Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank Chapter 18: Clients with Wounds MULTIPLE CHOICE 1. The nurse predicts that the wound capable of becoming ideally healed is a(n) a. abdominal incision. b. burn scar on the leg. c. cancerous lesion on the inside of the cheek. d. severe acne on the face. ANS: A An ideally healed wound can occur only in epidermal tissue or mucous membranes. Once there is injury through the dermis, scar tissue replaces the missing dermis and epidermis. Scar tissue, as in a burn, replaces normal dermis and epidermis and normal function cannot return to that area. A cancerous lesion will need surgical removal with a wide excision and deformity. Severe acne also leaves scars. DIF: Comprehension/Understanding REF: pp. 304-305 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology 2. A client has a chronic, nonhealing ulcer on the lower leg. The nurse thinks the client could benefit from negative-pressure wound therapy. The most appropriate action by the nurse would be to a. ask the charge nurse to discuss the matter with the physician. b. call the physician and request an order for a negative pressure machine. c. keep track of supplies used currently to estimate the cost of continuing the present regimen. d. request the physician write an order to consult the wound care nurse. ANS: D There are several options available for chronic, nonhealing wounds, including negative pressure therapy. Such wounds are best managed by a special team of wound care specialists, including a wound care nurse. The best way to collaborate with the physician to involve a wound care nurse is to apprise the physician of the problem and give a direct suggestion. DIF: Analysis/Analyzing REF: p. 320 OBJ: Intervention MSC: Safe, Effective Care Environment Management of Care-Consultation

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3. A nurse is changing a dressing over a clients abdominal surgical incision. Which action by the nurse is most important? a. Apply dressings using aseptic or sterile technique. b. Irrigate the wound with copious amounts of solution. c. Use strict sterile technique, including sterile gloves. d. Wash the suture line carefully to remove debris. ANS: A To prevent wound infection, change dressings with either aseptic or sterile technique. Strict sterile technique with sterile gloves is usually not needed. Do not touch the side of the dressing that will touch the client. A noninfected surgical incision does not need to be irrigated. You should not wash the suture line because the water might carry microorganisms into the wound along the sutures. DIF: Application/Applying REF: p. 313 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Medical and Surgical Asepsis 4. The edges of a clients appendectomy incision are approximated, and no drainage is noted. The nurse documents on the clients wound record that the incision appears to be healing by a. granulation. b. primary intention. c. secondary intention. d. tertiary intention. ANS: B Primary intention is the use of suture or other wound closures to approximate the edges of an incision or a clean laceration. Wounds healing by secondary intention are left open and heal by the generation of tissue. Tertiary intention is a wound that is capable of being sutured but is left open for the time being because of a high risk of infection. The wound will be closed later. Granulation tissue is newly formed tissue. DIF: Comprehension/Understanding REF: pp. 308-309 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology 5. The nurse who is using an enzymatic debridement ointment will a. apply the ointment liberally over large areas. b. keep the area moist after application. c. medicate the client before applying ointment to viable tissue.

Test Bank d. use the ointment cautiously on neoplastic ulcers.

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ANS: B Enzymatic agents work best in a moist environment. The ointment is applied to small areas and is never applied to neoplastic lesions or viable tissue. DIF: Application/Applying REF: p. 317 OBJ: Intervention MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications 6. A frail client with multiple chronic medical conditions has a chronic, infected, malodorous wound. The client begins to cry when the nurse tries to explain to the client an aggressive approach to wound care. The nurse should revise the plan to focus on a. better pain control so the client can tolerate the aggressive therapy. b. palliative care and quality of life. c. the clients emotional barrier to the recommended treatment. d. the possibility of eventual amputation. ANS: B For frail clients with little hope of recovery (especially in the setting of multiple chronic illnesses), aggressive treatment may not be appropriate. Palliative care, including pain control, odor management, drainage control, and quality of life, should become the main concerns. DIF: Application/Applying REF: p. 321 MSC: Psychosocial Adaptation Quality of Life OBJ: Intervention

7. A client must do dressing changes at home on a clean, but open, surgical wound. The nurse determines that goals for discharge instructions have been met when the client says: a. I will be sure to keep the skin surrounding the wound dry. b. I will sit under a heat lamp for 30 minutes a day to help dry up the drainage. c. If I run out of saline, I can irrigate the wound with half strength peroxide. d. Pulling out the dried up dressings will help clean the wound out. ANS: A The rule of thumb for wound care is to keep the clean wound bed moist and the surrounding skin dry to avoid skin breakdown. Re-epithelialization occurs best under moist conditions, so using heat lamps or other drying treatments is not recommended. Half strength peroxide should only be used in infected wounds. Pulling out a dried up dressing will damage the new granulation tissue. If the dressing is too dry to pull out of a clean wound, it should be moistened slightly. DIF: Analysis/Analyzing REF: p. 315 OBJ: Evaluation

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MSC: Health Promotion and Maintenance Self Care 8. A client with an open wound develops a temperature of 99.8 F. The most appropriate action by the nurse is to a. administer an antipyretic. b. continue to monitor the clients temperature. c. cool the clients environment. d. keep the client warm. ANS: B Fever is usually adaptive because bacterial reproduction is sensitive to even slight increases in temperature. DIF: Application/Applying REF: p. 310 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration 9. A nurse is caring for a client with a chronic lower leg wound caused by venous insufficiency. Which action by the nurse is most appropriate? a. Apply ice to the surrounding tissue. b. Elevate the leg and apply compression stockings. c. Keep the leg in one position to avoid further injury. d. Position the leg flat with heels elevated off the bed. ANS: B A wound caused or worsened by venous insufficiency needs to be elevated and treated with compression (i.e., TED hose). Applying ice to the surrounding tissues may damage them and create a bigger wound. Keeping the leg in one position could contribute to pressure ulcer development. Positioning the leg flat would not be beneficial since venous return is enhanced with elevation. DIF: Application/Applying REF: p. 313 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology 10. On removing a dressing from a client on the third postoperative day, the nurse notes thin, pinkcolored drainage and documents this as a. serous. b. sanguineous. c. serosanguineous. d. purulent.

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ANS: C Serosanguineous exudate is drainage composed of both serous fluid and blood. It is pink and usually fairly thin. DIF: Application REF: p. 311 MSC: Physiological Integrity OBJ: Assessment

11. When caring for a client with a wound healing by secondary intention, the nurse considers during care planning that this type of wound is a. healed with skin grafts. b. prone to dehiscence. c. sealed with sutures. d. susceptible to infection. ANS: D Wounds healing by secondary intention require the regeneration of much more tissue than wound healing by primary intention, and there is also increased risk of infection. DIF: Comprehension/Understanding REF: pp. 308-309 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration 12. A nurse is caring for four clients. Which client should the nurse assess first? The client with a/an a. eviscerated abdominal wound from surgery yesterday. b. infected lower leg ulcer and diabetes, who needs a blood sugar measurement. c. large open infected wound and temperature of 99.9 F. d. operative incision covered with a clean, dry dressing from surgery 8 hours ago. ANS: A An abdominal wound that has eviscerated has opened up with abdominal contents exposed. This is a surgical emergency and this is the client the nurse should see first. The blood sugar measurement can be delegated to the unlicensed assistive personnel. The client with the temperature of 99.9 F will not need antipyretics as even small temperature elevations are beneficial. The operative incision sounds normal. DIF: Evaluation/Evaluating REF: p. 321 OBJ: Assessment MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities 13. A client is being discharged with a large wound on the right ankle that has cellulitis. The client is obese, smokes 2 packs of cigarettes a day, and is sedentary. In the discharge instructions, which lifestyle modification would be most important for the nurse to include? The client should
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a. drink more water. b. lose weight. c. start an exercise routine. d. stop smoking. ANS: D Of the many factors that promote or retard angiogenesis and wound healing, one of the most important is adequate oxygenation. Smoking causes vasoconstriction and hypoxia because of the carbon monoxide in the smoke. Clients with cellulitis need a high-calorie, high-protein, high-carbohydrate diet rich in vitamins and nutrients. This is no time for the client to begin a weight loss program. Drinking plenty of water would be good for this client, but will not have as dramatic effect on wound healing as stopping smoking will. DIF: Analysis/Analyzing REF: p. 320 MSC: Health Promotion and Maintenance Lifestyle Choices OBJ: Intervention

14. To assist in the healing of a large leg ulcer, the nurse applies wet dressings to the wound to promote a. angiogenesis. b. chemotaxis. c. epithelialization. d. wound contraction. ANS: C Wound healing is optimized in a moist environment. When the environment is moist, collagen synthesis and granulation tissue formation are enhanced, cell migration and epithelial resurfacing occur more rapidly, and scab, crust, and eschar cannot form. Angiogenesis is the formation of new blood vessels. Chemotaxis is the movement of cells in relation to a chemical stimulation. Wound contraction can cause scarring and deformity. DIF: Comprehension/Understanding REF: p. 308 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology 15. A client has a large, sacral pressure ulcer with a red wound base and no drainage. Which solution would the nurse select as the most appropriate solution for cleansing this wound? a. A weak iodine solution b. Dakins solution c. Half-strength hydrogen peroxide d. Normal saline

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ANS: D Normal saline (NS) is the only solution recommended by the American Healthcare Policy and Research (AHCPR) group for wound care, such as in packing and cleaning. NS is physiologic, will not harm tissues, and adequately cleans most wounds. Iodine solutions, half-strength peroxide, and Dakins solutions can be used for the short-term management of infected wounds. DIF: Application/Applying REF: pp. 316-315 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Treatments 16. The nurse caring for a client receiving wet-to-dry dressings for mechanical debridement of a large wound would be aware that proper technique requires that the dressing should a. be left in place about 12 hours. b. be removed when it is totally dry. c. cause slight bleeding when removed to be effective. d. only be moist, not wet, when applied. ANS: D Mechanical debridement can be accomplished by the use of wet-to-dry dressings. A moist (not wet) dressing is positioned in the wound and held in place by an outer dressing or gauze wrap. As the dressing is removed it provides nonselective debridement. The dressing should only be left in place long enough for it to begin to dry (4-6 hours). Bleeding would indicate removal of granulation tissue. DIF: Application/Applying REF: p. 317 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Treatments 17. On a clients admission to the hospital, the nurse notes that the client has a yellow sacral decubitus ulcer. The nurse anticipates that the most appropriate wound treatment would be a. applying antibiotic ointment. b. surgical removal of eschar. c. using wet-to-dry dressings. d. vigorous cleansing with a Water Pik. ANS: C Yellow material in the wound base is a sloughy, necrotic type of material. Before a wound can heal, necrotic tissue must be removed. Mechanical debridement can be accomplished by using wet-to-dry dressings. Antibiotic ointment will not remove the debris. This wound does not have eschar, which is black and leathery in appearance. Vigorous cleaning with a Water Pik might lead to tissue damage as a result of high water pressure and should be avoided.
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DIF: Application/Applying REF: p. 317 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Treatments 18. A client has a small, shallow wound with a red base that does not require debridement. The dressing the nurse would choose when covering this wound is a a. dry woven gauze fastened with adhesive tape. b. non-adhering dressing with antibiotic ointment. c. wet nonwoven gauze. d. wet-to-dry gauze dressing. ANS: C If the wound is shallow, a thin layer of antibiotic ointment and a non-adhering dressing are used to cover it. Dry gauze would stick to the wound. The wound does not require wet-to-dry or wet dressings of any kind. DIF: Application/Applying REF: pp. 315-317 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Treatments 19. A clients dressing orders include calcium alginate (Kalistat). The nurse instructs the client that this application is appropriate for a(n) a. black wound. b. draining wound. c. infected wound. d. red wound. ANS: B Calcium alginate retains moisture and is left intact for 2 to 3 days as a treatment for a draining wound. DIF: Application/Applying REF: p. 316 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Treatments 20. The nurse is aware that the process by which capillary permeability is altered to allow the large neutrophils to pass through the capillary wall and to the wound site is called a. banding. b. marginating.

Test Bank c. replicating. d. segmenting. ANS: A The capillaries are layered with cells that allow a gateway for the large neutrophils to exit the capillary and enter the site of the wound to begin the inflammatory phase of healing. DIF: Comprehension/Understanding REF: p. 306 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology 21. Four days after a clients surgery, the nurse assesses a collagen mass under the clients suture line as an indication of a. abscess. b. edema. c. healing ridge. d. infection.

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ANS: C A ridge of collagen forms under the suture line 3 to 5 days after the incision is made. This collagenous mass is indicative of healing. DIF: Comprehension/Understanding REF: pp. 312-313 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems 22. The nurse informs the client that to reduce scarring, facial sutures are removed in a. 1 to 2 days. b. 4 to 7 days. c. 8 to 10 days. d. 12 to 14 days. ANS: B Sutures in areas such as the face, where scarring is avoided, are removed within 4 to 7 days. In most other areas, sutures are removed in 7 to 10 days. Sutures in the hand and foot are often removed in 1 to 2 weeks or longer. DIF: Comprehension/Understanding REF: p. 313 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Treatments MULTIPLE RESPONSE
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1. A client comes to the clinic with a wound that does not seem to be healing. Which assessments should the nurse make on this client specific to the wound? (Select all that apply.) a. Clients height and weight b. Diet and nutritional history c. Long-term use of steroids d. Size of the wound and amount of drainage e. Smoking and alcohol intake ANS: B, C, D, E Good wound healing requires a diet high in vitamin C, protein, carbohydrates, calories, and fluids. Steroids reduce the number of lymphocytes available for appropriate inflammatory response, and clients receiving long-term steroids have delayed wound healing. The size of the wound and any drainage coming from it are important parts of the physical assessment of a wound. Smoking causes vasoconstriction, which will delay the delivery of oxygen and nutrients to the wound. Height and weight, while part of a general assessment, do not provide information specific to a wound. Weight loss might indicate poor nutritional status. DIF: Analysis/Analyzing REF: pp. 307, 310, 315, 320 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology 2. A client is being discharged and will need to perform wound care and dressing changes in the home on a large, open wound. When designing a teaching plan for discharge, the nurse should include which of the following elements? (Select all that apply.) a. A videotape of the wound care procedure if possible b. Appropriate ways to irrigate the wound c. Cost of wound care supplies d. Detailed written instructions e. Types of supplies the client will need ANS: A, B, D, E A videotape of wound care would be very helpful for the client once he/she is home. Contact the facilitys biomedical communications department for assistance if the client or family does not have a video camera. All the steps in wound care should be covered, including cleansing and irrigating the wound and applying dressings properly. The client will need a list of supplies, but the cost of supplies is not essential. Detailed written instructions will be helpful also, but ensure the client and/or family can read. DIF: Synthesis/Creating REF: pp. 318-319 OBJ: Intervention

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