Nokea
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is a priority as a result of this assessment data?
- A. Obtain wound cultures.
- B. Start antibiotic therapy.
- C. Redress the wound with wet-to-dry dressings.
- D. Continue to monitor the wound for purulent drainage.
Correct Answer: A
Rationale: The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.
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The charge nurse observes a new graduate performing a dressing change on a patient with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?
- A. Uses a hydrocolloid dressing (DuoDerm) to cover the injury.
- B. Inserts a sterile cotton-tipped applicator into the pressure injury.
- C. Irrigates the pressure injury with a 30-ml syringe using sterile saline.
- D. Cleans the injury with a sterile dressing soaked in half-strength hydrogen peroxide.
Correct Answer: D
Rationale: Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.
Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient who has a stage 3 sacral pressure injury?
- A. Administer the ordered PRN oral opioid 30 minutes before the dressing change.
- B. Soak the old dressings with sterile saline a few minutes before removing them.
- C. Pour sterile saline onto the new dry dressings after the wound has been packed.
- D. Apply antimicrobial ointment before repacking the wound with moist dressings.
Correct Answer: A
Rationale: Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.
A patient who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions should the nurse instruct the family members that it is most important?
- A. Change the patient's bedding frequently.
- B. Use a hydrocolloid dressing over the injury.
- C. Record the size and appearance of the pressure injury weekly.
- D. Change the patient's position every 2 hours.
Correct Answer: D
Rationale: The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions also may be included in family teaching, but the most important instruction is to change the patient's position every 2-4 hours.
The nurse is caring for a patient with a systemic bacterial infection who has 'goose pimples,' feels cold, and rigors. At this stage of the febrile response, which of the following assessments should the nurse monitor?
- A. Skin flushing
- B. Muscle cramps
- C. Rising body temperature
- D. Decreasing blood pressure
Correct Answer: C
Rationale: The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.
A patient is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue. A stage 1 pressure injury has intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injuries have partial-thickness skin loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.