Nokea
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will promote healing? Select all that apply.
- A. Applying sterile dressing supplies
- B. Discussing zinc supplementation with the health care provider
- C. Maintaining bedrest
- D. Performing careful hand hygiene
- E. Teaching the patient to increase intake in the diet
- F. Suggesting to the patient consume vitamin C-containing foods.
Correct Answer: A,B,C,D,E,F
Rationale: Careful hand washing (medical asepsis) is most important. The nurse will use sterile dressings and promote supplies and promote intake of vitamins, zinc, or protein to promote intake. Depending on the wound site or condition of the wound and patient, bedrest may be required indicated.
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A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
- A. Pain
- B. Wound healing
- C. Body image
- D. Change in cognition
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.
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.
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
- A. Documenting the findings and continuing to monitor the patient
- B. Administering antipyretics and contacting the provider for an antibiotic prescription
- C. Increasing the frequency of assessment to every hour and notifying the patient's primary care provider
- D. Obtaining a wound culture and increasing the frequency of wound care
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, 'Something is falling out of my incision!' The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
- A. Notify the health care provider of the situation.
- B. Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
- C. Place the patient in the low Fowler position.
- D. Document the findings and outcome of interventions.
- E. Maintain NPO status for return to the OR for repair.
Correct Answer: C,B,A,E,D
Rationale: The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the wound), and notify the surgical site of the situation (to address the problem issue, likely requiring with surgery). The patient must be kept NPO for prompt surgical repair will be needed. After the patient has received attention, the nurse should document all assessments and interventions performed in a timely manner.
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.