NURS424, chapter 10, Complex Wound Management
Questions With Complete Solutions
A client is admitted from home care with a pressure ulcer that
extends into the SC tissue. How would the nurse describe this
wound? Correct Answers Stage III pressure ulcer
A client is brought to the ED after being injured in a tornado.
The client was found in a muddy ditch and has multiple cuts and
abrasions from debris. What nursing measures are indicated to
prevent infections in these wounds? Correct Answers Cleanse
the wounds as soon as possible.
Require hand hygiene for all persons who come in contact with
the client.
Assist with debridement as indicated.
Administer antibiotics as directed
A client is having surgery for a ruptured appendix today, and the
incision is expected to be closed by tertiary intention. What
education about the wound will the nurse provide? Correct
Answers "Your incision will be open to allow for drainage"
" You will require another procedure to close the incision"
A client is receiving autolytic debridement with a hydrocolloid
wafer dressing. The nurse notes a collection of yellow fluid
under the dressing on the day before the dressing is scheduled to
be changed. What nursing action is indicated? Correct Answers
leave the dressing intact
A client is receiving negative pressure wound therapy (NPWT).
Upon removal of the sponge, the nurse notes that granulation
, tissue has grown into the sponge. The client complains of pain.
What actions should the nurse take? Correct Answers Wet the
sponge with normal saline
Discuss changing the sponge more frequently with the
healthcare provider.
A client presents to the ED w/ a minor abrasion on the leg that
occurred while he was mowing the lawn. The client states, "This
is such a small scratch, but it hurts a lot." Assessment reveals
slight redness and edema at the site, which feels slightly warm to
touch. Which assessment findings are of most concern to the
nurse? Correct Answers The injury is on the client's leg
The pain from the scratch is out of proportion to its size.
A client will be admitted following extensive surgery for
Fournier gangrene. The nurse who will provide care for this
client should prepare for which postoperative interventions?
Correct Answers Antibiotic therapy.
Special fecal management care.
Pain management.
A dry wound environment has which effect? Correct Answers It
leads to cell desiccation.
A stage II pressure ulcer is an example of which type of wound?
Correct Answers partial thickness
Adverse effects of microbes on wound healing Correct Answers
- microbes compete with host cells for nutrients and oxygen
- bacteria release exotoxins that are cytotosic
Questions With Complete Solutions
A client is admitted from home care with a pressure ulcer that
extends into the SC tissue. How would the nurse describe this
wound? Correct Answers Stage III pressure ulcer
A client is brought to the ED after being injured in a tornado.
The client was found in a muddy ditch and has multiple cuts and
abrasions from debris. What nursing measures are indicated to
prevent infections in these wounds? Correct Answers Cleanse
the wounds as soon as possible.
Require hand hygiene for all persons who come in contact with
the client.
Assist with debridement as indicated.
Administer antibiotics as directed
A client is having surgery for a ruptured appendix today, and the
incision is expected to be closed by tertiary intention. What
education about the wound will the nurse provide? Correct
Answers "Your incision will be open to allow for drainage"
" You will require another procedure to close the incision"
A client is receiving autolytic debridement with a hydrocolloid
wafer dressing. The nurse notes a collection of yellow fluid
under the dressing on the day before the dressing is scheduled to
be changed. What nursing action is indicated? Correct Answers
leave the dressing intact
A client is receiving negative pressure wound therapy (NPWT).
Upon removal of the sponge, the nurse notes that granulation
, tissue has grown into the sponge. The client complains of pain.
What actions should the nurse take? Correct Answers Wet the
sponge with normal saline
Discuss changing the sponge more frequently with the
healthcare provider.
A client presents to the ED w/ a minor abrasion on the leg that
occurred while he was mowing the lawn. The client states, "This
is such a small scratch, but it hurts a lot." Assessment reveals
slight redness and edema at the site, which feels slightly warm to
touch. Which assessment findings are of most concern to the
nurse? Correct Answers The injury is on the client's leg
The pain from the scratch is out of proportion to its size.
A client will be admitted following extensive surgery for
Fournier gangrene. The nurse who will provide care for this
client should prepare for which postoperative interventions?
Correct Answers Antibiotic therapy.
Special fecal management care.
Pain management.
A dry wound environment has which effect? Correct Answers It
leads to cell desiccation.
A stage II pressure ulcer is an example of which type of wound?
Correct Answers partial thickness
Adverse effects of microbes on wound healing Correct Answers
- microbes compete with host cells for nutrients and oxygen
- bacteria release exotoxins that are cytotosic
