Nokea
The nurse is caring for an adult patient with stage 3 pressure injuries on both heels who has been in hospital for 6 days. Which of the following timeframes for wound assessment is accurate when a patient is in the acute care setting?
- A. Every 4 hours
- B. Every 6 hours
- C. Every 12 hours
- D. Every 24 hours
Correct Answer: D
Rationale: In acute care, the patient should be reassessed every 24 hours. In long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and at least monthly or every 3 months thereafter.
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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 planning care for a patient and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?
- A. Pressure injury with pink granulation tissue
- B. Surgical incision with pink, approximated edges
- C. Full-thickness burn filled with dry, black material
- D. Wound with purulent drainage and dry brown areas
Correct Answer: D
Rationale: Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.
Which of the following nursing actions is most likely to detect early signs of infection in a patient who is taking immuno-suppressive medications?
- A. Monitor white blood cell count
- B. Check the skin for areas of redness.
- C. Check the temperature every 2 hours.
- D. Ask about fatigue or feelings of malaise.
Correct Answer: D
Rationale: Common clinical manifestations of inflammation and infection are frequently not present when patients receive immuno-suppressive medications. The earliest manifestation of an infection may be 'just not feeling well'.
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.