Nokea
A patient has had emergency surgery because of a bowel obstruction. The wound becomes infected with Escherichia coli. This likely occurred because
- A. These bacteria are always present on the skin and easily enter a wound if sterile technique is not used.
- B. These bacteria grow in the absence of oxygen, which is the case in the bowel.
- C. These bacteria are present in the bowel, and with emergency surgery there is no time to perform special bowel preparations.
- D. The patient had poor nutritional intake because these bacteria grow in dying tissue.
Correct Answer: C
Rationale: E. coli, common in the bowel, likely contaminated the wound during emergency surgery due to lack of bowel prep time.
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Match the following types of wound healing with their examples: First intention
- A. A traumatic wound first left open to drain and then sutured closed
- B. An appendectomy incision sutured closed
- C. A pressure ulcer being packed with moist gauze
Correct Answer: B
Rationale: First intention healing occurs when wound edges are closely approximated, as in a sutured appendectomy incision.
You are a nurse, and you are running behind schedule on a very busy workday. The UAP offers to change a patient's abdominal dressing for you. She is a first-semester nursing student. Which is the most appropriate response?
- A. That would be great. Don't forget to measure the open area in the middle of her incision for me.'
- B. I know you have been taught to do this in school, so you are not the same as the other UAPs. Go ahead and change the dressing.'
- C. Thanks, but could you help Mr. Wu walk in the hall instead? That way I can get that dressing changed.'
- D. You know you can't do that as a UAP. I would be in big trouble if I let you change that dressing!'
Correct Answer: C
Rationale: UAPs, including nursing students, are not permitted to perform complex tasks like dressing changes, which require nursing judgment. Delegating a simpler task is appropriate.
If a patient had a stage 3 pressure injury, you would expect to see which of the following on assessment?
- A. Erythema of intact skin that does not blanch and is not purple or maroon in color
- B. Intact serum-filled blisters and broken blisters with shallow, pink or red, moist ulcerations
- C. An open area that reveals damage to the epidermis, dermis, subcutaneous tissue, muscle, fascia, tendon, joint capsule, and bone
- D. An open area that extends through the epidermis, dermis, and subcutaneous tissue with possible undermining and tunneling
Correct Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness loss of skin and subcutaneous tissue, often with undermining or tunneling.
A patient is at risk for wound dehiscence as a result of nutritional issues and medical history. Which interventions should be included in the care plan?
- A. Assist the patient to splint the incision with a pillow when coughing.
- B. Enforce strict bedrest with bathroom privileges only.
- C. Administer stool softeners and antinausea medicine promptly.
- D. Obtain VS every 15 minutes.
Correct Answer: A,C
Rationale: Splinting the incision and preventing straining (via stool softeners/antinausea meds) reduce stress on the wound, preventing dehiscence.
During the inflammatory process, which of the following physiological responses occur?
- A. Capillaries dilate, causing erythema and increased warmth at the site of injury.
- B. Leukocytes are shunted away from the site to fight infection.
- C. Leukocytes move into the interstitial space and attack microorganisms.
- D. Red blood cells deliver more oxygen and nutrients to promote healing.
- E. Fluid in the interstitial spaces prevents redness and pain.
- F. Edema causes pressure on nerve endings, resulting in discomfort and pain.
Correct Answer: A,C,D,F
Rationale: During inflammation, capillaries dilate (erythema and warmth), leukocytes migrate to fight infection, red blood cells supply oxygen/nutrients, and edema causes pain. Leukocytes are not shunted away, and fluid does not prevent redness/pain.