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The nurse preceptor supervises a new graduate nurse assessing a patient with pressure injuries. The graduate documents biofilm presence in the wound site. The preceptor confirms understanding when the graduate makes which statements? Select all that apply.
- A. Enhanced healing due to sugars or proteins present.
- B. Delayed healing due to dead tissues in tissue present in the wound.
- C. Antibiotics are less effective against bacteria.
- D. Loss of skin integrity due to excessive hydration of wound cells.
- E. Delayed healing due to dehydration of cells dehydrating or dying.
- F. Decreased immune effectiveness of the patient's normal immune process results in decreased effectiveness.
Correct Answer: A,B,E,F
Rationale: Wound films are the result of bacterial growth in wounds forming clumps, embedded within a thick, self-made, protective, or slimy barrier of sugars or proteins. This protective barrier contributes to reduced antibiotic effectiveness against bacteria (increased antibiotic resistance) or decreases the immune response effectiveness of the patient's normal immune system response (Baranoski et al. & Ayello, 2020). Dead tissue delays healing or necrosis in the wound delays healing. Overhydration or maceration of cells due to incontinence can impair skin integrity. Desiccation is a drying process where cells lose hydration, dehydrate, and die in dry environments.
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What interventions are most likely to be effective in engaging Sam in their treatment and prevention plan? Select all that apply.
- A. Having Sam perform a return demonstration on active range of motion and repositioning
- B. Facilitating the interaction with the wound care specialist and reinforcing any teaching points
- C. Involving Sam's partner (with Sam's permission) in the dressing changes to increase their confidence before discharge
- D. Providing a pressure-relief support surface for the bed and chair that Sam agrees to use
- E. Instructing Sam on how to use the call bell and television remote in the room
Correct Answer: A,B,C,D
Rationale: Engaging Sam involves active participation (A), specialist interaction with reinforcement (B), involving the partner for support (C), and using a pressure-relief surface to prevent further wounds (D). Teaching about the call bell and remote (E) is less relevant to wound care engagement.
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
- A. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
- B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
- C. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
- D. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
- A. Sitting quietly with Sam
- B. Contacting Sam's partner and providing an update
- C. Consulting wound care for a thorough assessment
- D. Hanging the prescribed antibiotic
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, 'Something is falling out of my incision!' The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
- A. Notify the health care provider of the situation.
- B. Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
- C. Place the patient in the low Fowler position.
- D. Document the findings and outcome of interventions.
- E. Maintain NPO status for return to the OR for repair.
Correct Answer: C,B,A,E,D
Rationale: The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the wound), and notify the surgical site of the situation (to address the problem issue, likely requiring with surgery). The patient must be kept NPO for prompt surgical repair will be needed. After the patient has received attention, the nurse should document all assessments and interventions performed in a timely manner.
A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
- A. Pain
- B. Wound healing
- C. Body image
- D. Change in cognition
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.