Nokea
Classify the following wounds as either open or closed: A. Contusion, B. Abrasion, C. Laceration, D. Pressure injury
- A. A: Closed, B: Open, C: Open, D: Open
- B. A: Open, B: Closed, C: Closed, D: Closed
- C. A: Closed, B: Closed, C: Open, D: Open
- D. A: Open, B: Open, C: Closed, D: Closed
Correct Answer: A
Rationale: Contusions are closed (bruising under intact skin), while abrasions, lacerations, and pressure injuries are open (skin is broken).
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Before you go in the room to change the dressing for your assigned patient, who has a stage 3 pressure injury infected with MRSA, your first priorities will be to
- A. Determine supplies needed for the dressing change.
- B. Obtain appropriate PPE for caring for a patient with MRSA.
- C. Review sterile technique to prevent contaminating the wound.
- D. Review how to assess a stage 3 pressure injury.
- E. Ask the patient how the other nurses have done the dressing change.
Correct Answer: B,C
Rationale: For an MRSA-infected wound, obtaining PPE and reviewing sterile technique are priorities to prevent transmission and further contamination.
A patient with an open leg wound has the following laboratory results on his chart: WBC 15,350 mm^3 with an elevated percentage of neutrophils. What does this tell you about the patient's wound?
- A. He most likely no longer has any wound infection.
- B. He most likely has an acute wound infection.
- C. He most likely has a chronic wound infection.
- D. He most likely has a widespread bacterial infection.
Correct Answer: B
Rationale: Elevated WBC and neutrophils indicate an active immune response, typically seen in acute infections, suggesting the wound is acutely infected.
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.
Your patient with a stage 3 pressure injury infected with MRSA is on contact precautions. Which of the following PPE will you obtain when you enter his room?
- A. Gloves
- B. Gown
- C. Mask
- D. Goggles
Correct Answer: A,B
Rationale: Contact precautions for MRSA require gloves and a gown to prevent direct contact with the patient or contaminated surfaces.
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.