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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.
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An elderly patient who lives alone and has a vascular stasis ulcer on his right leg is most at risk for infection because he
- A. May not see well enough to notice changes in the wound that indicate infection.
- B. Is unable to stay off of his leg, which will compromise circulation to the area.
- C. Does not eat healthy meals, causing a lack of granulation tissue.
- D. Lacks the ability to understand the way that antibiotics work.
Correct Answer: A
Rationale: Poor vision in the elderly can prevent early detection of infection signs, increasing infection risk in chronic wounds like stasis ulcers.
Which of the following orders would you expect the health-care provider to write after receiving laboratory results for the patient in Question 20?
- A. Bedrest with bathroom privileges
- B. Discharge tomorrow morning
- C. Wound culture and sensitivity
- D. Low-protein diet
Correct Answer: C
Rationale: A wound culture and sensitivity test is appropriate to identify the specific bacteria and effective antibiotics for an infected wound.
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 colonized wound is one in which
- A. There is potential for becoming infected.
- B. Infection is present as a result of gross contamination related to trauma.
- C. Infection is present as evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue.
- D. A high number of microorganisms are present without signs and symptoms of infection.
Correct Answer: D
Rationale: A colonized wound has many microorganisms but no clinical signs of infection, distinguishing it from an infected wound.
Match the following types of wound healing with their examples: Second 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: C
Rationale: Second intention healing involves granulation tissue filling an open wound, as in a pressure ulcer packed with gauze.