BSN 266 Sherpaths Nutrition || Already Graded A+.
Question 2 of 9
Which statements indicate that the patient understands the role of inflammation in wound
healing?
Select all that apply.
"Inflammation will impede the healing process of my wound."
"The presence of inflammation indicates my wound is infected with bacteria."
"Inflammation is responsible for the redness, heat, and swelling of my wound."
"The inflammatory response works to clean the wound of organisms and debris."
"The inflammatory response can remove living organisms, but not tissue and other foreign
bodies." correct answers "Inflammation is responsible for the redness, heat, and swelling of my
wound."
"The inflammatory response works to clean the wound of organisms and debris."
Question 3 of 9
The nurse is caring for a patient with an uninfected surgical wound. How would the nurse expect
this wound to heal?
Inflammation
Degranulation
First intention
Second intention correct answers First intention
A clean laceration or an uninfected surgical wound would heal by first intention.
Question 4 of 9
A patient presents to the clinic with a full-thickness pressure ulcer to the sacrum. Which finding
indicates this patient may likely require surgical intervention for the wound?
The patient is a paraplegic who sits in a wheelchair all day.
The patient is able to independently perform daily wound care.
The patient's wound is red and blistering at the wound edges.
,Wound care supplies are not covered by the patient's insurance plan. correct answers The patient
is a paraplegic who sits in a wheelchair all day.
A patient who is a paraplegic that sits in a wheelchair all day and has a full-thickness pressure
ulcer to the sacrum. The patient's wound has a low probability for healing on its own. This
patient would require surgical intervention to treat the wound.
Question 5 of 9
A registered nurse is supervising a student nurse performing a dressing change. Which action
made by a student nurse requires intervention by the registered nurse?
Measuring the wound's length, width, and depth
Packing the wound with a normal saline moistened gauze
Obtaining the wound culture and sensitivity after cleaning
Applying debridement enzyme ointment to the healthy tissue correct answers Applying
debridement enzyme ointment to the healthy tissue
Enzyme debriding ointments should only be applied to necrotic or eschar tissue, not to healthy
tissue. This ointment is used to eradicate the dead tissue.
Question 6 of 9
A patient presents with a wound dehiscence requiring wet-to-dry dressing changes. The patient
asks about trying that "wound vacuum thing" that someone else had. Which finding would make
negative-pressure wound therapy (NPWT) contraindicated?
The patient is receiving anticoagulants for atrial fibrillation.
The wound bed is beefy red with a slight amount of eschar.
The patient has copious amounts of serosanguinous drainage.
The dressing must be changed every 4 hours and the patient lives alone. correct answers The
patient is receiving anticoagulants for atrial fibrillation.
The patient taking anticoagulants would not be a candidate for NPWT as it is contraindicated as
the patient could begin bleeding into the wound vacuum canister.
Question 7 of 9
, A nurse is caring for a patient 2 days postoperative from appendectomy. The patient reports
incisional pain of 4/10, and the nurse notes erythema at the margins of the wound, temperature of
100.4° F orally, and serosanguinous drainage on the dressing. Based on this assessment, what
conclusion should the nurse make?
A drain should be placed on the wound.
The incision is showing signs of infection and the surgeon should be notified.
The patient is experiencing a wound dehiscence and should be monitored.
These are typical findings postappendectomy and require no further intervention. correct answers
The incision is showing signs of infection and the surgeon should be notified.
Erythema on the wound margins and an increased oral temperature are signs of a possible
surgical wound infection. The surgeon should be notified of these findings.
Question 8 of 9
The nurse is preparing to change the dressing to an ischial wound. The order has been changed
from a wet-to-dry dressing to a wet-to-damp dressing. The patient asks the nurse why there is a
change to a wet-to-damp dressing. What is the nurse's best response?
"A wet-to-damp dressing protects the periwound area from maceration."
"Using a wet-to-damp dressing decreases how often we need to change the dressing."
"A wet-to-damp dressing protects the wound bed from trauma during dressing changes."
"Using a wet-to-damp dressing decreases the risk of bacterial growth in the wound bed." correct
answers "A wet-to-damp dressing protects the wound bed from trauma during dressing changes."
Using a wet-to-damp dressing keeps the wound bed moist and protects it from trauma during
dressing changes.
Question 9 of 9
A 24-year-old sustained a laceration to the lower leg and is having a difficult time healing.
Which meal would be appropriate for the nurse to order for the patient?
Oatmeal and grapes
Granola bars with peaches
Waffles with syrup and a banana
Question 2 of 9
Which statements indicate that the patient understands the role of inflammation in wound
healing?
Select all that apply.
"Inflammation will impede the healing process of my wound."
"The presence of inflammation indicates my wound is infected with bacteria."
"Inflammation is responsible for the redness, heat, and swelling of my wound."
"The inflammatory response works to clean the wound of organisms and debris."
"The inflammatory response can remove living organisms, but not tissue and other foreign
bodies." correct answers "Inflammation is responsible for the redness, heat, and swelling of my
wound."
"The inflammatory response works to clean the wound of organisms and debris."
Question 3 of 9
The nurse is caring for a patient with an uninfected surgical wound. How would the nurse expect
this wound to heal?
Inflammation
Degranulation
First intention
Second intention correct answers First intention
A clean laceration or an uninfected surgical wound would heal by first intention.
Question 4 of 9
A patient presents to the clinic with a full-thickness pressure ulcer to the sacrum. Which finding
indicates this patient may likely require surgical intervention for the wound?
The patient is a paraplegic who sits in a wheelchair all day.
The patient is able to independently perform daily wound care.
The patient's wound is red and blistering at the wound edges.
,Wound care supplies are not covered by the patient's insurance plan. correct answers The patient
is a paraplegic who sits in a wheelchair all day.
A patient who is a paraplegic that sits in a wheelchair all day and has a full-thickness pressure
ulcer to the sacrum. The patient's wound has a low probability for healing on its own. This
patient would require surgical intervention to treat the wound.
Question 5 of 9
A registered nurse is supervising a student nurse performing a dressing change. Which action
made by a student nurse requires intervention by the registered nurse?
Measuring the wound's length, width, and depth
Packing the wound with a normal saline moistened gauze
Obtaining the wound culture and sensitivity after cleaning
Applying debridement enzyme ointment to the healthy tissue correct answers Applying
debridement enzyme ointment to the healthy tissue
Enzyme debriding ointments should only be applied to necrotic or eschar tissue, not to healthy
tissue. This ointment is used to eradicate the dead tissue.
Question 6 of 9
A patient presents with a wound dehiscence requiring wet-to-dry dressing changes. The patient
asks about trying that "wound vacuum thing" that someone else had. Which finding would make
negative-pressure wound therapy (NPWT) contraindicated?
The patient is receiving anticoagulants for atrial fibrillation.
The wound bed is beefy red with a slight amount of eschar.
The patient has copious amounts of serosanguinous drainage.
The dressing must be changed every 4 hours and the patient lives alone. correct answers The
patient is receiving anticoagulants for atrial fibrillation.
The patient taking anticoagulants would not be a candidate for NPWT as it is contraindicated as
the patient could begin bleeding into the wound vacuum canister.
Question 7 of 9
, A nurse is caring for a patient 2 days postoperative from appendectomy. The patient reports
incisional pain of 4/10, and the nurse notes erythema at the margins of the wound, temperature of
100.4° F orally, and serosanguinous drainage on the dressing. Based on this assessment, what
conclusion should the nurse make?
A drain should be placed on the wound.
The incision is showing signs of infection and the surgeon should be notified.
The patient is experiencing a wound dehiscence and should be monitored.
These are typical findings postappendectomy and require no further intervention. correct answers
The incision is showing signs of infection and the surgeon should be notified.
Erythema on the wound margins and an increased oral temperature are signs of a possible
surgical wound infection. The surgeon should be notified of these findings.
Question 8 of 9
The nurse is preparing to change the dressing to an ischial wound. The order has been changed
from a wet-to-dry dressing to a wet-to-damp dressing. The patient asks the nurse why there is a
change to a wet-to-damp dressing. What is the nurse's best response?
"A wet-to-damp dressing protects the periwound area from maceration."
"Using a wet-to-damp dressing decreases how often we need to change the dressing."
"A wet-to-damp dressing protects the wound bed from trauma during dressing changes."
"Using a wet-to-damp dressing decreases the risk of bacterial growth in the wound bed." correct
answers "A wet-to-damp dressing protects the wound bed from trauma during dressing changes."
Using a wet-to-damp dressing keeps the wound bed moist and protects it from trauma during
dressing changes.
Question 9 of 9
A 24-year-old sustained a laceration to the lower leg and is having a difficult time healing.
Which meal would be appropriate for the nurse to order for the patient?
Oatmeal and grapes
Granola bars with peaches
Waffles with syrup and a banana
