Nokea
The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?
- A. Cellulitis
- B. Dehiscence
- C. Evisceration
- D. Extravasation
Correct Answer: B
Rationale: Dehiscence is separation of a surgical incision or rupture of a wound closure.
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The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
- A. Destruction of tissue
- B. Bleeding
- C. Mechanical débridement
- D. Prevention of infection
Correct Answer: C
Rationale: The primary purpose of a wet-to-dry dressing is to débride a wound mechanically.
The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service?
- A. Positive pressure is applied by this device.
- B. Healing is facilitated by decrease in drainage.
- C. Promotes formulation of granulation tissue.
- D. Reduces local and peripheral edema.
- E. Drops bacterial level in wound.
Correct Answer: C,D,E
Rationale: Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed.
The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
- A. Dirty wound
- B. Clean-contaminated wound
- C. Contaminated wound
- D. Clean wound
Correct Answer: D
Rationale: A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively.
A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for a stage 2 foot injury. The patient refuses to follow an ADA diet as ordered by a health care provider and is morbidly obese. The nurse assesses the injury to be healing free from signs and symptoms of infection with a positive pedal pulse and warm to touch. What patient problem will be identified as a priority?
- A. Infection
- B. Altered nutrition: more than body requirements
- C. Impaired skin integrity
- D. Altered peripheral tissue perfusion
Correct Answer: B
Rationale: The nurse's assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority patient problem for this patient is altered nutrition: more than body requirements related to diet noncompliance.
Which are the phases of wound healing?
- A. Reconstruction
- B. Hemostasis
- C. Inflammation
- D. Granulation
- E. Maturation
Correct Answer: A,B,C,E
Rationale: The steps in wound healing are hemostasis, inflammation, reconstruction, and maturation.