Chapter 39: Dressings, Bandages, and Binders Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _____ dressing.

a.

pressure

b.

alginate

c.

foam

d.

hydrocolloid

ANS: A

Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate.

DIF: Cognitive Level: Application REF: Text reference: p. 943

OBJ: Choose the correct dressing for a wound. TOP: Pressure Dressings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. The nurse is changing a dry, woven gauze dressing when she notices that the gauze has inadvertently stuck to the wound. What should the nurse do?

a.

Pull the dressing off to aid in debridement.

b.

Recover the dressing and leave in place.

c.

Moisten the gauze to minimize trauma.

d.

Ensure that the shiny side of the dry gauze dressing does not stick.

ANS: C

When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma. Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound.

DIF: Cognitive Level: Application REF: Text reference: p. 946

OBJ: Understand the technique of a dressing, bandage, or binder application.

TOP: Dry Woven Gauze Dressings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient who has a wound healing by primary intention that has little to no drainage. Which dressing is most appropriate for this type of wound?

a.

Moist-to-dry dressing

b.

Hydrocolloid dressing

c.

Dry dressing

d.

Hydrogel dressing

ANS: C

Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris. Hydrogel dressings (e.g., Curasol, IntraSite Gel, Vigilon) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues.

DIF: Cognitive Level: Analysis REF: Text reference: p. 946

OBJ: Choose the correct dressing for a wound. TOP: Dry Dressings

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

4. The nurse would consider a dry dressing appropriate for a wound that requires which of the following?

a.

Protection

b.

Debridement

c.

Absorption of heavy exudate

d.

Healing by second intention

ANS: A

A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention.

DIF: Cognitive Level: Application REF: Text reference: p. 946

OBJ: Choose the correct dressing for a wound. TOP: Dry Dressings

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

5. What should the nurse do for a patient who is having a wet-to-dry dressing applied?

a.

Moisten the old inner dressing to remove it.

b.

Pack the gauze in flat pieces into the wound.

c.

Wet the new inner dressing with a cytotoxic solution.

d.

Apply a secondary dressing over the inner wet packing.

ANS: D

The primary purpose of wet-to-dry dressings is to mechanically debride a wound. The moistened contact layer of the dressing (primary dressing) increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides the wound of tissue when the dressing is removed. The moistened gauze must be covered with a secondary dressing layer that is dry. It is incorrect technique and a common error by some clinicians to moisten the dried gauze before removing it. This defeats the purpose of using this type of dressing and reduces the amount of debris that the dressing will remove. Open or fluff the woven gauze that will be placed directly against the wound bed. Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions.

DIF: Cognitive Level: Application REF: Text reference: p. 946

OBJ: Choose the correct dressing for a wound. TOP: Wet-to-Dry Dressings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. Moist-to-dry dressings consist of gauze moistened with an appropriate solution. What should the nurse do when caring for a patient who has a pressure wound that requires debridement?

a.

Saturate the primary dressing with saline or lactated Ringers solution.

b.

Moisten the primary dressing with saline or lactated Ringers solution.

c.

Moisten the primary dressing with acetic acid.

d.

Moisten the primary dressing with povidone-iodine.

ANS: B

Moist-to-dry dressings consist of gauze moistened with an appropriate solution. Commonly used wetting agents include normal saline and lactated Ringers solution, which are isotonic solutions that aid in mechanical debridement. A dressing that is too wet causes tissue maceration and bacterial growth. It also does not dry out and therefore does not remove necrotic tissue when it is being removed from the wound. Acetic acid is effective against Pseudomonas aeruginosa but is toxic to fibroblasts in standard dilutions. Povidone-iodine is a rapid-acting antimicrobial agent for cleansing intact skin and is never used on a healthy granulating wound bed.

DIF: Cognitive Level: Application REF: Text reference: p. 946

OBJ: Choose the correct dressing for a wound. TOP: Wet-to-Dry Dressings

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

7. The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

a.

filling two thirds of the wound cavity.

b.

leaving saline-soaked folded gauze squares in place.

c.

putting the dressing in very tightly.

d.

extending only to the upper edge of the wound.

ANS: D

Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface. If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed.

DIF: Cognitive Level: Application REF: Text reference: p. 950

OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly.

TOP: Packing the Wound KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. What should the nurse do for a patient with a sudden severe hemorrhage?

a.

Go for help.

b.

Drape the patient.

c.

Apply direct pressure.

d.

Put on clean or sterile gloves.

ANS: C

Apply direct pressure immediately. Seek assistance after pressure is applied. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities.

DIF: Cognitive Level: Application REF: Text reference: p. 953

OBJ: Choose the correct dressing for a wound. TOP: Hemostasis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. What should the nurse anticipate might happen to a patient if bleeding cannot be controlled?

a.

Skin dryness

b.

Bradycardia

c.

Hypovolemic shock

d.

Hypertension

ANS: C

Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shock. Hypertension is an increase in blood pressure.

DIF: Cognitive Level: Application REF: Text reference: p. 955

OBJ: Assess a wound correctly. TOP: Hypovolemic Shock

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

10. How should the nurse proceed when applying a pressure bandage?

a.

Elevate the extremity or area of bleeding.

b.

Wrap pressure-bandage gauze in a proximal-to-distal direction.

c.

Apply pressure to diminish the pulse to the distal body part.

d.

Wrap tape around the circumference of the site to secure the gauze padding.

ANS: A

As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity.

DIF: Cognitive Level: Application REF: Text reference: p. 954

OBJ: Understand the technique of a dressing, bandage, or binder application.

TOP: Pressure Bandage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond?

a.

Initiate intravenous (IV) therapy.

b.

Order blood for transfusions.

c.

Remove and reapply any dressings.

d.

Monitor vital signs every 15 minutes.

ANS: D

Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a providers order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.

DIF: Cognitive Level: Application REF: Text reference: p. 955

OBJ: Understand the technique of a dressing, bandage, or binder application.

TOP: Hemorrhage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. The patient is being sent home from the hospital after a cardiac catheterization. What should the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site?

a.

Call the physician.

b.

Call 9-1-1.

c.

Apply pressure to the site.

d.

Apply a new bandage.

ANS: C

Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site.

DIF: Cognitive Level: Application REF: Text reference: p. 956

OBJ: Assess a wound correctly. TOP: Hemorrhage

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

13. The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon?

a.

Pull the pipe out in the direction of entry.

b.

Push the pipe through to the other side, then out.

c.

Leave the pipe in place.

d.

None of the above.

ANS: C

If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures.

DIF: Cognitive Level: Application REF: Text reference: p. 956

OBJ: Assess a wound correctly. TOP: Penetrating Objects

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond?

a.

Culture the wound.

b.

Leave the current dressing in place.

c.

Apply gauze over the top of the dressing.

d.

Remove and stretch the film more tightly over the wound.

ANS: A

Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained.

DIF: Cognitive Level: Application REF: Text reference: p. 956

OBJ: Assess a wound correctly. TOP: Film Dressings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed?

a.

Apply a film dressing after culturing the wound.

b.

Apply a film dressing after cleansing the area.

c.

Choose another type of dressing for this wound.

d.

Keep the wound open to air.

ANS: C

If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, rather than transparent film dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and family that collection of wound fluid under the dressing is not pus, but rather is a result of normal interaction of body fluids with the dressing.

DIF: Cognitive Level: Application REF: Text reference: p. 957

OBJ: Choose the correct dressing for a wound. TOP: Film Dressings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. In what type of wound is a foam dressing contraindicated?

a.

Shallow stage II ulcer

b.

Exudative stage II ulcer

c.

Wound that has tunneling

d.

Wound that is infected

ANS: C

Foam dressings are not appropriate when there is wound tunneling because the dressing expands, which can enlarge the tunnels. International pressure ulcer guidelines recommend foam for use on exudative stage II and shallow stage II pressure ulcers. Foam dressings are also used to dress infected wounds.

DIF: Cognitive Level: Application REF: Text reference: p. 959

OBJ: Choose the correct dressing for a wound. TOP: Foam Dressings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as:

a.

an expected occurrence.

b.

a wound infection requiring a culture.

c.

an adverse reaction to the hydrocolloid components.

d.

excessive exudate requiring a different type of dressing.

ANS: A

Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odor. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound.

DIF: Cognitive Level: Application REF: Text reference: p. 961

OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly.

TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. What should the nurse remember to do when applying a hydrocolloid dressing?

a.

Apply granules after applying the wafer.

b.

Never use a secondary dressing.

c.

Hold the dressing in place.

d.

Use silk tape to hold the dressing in place.

ANS: C

Hold the dressing in place for 30 to 60 seconds after application. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case of a deep wound, hydrocolloid granules or paste is applied before the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic, paper tape around the edges of the hydrocolloid dressing.

DIF: Cognitive Level: Application REF: Text reference: p. 962

OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly.

TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. Which of the following is an appropriate procedure for the nurse to implement during the application of an absorption or alginate dressing?

a.

Never cut the dressing to fit the wound.

b.

Irrigate the wound gently to remove residual gel.

c.

Fill the wound cavity entirely with the dressing material.

d.

Never use a secondary dressing.

ANS: B

Cleanse the area gently with moist 4 4 sterile gauze pads, swabbing exudate away from the wound, or spray with a wound cleanser. Cleansing effectively removes any residual dressing gel without injuring newly formed delicate granulation tissue formed in the healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid.

DIF: Cognitive Level: Application REF: Text reference: p. 961

OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly.

TOP: Alginate Dressings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. The nurse is caring for a patient who had a negative-pressure wound dressing. The nurse realizes that the system is working properly when the vacuum setting is set at which of the following levels?

a.

40 mm Hg

b.

210 mm Hg

c.

125 mm Hg

d.

25 mm Hg

ANS: C

The target negative pressures for wound healing range from 50 mm Hg to 175 mm Hg, but a setting of 125 mm Hg is most common.

DIF: Cognitive Level: Application REF: Text reference: p. 965

OBJ: Change a negative-pressure wound therapy dressing correctly.

TOP: Negative-Pressure Wound Therapy (NPWT)

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

21. The nurse is caring for a patient who has a negative-pressure dressing. The nurse realizes that typically the dressing should be changed:

a.

every shift.

b.

daily.

c.

every 8 hours.

d.

every 48 hours.

ANS: D

You will typically change an entire NPWT dressing and wound filler every 48 hours or 3 times per week. The schedule for changing NPWT dressings varies and is based on the type and condition of the wound. An infected wound may need a dressing change every 24 hours, whereas a clean wound can be changed 3 times a week.

DIF: Cognitive Level: Application REF: Text reference: p. 965

OBJ: Change a negative-pressure wound therapy dressing correctly.

TOP: Negative-Pressure Wound Therapy (NPWT)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

22. The nurse is preparing to apply a gauze bandage to a dressing on the patients wrist. How should the nurse proceed?

a.

Use a 3-inch bandage.

b.

Use a 2-inch bandage.

c.

Apply from the elbow toward the wrist.

d.

Secure the bandage with a safety pin.

ANS: B

When applying a gauze or elastic bandage, you select a type of bandage and bandage width depending on the size and shape of the body part to be bandaged. For example, 3-inch bandages are used most commonly for the adult leg. A smaller, 2-inch bandage normally is used for the upper extremity. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage.

DIF: Cognitive Level: Application REF: Text reference: pp. 969-971

OBJ: Demonstrate the technique for applying turned bandages correctly.

TOP: Applying a Bandage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23. Which of the following tasks might be delegated to nursing assistive personnel (NAP)?

a.

Pressure dressing to an actively bleeding wound

b.

Chronic wound that needs a nonsterile moist-to-dry dressing change

c.

Hydrogel dressing change

d.

Wound assessment during the dressing change

ANS: B

The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see facility policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated.

DIF: Cognitive Level: Application REF: Text reference: p. 959

OBJ: Assess a wound correctly. TOP: Delegation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

1. Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.)

a.

Maintains a moist environment

b.

Prevents the spread of microorganisms

c.

Increases patient comfort

d.

Controls bleeding

ANS: A, B, C, D

Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 942

OBJ: Discuss the purposes of dressings, bandages, and abdominal binders.

TOP: Functions of Dressings KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.)

a.

Burns

b.

Surgical incisions

c.

Infected wounds

d.

Deep pressure ulcers

ANS: A, C, D

Healing by secondary intention occurs when a wound is left open. Healing results in the formation of granulation tissue from the bottom of the wound and eventual epithelialization from the sides of the wound to close the defect. During the process of epithelialization, epithelial cells migrate and proliferate from the wound edges to cover the wound surface. Burns, infected wounds, and deep pressure ulcers heal in this manner.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 943

OBJ: Assess a wound correctly. TOP: Secondary Intention

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

3. Hydrocolloid dressings are used for which of the following? (Select all that apply.)

a.

Maintaining a moist wound environment

b.

Autolytic debriding of necrotic wounds

c.

Absorption of moderately draining wounds

d.

Protecting from friction

ANS: A, B, C

Hydrocolloid dressings comprise elastometric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 959

OBJ: Choose the correct dressing for a wound. TOP: Hydrocolloid Dressings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Negative-pressure wound therapy (NPWT) would be contraindicated in which of the following? (Select all that apply.)

a.

Dehisced wounds

b.

Pressure ulcers

c.

Malignancies

d.

Necrotic tissue with eschar

ANS: C, D

NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together. It is commonly used for acute, chronic, traumatic, and dehisced wounds; pressure ulcers; and partial-thickness burns and as a bolster for skin grafts. Contraindications for NPWT for chronic wounds are exposed vital organs, inadequately debrided wounds, untreated osteomyelitis or sepsis near a wound, untreated coagulopathy, necrotic tissue with eschar, and malignancy within a wound.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 964-965

OBJ: Choose the correct dressing for a wound.

TOP: Negative-Pressure Wound Therapy (NPWT)

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

5. In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.)

a.

Remove the binder and assess the skin and wound every 8 hours.

b.

Evaluate the patients ability to breathe deeply and cough effectively every 4 hours.

c.

Evaluate the patients pulmonary function every 8 hours.

d.

Remove the binder at least daily.

ANS: A, B

Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patients ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 973

OBJ: Apply an abdominal binder correctly. TOP: Abdominal Binder

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The nurse is demonstrating a dressing change to a nursing student. What key safety features should she emphasize during the process? (Select all that apply.)

a.

Knowing the type of wound

b.

Knowing the expected amount of drainage

c.

Knowing the patients blood type

d.

Knowing whether drainage tubes are present

ANS: A, B, D

It is important to:

1. Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used.

2. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing.

3. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing.

Knowing the patients blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done.

DIF: Cognitive Level: Application REF: Text reference: pp. 945-946

OBJ: Assess a wound correctly. TOP: Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

COMPLETION

1. A __________ dressing comes in direct contact with the wound bed.

ANS:

primary

A primary dressing comes in direct contact with the wound bed.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 943

OBJ: Discuss the purposes of dressings, bandages, and abdominal binders.

TOP: Primary Dressing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. _____________ dressings cover or hold primary dressings in place.

ANS:

Secondary

Secondary dressings cover or hold primary dressings in place.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 943

OBJ: Discuss the purposes of dressings, bandages, and abdominal binders.

TOP: Secondary Dressing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. ___________ healing takes place when tissue is cleanly cut and the margins are reapproximated.

ANS:

Primary

Primary healing takes place when tissue is cleanly cut and the margins are reapproximated.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 943

OBJ: Properly assess a wound. TOP: Primary Healing

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

4. _______________ dressings are used for wounds that require debridement.

ANS:

Moist-to-dry

Moist-to-dry dressings are used for wounds that require debridement.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 946

OBJ: Choose the correct dressing for a wound. TOP: Moist-to-Dry Dressing

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

5. A _______________ is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters.

ANS:

transparent dressing

A transparent dressing is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing. These dressings manage superficial, minimally draining wounds and often are used for protection over high-friction areas and over IV catheters.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 956

OBJ: Choose the correct dressing for a wound. TOP: Film Dressings

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

6. _______________ is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.

ANS:

Negative-pressure wound therapy (NPWT)

NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 964

OBJ: Choose the correct dressing for a wound.

TOP: Negative-Pressure Wound Therapy (NPWT)

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

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