Nokea
You are a nurse, and you are running behind schedule on a very busy workday. The UAP offers to change a patient's abdominal dressing for you. She is a first-semester nursing student. Which is the most appropriate response?
- A. That would be great. Don't forget to measure the open area in the middle of her incision for me.'
- B. I know you have been taught to do this in school, so you are not the same as the other UAPs. Go ahead and change the dressing.'
- C. Thanks, but could you help Mr. Wu walk in the hall instead? That way I can get that dressing changed.'
- D. You know you can't do that as a UAP. I would be in big trouble if I let you change that dressing!'
Correct Answer: C
Rationale: UAPs, including nursing students, are not permitted to perform complex tasks like dressing changes, which require nursing judgment. Delegating a simpler task is appropriate.
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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.
In what order do wounds heal?
- A. Reconstruction phase, maturation phase, inflammatory phase
- B. Inflammatory phase, reconstruction phase, maturation phase
- C. Prodromal phase, symptoms phase, inflammatory phase, reconstruction phase
- D. Symptoms phase, maturation phase, inflammatory phase, reconstruction phase
Correct Answer: B
Rationale: Wounds heal in three phases: inflammatory (immediate response), reconstruction (tissue repair), and maturation (scar formation).
All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.
Which are accurate statements about a deep tissue pressure injury?
- A. It may be caused by a medical device, such as a splint.
- B. It is deep red, maroon or purple colored, and does not blanch.
- C. It may be intact or nonintact skin.
- D. It is at least 2 cm deep or deeper.
- E. It is the result of prolonged pressure and/or shear force.
Correct Answer: A,B,C,E
Rationale: Deep tissue pressure injuries involve non-blanching discoloration, can be intact or nonintact, and result from pressure/shear, often from devices.
You are calling a health-care provider to report a possible wound infection. What information will you include in your report?
- A. Most recent vital signs
- B. Amount and type of wound drainage
- C. Observed signs of infection
- D. Type and frequency of bowel movements
- E. Patient's rating of his or her pain
- F. Amount of activity the patient has had in the past 24 hours
- G. Laboratory results
Correct Answer: A,B,C,E,G
Rationale: Vital signs, drainage, infection signs, pain, and lab results are critical for assessing and managing a potential wound infection.