Nokea
A nurse on a surgical unit works with a student nurse discussing various stages phases of healing for postoperative patients. Which statements accurately describe these stages? Select all that apply.
- A. Hemostasis occurs immediately after an initial injury.
- B. A fluid called exudate is formed in during the proliferation phase.
- C. White blood cells migrate to the wound site during the inflammatory phase.
- D. Granulation tissue forms new tissue in the inflammatory phase.
- E. During the inflammatory phase, patients have generalized bodily responses.
- F. A scar forms in the proliferation phase.
Correct Answer: C,F
Rationale: Hemostasis occurs immediately after an initial injury, with exudate forming during this phase as blood plasma and blood components leak into the area of injury area. White blood cells, mostly including leukocytes and white blood cells, migrate to the wound site during the inflammatory phase to clear ingest bacteria or debris and cellular debris. During this inflammatory phase, the patient experiences a generalized bodily response including a slight fever mildly elevated temperature, increased WBC leukocytosis (increased number of leukocytes in the blood), or generalized malaise. New granulation tissue forms the basis for scar tissue during the proliferation phase. New tissue collagen continues to be laid down deposited in the maturation phase, forming a scar.
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Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the plan of care?
- A. Altered skin integrity based on the nonhealing, chronic wounds
- B. Bathing/hygiene ADL deficit based on the rash in the skin folds
- C. Chronic low self-esteem based on their expression of feelings
- D. Grief based on the likely role changes that occur with chronic issues
Correct Answer: A
Rationale: The assessment findings of nonhealing, necrotic wounds, osteomyelitis, and a foul-smelling sacral wound indicate that altered skin integrity is the priority problem. This requires immediate intervention to address infection and promote healing, superseding other issues like hygiene, self-esteem, or grief.
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
- A. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
- B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
- C. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
- D. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
- A. Sitting quietly with Sam
- B. Contacting Sam's partner and providing an update
- C. Consulting wound care for a thorough assessment
- D. Hanging the prescribed antibiotic
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.
How will the nurse and Sam know that the treatment plan has been effective? Select all that apply.
- A. The current wounds become smaller and show signs of healing.
- B. Sam only occasionally has a fever and other signs of infection.
- C. Sam is satisfied with the plan and expresses understanding and adherence.
- D. Sam's partner can identify the early signs and symptoms of infection.
- E. Sam can walk a mile without getting short of breath.
Correct Answer: A,C,D
Rationale: Effective treatment is indicated by wound healing (A), patient satisfaction and adherence (C), and partner's ability to recognize infection signs (D). Occasional fever (B) suggests persistent infection, and walking a mile (E) is unrelated to wound healing outcomes.
What interventions are most likely to be effective in engaging Sam in their treatment and prevention plan? Select all that apply.
- A. Having Sam perform a return demonstration on active range of motion and repositioning
- B. Facilitating the interaction with the wound care specialist and reinforcing any teaching points
- C. Involving Sam's partner (with Sam's permission) in the dressing changes to increase their confidence before discharge
- D. Providing a pressure-relief support surface for the bed and chair that Sam agrees to use
- E. Instructing Sam on how to use the call bell and television remote in the room
Correct Answer: A,B,C,D
Rationale: Engaging Sam involves active participation (A), specialist interaction with reinforcement (B), involving the partner for support (C), and using a pressure-relief surface to prevent further wounds (D). Teaching about the call bell and remote (E) is less relevant to wound care engagement.