Nokea
The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
- A. Improves overall tissue perfusion.
- B. Promotes release of oxygen to tissues.
- C. Causes hemoglobin to have a greater affinity for oxygen.
- D. Causes hemoglobin to have a decreased affinity for oxygen.
Correct Answer: C
Rationale: Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.
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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.
Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?
- A. Fibrin
- B. Thrombin
- C. Protime
- D. Calcium
Correct Answer: A
Rationale: Fibrin in the clot begins to hold the wound together.
The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?
- A. Remove 7 more alternate staples and securely tape with Steri-Strips.
- B. Cover with moist dressing and apply a binder.
- C. Continue to remove staples as ordered because this is an expected outcome.
- D. Leave the 12 staples in place and record the separation.
Correct Answer: D
Rationale: If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation.
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.
When removing the dressing on a patient the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
- A. Call the RN.
- B. Gently remove the gauze with sterile forceps.
- C. Cover with occlusive dressing.
- D. Moisten the dressing with sterile water.
Correct Answer: D
Rationale: When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.