Nokea
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.
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All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.
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.
While assessing the skin of a patient on bedrest, you notice a pale area over the left hip with a small blister in the center. What action will you take?
- A. Massage the area vigorously with lotion to promote circulation.
- B. Notify the health-care provider that a pressure injury has developed.
- C. Document your findings and assess again in 2 hours.
- D. Order a special gel-filled mattress for the patient.
Correct Answer: B
Rationale: A pale area with a blister suggests a developing pressure injury, requiring immediate notification of the provider for intervention.
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.