Chapter 38: Wound Care and Irrigations Nursing School Test Banks

MULTIPLE CHOICE

1. When is healing by primary intention expected?

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

ANS: D

Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 922

OBJ: Differentiate between primary and secondary intention wound healing.

TOP: Primary Intention KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed?

a.

Change the dressing so she can assess the wound.

b.

Administer an analgesic 30 to 45 minutes before a dressing change.

c.

Culture the wound if wound exudate is present.

d.

Administer an analgesic 30 minutes after a dressing change.

ANS: B

To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth.

DIF: Cognitive Level: Application REF: Text reference: p. 922

OBJ: Perform a wound assessment. TOP: Medicating the Patient Before Dressing Changes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system?

a.

Decreases the amount of angiogenesis

b.

Reduces mechanical stretch of tissue

c.

Dressing should not need to be changed for 48 hours

d.

Helps create a dry environment

ANS: C

The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels), and that this stimulates the production of new blood vessels via mechanical stretch of the tissue. The dressing placed into the wound maintains a moist environment to facilitate healing. A suction device is placed over the dressing, and the dressing, suction, and wound area are covered with a transparent dressing, which provides the air-tight seal necessary for negative-pressure wound therapy (NPWT).

DIF: Cognitive Level: Application REF: Text reference: p. 923

OBJ: Perform a wound assessment. TOP: Negative-Pressure Wound Therapy (NPWT)

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

4. 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?

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.

ANS: C

When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.

DIF: Cognitive Level: Application REF: Text reference: p. 923

OBJ: Perform wound irrigation. TOP: Irrigation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

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.

ANS: C

The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke.

DIF: Cognitive Level: Application REF: Text reference: p. 923

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Cleansing an Incision KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The nurse answers the patients call light to find the patient agitated and stating that she felt something pop. The nurse finds that the patients abdominal surgical wound has eviscerated. What should the nurse do?

a.

Try to reinsert the abdominal contents.

b.

Cover the wound with a dry sterile dressing.

c.

Notify the surgeon when he makes rounds.

d.

Cover the wound with a moist saline dressing.

ANS: D

This is a surgical emergency, and the nurse needs to cover the wound with a moist saline dressing, immediately notify the surgeon, and prepare the patient for emergency surgery.

DIF: Cognitive Level: Application REF: Text reference: p. 924

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Evisceration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. The nurse prepares to irrigate the patients wound. What is the primary reason for this procedure?

a.

Decrease scar formation.

b.

Remove debris from the wound.

c.

Improve circulation from the wound.

d.

Decrease irritation from wound drainage.

ANS: B

Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. The primary purposes of wound irrigation do not include decreasing scar formation, improving circulation, or decreasing irritation.

DIF: Cognitive Level: Application REF: Text reference: p. 926

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Irrigation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. Which of the following approaches is correct technique when wound irrigation is performed?

a.

Placing the patient in supine position

b.

Placing the syringe directly into the wound

c.

Using sterile technique for a chronic wound

d.

Selecting a soft catheter for deep wounds with small openings

ANS: D

If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds).

DIF: Cognitive Level: Application REF: Text reference: p. 926

OBJ: Perform wound irrigation. TOP: Irrigation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?

a.

Graft sites

b.

Wounds with exposed blood vessels

c.

Necrotic tissue

d.

Wounds with exposed muscle or tendons

ANS: C

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone.

DIF: Cognitive Level: Application REF: Text reference: p. 926

OBJ: Perform wound irrigation. TOP: Pulsatile High-Pressure Lavage

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. When should a nurse consider culturing a wound?

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

ANS: D

Consider culturing a wound if it has a foul, purulent odor; inflammation surrounds the wound; a nondraining wound begins to drain; or the patient is febrile.

DIF: Cognitive Level: Application REF: Text reference: p. 929

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Wound Culture KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

11. When teaching about wound care in the home environment, the nurse instructs the patient and caregiver to:

a.

make normal saline with 8 teaspoons of salt and .1 gallon of distilled water.

b.

use normal saline for 1 week and then discard it.

c.

not apply topical anesthetics before wound care.

d.

call the physicians office to have someone come to the home and complete the wound care.

ANS: A

Teach the patient and caregiver how to make normal saline, especially if cost is an issue. They can make normal saline by using 8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month. The saline solution should be allowed to reach room temperature before use. Commonly used topical anesthetic solutions include 2% and 4% lidocaine jelly, which inactivates exposed wound pain receptors. Some patients need to receive wound care management in an outpatient wound care clinic. Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies.

DIF: Cognitive Level: Application REF: Text reference: p. 930

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

a.

The wound edges are separated.

b.

No drainage or erythema is present.

c.

The patient is anxious about their removal.

d.

A cosmetically aesthetic result would not be achieved.

ANS: A

Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges, normal color, and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, the wound has not healed properly. Notify the health care provider because sutures or staples may need to remain in place. Absence of drainage and erythema would indicate that sutures are ready for removal. Steps could be taken to relieve the patients anxiety, but suture removal is based on the condition of the wound. Timing of suture removal is based on adequate wound healing.

DIF: Cognitive Level: Application REF: Text reference: p. 931

OBJ: Remove sutures or staples. TOP: Wound Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. What should the nurse do when removing intermittent sutures?

a.

Snip both sides of the suture before removing.

b.

Snip the suture as close to the knot as possible.

c.

Snip the suture as close to the skin as possible.

d.

Pull up the knot to apply as much tension as possible.

ANS: C

Snip the suture as close to the skin as possible at the end distal to the knot. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knot of the suture with forceps, and gently pull up the knot while slipping the tip of the scissors under the suture near the skin.

DIF: Cognitive Level: Application REF: Text reference: p. 933

OBJ: Remove sutures or staples. TOP: Removing Sutures

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. What should the nurse do when performing suture or staple removal?

a.

Snip both ends of the sutures.

b.

Apply tension to the suture line to remove the sutures.

c.

Pull the exposed surface of the suture through the tissue below the epidermis.

d.

Apply Steri-Strips if any separation greater than the width of two stitches is present.

ANS: D

Apply Steri-Strips if any separation greater than two stitches or two staples in width is apparent, to maintain contact between wound edges. This supports the wound by distributing tension across the wound and eliminates closure technique scarring. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knotted end with forceps, and in one continuous smooth action, pull the suture through from the other side; this smoothly removes the suture without additional tension to the suture line. Tension on the suture line is not required. Never pull the exposed surface of any suture into tissue below the epidermis. The exposed surface of any suture is considered contaminated.

DIF: Cognitive Level: Application REF: Text reference: p. 934

OBJ: Remove sutures or staples. TOP: Removing Sutures

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

Dry sterile dressing

b.

Jackson-Pratt (JP) drain

c.

Hemovac drain

d.

No drain

ANS: C

If drainage accumulates in the wound bed, wound healing is delayed. Drainage is removed by using a closed or an open drain system, even if the amount of drainage is small. A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range; the Hemovac drain accommodates more drainage, usually up to 500 mL in 24 hours.

DIF: Cognitive Level: Application REF: Text reference: p. 935

OBJ: Demonstrate care of a wound drainage system. TOP: Drainage Systems

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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

a.

Replace the Hemovac drain fully expanded.

b.

Attach the drainage tubing to the patients gown.

c.

Tilt the evacuator of the Hemovac away from the plug.

d.

Complete the dressing change before the drainage evacuation.

ANS: B

Pinning drainage tubing to the patients gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times.

DIF: Cognitive Level: Application REF: Text reference: p. 936

OBJ: Demonstrate care of a wound drainage system. TOP: Drainage Systems

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

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 patients gown.

d.

Place the Hemovac on a flat surface.

ANS: D

Place the evacuator on a flat surface with the open outlet facing upward; continue pressing downward until the bottom and the top are in contact; hold the surfaces together with one hand, quickly cleanse the opening and the plug with the other hand, and immediately replace the plug; and then secure the evacuator to the patients bed. Compression of the surface of the Hemovac creates a vacuum. Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation. Be sure the Penrose drain has a sterile safety pin in place. This pin prevents the drain from being pulled below the skins surface. Compress the bulb of a JP drain over the drainage container. Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container. Replacing the cap immediately prevents tension on the drainage tubing, but does not help to reestablish the vacuum.

DIF: Cognitive Level: Application REF: Text reference: p. 937

OBJ: Demonstrate care of a wound drainage system.

TOP: Reestablishing Vacuum of Drainage Systems

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. The nurse is explaining wound healing to a patient. Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound?

a.

A reduction in the size of the wound is noted.

b.

The epithelial cells duplicate.

c.

Synthesis of collagen occurs at the site.

d.

Blood flow to the wound and arrival of white blood cells are increased.

ANS: D

Vasodilatation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (white blood cells) arrive in the wound to begin wound cleanup. Macrophages, a type of white blood cell, appear and begin to regulate wound repair. The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound. It is during the proliferative stage, not the inflammatory stage, that contraction causes a reduction in the size of the wound, duplication of epithelial cells occurs, and collagen is synthesized.

DIF: Cognitive Level: Application REF: Text reference: p. 921

OBJ: Discuss the bodys response during each stage of the wound-healing process.

TOP: Phases of Wound Healing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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

a.

Alginates

b.

Hydrogel

c.

Hydrocolloid

d.

Transparent film

ANS: A

Alginates are used for absorption of heavy to moderate wound exudate. Hydrogels are used for dry wounds to wounds with minimal exudate. Hydrocolloids are used to absorb minimal to moderate exudate. Transparent film has no absorption quality.

DIF: Cognitive Level: Application REF: Text reference: p. 927

OBJ: Discuss the bodys response during each stage of the wound-healing process.

TOP: Dressings KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

20. 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?

a.

Age

b.

Smoking

c.

Underlying cardiopulmonary conditions

d.

Hemoglobin

ANS: B

Factors that decrease oxygenation include decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions. Smoking is the only one of these factors that can be modified by the patient alone. Age causes vascular changes.

DIF: Cognitive Level: Application REF: Text reference: p. 924

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Skin KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

21. The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing. Which of the following can be appropriately delegated to the nurse assistant?

a.

Performing a sterile dressing change

b.

Observing for any drainage on the dressing

c.

Performing wound assessment during the dressing change

d.

Notifying the physician of drainage present on the dressing

ANS: B

Wound assessment and sterile dressing changes cannot be delegated to nursing assistive personnel (NAP). The nurse can direct the NAP to report any drainage from the wound that is present on the sheets or as strike-through from the dressing. The NAP should not be reporting this to a physician.

DIF: Cognitive Level: Application REF: Text reference: p. 925

OBJ: Perform a wound assessment. TOP: Delegation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Management of Care

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

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

ANS: C

Do not force a catheter into a wound because this will cause tissue damage. Using a 19-gauge angiocatheter and a 35-cc syringe is acceptable. If you need to irrigate a deep wound with a small opening, use a soft catheter and insert it 1.3 cm to avoid touching the fragile inner wall of the wound.

DIF: Cognitive Level: Application REF: Text reference: p. 929

OBJ: Perform wound irrigation. TOP: Delegation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Management of Care

MULTIPLE RESPONSE

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

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.

ANS: A, B, C, D

The skin defends the body by serving as a sensory organ for pain, touch, and temperature, and it has an acid pH, which is often called the acid mantle.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 920

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Skin KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. 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.)

a.

Liver cells

b.

Skin cells

c.

Renal tubules

d.

Central nervous system neurons

ANS: A, C, D

Physiologically, wound healing occurs in the same way for all patients, with skin cells and some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes cells of the liver, renal tubules, and central nervous system neurons.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 921

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Wound Healing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. 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.)

a.

Hemostasis

b.

Inflammation

c.

Proliferation

d.

Maturation

ANS: A, B, C, D

In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation.

DIF: Cognitive Level: Application REF: Text reference: p. 921

OBJ: Discuss the bodys response during each stage of the wound-healing process.

TOP: Phases of Wound Healing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. 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.)

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.

ANS: A, B, C

NPWT supports wound healing by optimizing blood flow, removing wound fluid, and maintaining a moist environment.

DIF: Cognitive Level: Application REF: Text reference: p. 923

OBJ: Perform a wound assessment. TOP: Negative-Pressure Wound Therapy (NPWT)

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

5. Wounds that have been approved for treatment using NPWT include which of the following? (Select all that apply.)

a.

Pressure ulcers

b.

Diabetic ulcers

c.

Traumatic wounds

d.

Venous stasis ulcers

ANS: A, B, C, D

Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT.

DIF: Cognitive Level: Application REF: Text reference: p. 923

OBJ: Perform a wound assessment. TOP: Negative-Pressure Wound Therapy (NPWT)

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

6. The nurse is caring for a patient who has had major abdominal surgery. She is concerned about the possibility of dehiscence. During her assessment, she makes sure she assesses for which of the following contributing factors?(Select all that apply.)

a.

Age

b.

Malnutrition/obesity

c.

Gender

d.

Use of steroids

ANS: B, D

Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids.

DIF: Cognitive Level: Application REF: Text reference: p. 924

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Dehiscence KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. The _____________ is composed of newly formed collagen, and the nurse can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9.

ANS:

healing ridge

The healing ridge is composed of newly formed collagen, and you can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. Lack of a ridge is cause for concern, and you will need to begin interventions promptly to reduce mechanical strain on the wound.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 921

OBJ: Discuss the bodys response during each stage of the wound-healing process.

TOP: The Healing Ridge KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. Healing by ________ intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.

ANS:

tertiary

Healing by tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed. Scarring is usually minimal.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 922

OBJ: Perform a wound assessment. TOP: Tertiary Intention

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. ___________ is black, brown, or tan tissue in the wound that should be removed before wound healing can begin.

ANS:

Eschar

Black, brown, or tan tissue in the wound is eschar that should be removed before wound healing can begin.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 922

OBJ: Perform a wound assessment. TOP: Eschar

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. _____________ uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

ANS:

Irrigation

Irrigation uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 923

OBJ: Perform wound irrigation. TOP: Irrigation

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

5. A failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level is known as ______________.

ANS:

dehiscence

Dehiscence, a failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level. It occurs fairly early after surgery (5 to 8 days after surgery) in patients in whom the normal healing response lags.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 924

OBJ: Explain factors that impair or promote normal wound healing.

TOP: Dehiscence KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

6. ___________ are threads of wire or other materials used to sew body tissues together.

ANS:

Sutures

Sutures are threads of wire or other materials used to sew body tissues together.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 930

OBJ: Remove sutures or staples. TOP: Sutures

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is considered a __________ drainage system.

ANS:

closed

A closed drainage system such as the JP drain (Figure 38-8) or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 935

OBJ: Demonstrate care of a wound drainage system. TOP: Closed Drain Systems

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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