ’s pressure ulcer. What phase of wound healing is represented by granulation tissue?
A. Maturation phase
B. Proliferative phase
C. Inflammatory phase
D. Hemostasis phase
B
The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest, particularly in surgical wounds?
A. During the first 24 to 48 hours after surgery
B. Between 48 and 60 hours after surgery
C. Between 60 and 72 hours after surgery
D. 7 days after surgery, when the client is more active
A
Often occurring during wound management, autolylic, chemical, and surgical are all methods of what?
A. Cleansing
B. Dressings
C. Debridement
D. Growth factors
C
Often occurring during wound management, autolylic, chemical, and surgical are all methods of what?
A. Cleansing
B. Dressings
C. Debridement
D. Growth factors
D
A 40-year-old client is a new paraplegic. The client is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the client’s education. Regarding that education, the nurse should have included which of the following guidelines?
A. Should sit in chair for 3 hours
B. Should shift his weight in a chair every 15 minutes
C. Should use a donut-shaped chair cushion
D. Should use a rigid cushion for full support
B
During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:
A. Placing the client in Fowler’s position and returning in 2 hours
B. Massaging the reddened area and repositioning the client
C. Inserting a urinary catheter to prevent moisture from urinary incontinence
D. Repositioning the client off the coccyx area and reassessing the area in an hour
D
The nurse is to collect a specimen for culture after assessing the client’s wound drainage. The best technique for obtaining the culture is:
A. Collecting the specimen from accumulated drainage
B. Swabbing from the outside skin edge inward
C. Cleansing the wound first
D. Sending the soiled dressing to the laboratory
C
The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why was the hydrogel dressing the best choice for this client?
A. It is soothing and reduces pain in the wound.
B. It can be used as a preventative dressing for high-risk friction areas.
C. It permits the nurse to view the wound.
D. It provides a wicking action.
A
The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?
A. Reflex vasoconstriction occurs.
B. Reflex vasodilation occurs.
C. Systemic response occurs.
D. Local response occurs
A
When repositioning an immobile client the nurse notices redness over a bony prominence. When the area is assessed the red spot blanches with fingertip touch, indicating:
1. a local skin infection requiring antibiotics
2. this client has sensitive skin and requires special bed linen
3. a stage III pressure ulcer needing the appropriate dressing
4. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
4. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
This type of pressure ulcer has an observable pressure related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature, tissue consistency, and or sensation:
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
1. stage I
When obtaining a wound culture to determine the presence of a wound infection, the specimen should be taken from the
1. necrotic tissue
2. drainage on the dressing
3. wound drainage
4. wound after it has first been cleansed with normal saline
4. wound after it has first been cleansed with normal saline
Postoperatively the client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. the correct intervention would be to:
1. Allow the area to be exposed to air until all drainage has stopped
2. place several cold packs over the areas protecting the skin around the wound
3. Cover the areas with sterile saline-soaked towels and immediatly notify the surgical team; this is likely to indicate a wound evisceration
4. Cover the area with sterile gauze, place a tight binder over the areas, Ask the client to remain in bed for 30 mins becasue this is a minor opening in the surgical wound and should reseal quickly
3. Cover the areas with sterile saline-soaked towels and immediatly notify the surgical team; this is likely to indicate a wound evisceration
Serous drainage from a wound is defined as:
1. fresh bleeding
2. clear watery plasma
3. thick and yellow
4. beige to brown and foul smelling
2. clear watery plasma
for a client who has a muscle sprain, localized hemorrhage or hematoma, this helps prevent edema formation, control bleeding and anesthetize the body part.
1. binder
2. ice bag
3. ace bandage
4. absorptive diaper
2. ice bag
Interventions to manage a client who is experiencing fecal and urinary incontinence include:
1. Use of a large absorbent diaper, changing when saturated
2. keeping the buttocks exposed to air at all times
3. utilization of an incontinence cleanser, followed by application of a moisture barrier ointment
4. Frequent cleansing application of an ointment and covering the areas with a thick absorbent towel
3. utilization of an incontinence cleanser, followed by application of a moisture barrier ointment
The best description of a hydrocolloid dressing is
1. a seaweed derivative that is highly absorptive
2. premoistened gauze placed over the granulating wound
3 a debriding enzyme that is used to remove necrotic tissue
4. a dressing that forms a gel that interacts with the wound surface
4. a dressing that forms a gel that interacts with the wound surface
A binder placed around a surgical client with a new abdominal wound is indicated for:
1. collection of wound drainage
2. reduction of abdominal swelling
3. reduction of stress on the abdominal incision
4. stimulation of peristalsis (returned of bowel function) from direct pressure
3. reduction of stress on the abdominal tissue
Application of a warm compress is indicated
1. to relieve edema
2. For a client who is shivering
3. to promote healing by simulating blood flow
4. to protect bony prominences from pressure ulcers
1. to relieve edema