Chapter 25: Wound Care and Irrigation Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition

Multiple Choice

1. The nurse assesses several preoperative patients for potential postoperative referrals to the wound care team. Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing?

a. Eight weeks postpartum from live vaginal birth in for tubal ligation b. Older than 70 years, coronary artery disease, and hypertension c. Six-week course of radiation therapy for a cancerous tumor d. Chronic obstructive lung disease on long-term prednisone therapy

ANS: A

The patient with the lowest risk of delayed wound healing is the patient scheduled for a tubal ligation because she is likely to be 40 years old or younger, decreasing the risk for chronic disease. She is likely to have generally good health as evidenced by a live vaginal birth. The older patient with coronary artery disease and hypertension has atherosclerotic lesions in the heart aggravated by high blood pressure. The patient is likely to have atherosclerotic lesions in other vessels because atherosclerosis is a nonselective disease; thus the patient is at risk for delayed healing because of the potential for impaired tissue perfusion. Radiation therapy increases the risk of postradiation scarring and fibrosis which increases the risk of delayed healing. The patient taking prednisone is at high risk for delayed healing because glucocorticoids suppress inflammation and the immune system.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. The temperature is 103.1° F (39.5° C) at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient’s pain has been increasing gradually.

2. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on the fourth postoperative day?

ANS: B

By the fourth postoperative day the patient’s surgical incision is expected to have slight redness and swelling but no drainage, indicating a physiological, expected, inflammatory response to tissue injury. A temperature of 39.5° C is febrile and warrants further investigation to rule out infection. Spongy, warm skin around the wound area can indicate infection and requires follow-up. Increasing pain can indicate that the wound status is deteriorating and needs to be assessed.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Scrubs the drain insertion site in a back-and-forth manner. b. Cleans the incision from wound edges toward the center. c. Applies clean gloves after removing the old dressing; inspects the wound. d. Dons sterile gloves, removes the dressing, and inspects the wound.

3. The nurse prepares to assess the patient’s wound after removing the dressing. Which does the nurse implement to promote infection control?

ANS: C

First the nurse applies clean gloves, and then removes soiled dressings and examines dressings for quality of drainage (color, consistency), presence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). The nurse discards dressings in a waterproof biohazard bag, removes and discards gloves, performs hand hygiene, and applies clean gloves. Then the nurse inspects the wound and determines the type of wound healing (e.g., primary or secondary intention). The wound is cleansed from the cleanest to the dirtiest area to avoid contamination of the cleaner area. The nurse does not need to put on sterile gloves to remove the dressing but does need to change gloves before inspecting the wound.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Empty the drain every 2 hours and measure the contents. b. Maintain a small, steady amount of tension on the drain tubing. c. Record the amount removed from each drain separately. d. Keep the collection end of the drain lower than the patient’s waist.

4. The nurse teaches a patient about self-care of two Jackson-Pratt drains after breast surgery. What does the nurse include in patient teaching?

ANS: C

Since the patient has two Jackson-Pratt drains, the amount removed from each drain should be recorded separately to allow the health care provider to know their effectiveness and when they can be removed. The bulb should be emptied when it is approximately two-thirds full, and a household device should be used to measure the contents as precisely as possible. The nurse instructs the patient to avoid putting tension on the tubing and to keep the bulb below the insertion site. Waist level is probably as low as the tubing can reach and still allow slack in the tubing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. They provide a skin barrier. b. They provide gentle support. c. They prevent scarring of the wound. d. They collect additional drainage.

5. The nurse teaches a patient about Steri-Strips after suture removal. What information does the nurse include in patient teaching?

ANS: B

Steri-Strips provide continued support to the incision after sutures or staples are removed. The nurse instructs the patient to expect the Steri-Strips to curl up and eventually fall off the skin and instructs the patient not to remove them. Steri-Strips do not provide a barrier since they are not applied continuously along the incision. The method of skin closure, site, and patient status determine the level of scarring. Steri-Strips are able to absorb only a few drops of drainage.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Cuts the foam smaller than wound edges. b. Uses black foam to prevent granulation tissue from forming. c. Determines if the patient needs pain medication before beginning the procedure. d. Checks the dressing to ensure that the device’s tubes are functioning.

6. The nurse performs a dressing change for a patient with a negative-pressure wound therapy device. Which step does the nurse implement to facilitate wound healing?

ANS: D

The nurse checks the dressing and tubing placement frequently to prevent new skin breakdown and aggravation of impaired tissue. The foam is cut to fit the entire wound bed, including tunnels and undermined areas, because the therapy cannot facilitate wound healing if it cannot reach the damaged tissue. Black foam is used to assist in granulation tissue formation. Pain medication might be needed, but it does not affect wound healing unless the nurse can’t manipulate the wound enough for a proper fit.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Limit heavy lifting activities. b. Ambulate several times a day. c. Soak in the bathtub for relaxation. d. Use a pillow to support incision.

7. The nurse applies Steri-Strips to the patient’s surgical site after suture removal. During patient teaching, what does the nurse instruct the patient to avoid doing?

ANS: C

The nurse instructs the patient to avoid soaking in the bathtub. Soaking in water decreases the longevity of the Steri-Strips. The nurse instructs the patient to avoid heavy lifting completely to prevent exposing the new incision to excessive pressure. If the incision separates or eviscerates, the patient’s risk of infection and complications increases. The nurse encourages the patient to ambulate several times a day to prevent deconditioning, thromboembolic events, pneumonia, and constipation. The patient is also instructed to support the incision with a pillow for turning, coughing, deep breathing, and other activities as necessary.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The area could have an increased risk of visible scarring. b. There is a small open area along the incision. c. The site is without drainage or erythema. d. The patient is quite anxious about the staple removal.

8. The nurse evaluates the surgical incision before removing the patient’s staples. What assessment finding would suggest staple removal is contraindicated for now?

ANS: B

The nurse avoids removing staples from an incision with an open area because this indicates the incision has delayed healing. If the nurse removes the staples too soon, the risk of infection increases from wound dehiscence or evisceration. The method of wound closure, healing progression, and patient nutritional status determines scarring; staple removal generally has no effect on scarring. A surgical incision without drainage or redness has clinical indicators consistent with a healing wound. Patients are frequently anxious about procedures perceived as potentially painful; thus, the nurse instructs the patient to expect a stinging sensation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Assess the type of suture material used. b. Snip off both ends of the suture material. c. Cleanse crusting with hydrogen peroxide. d. Plan staple removal for postoperative day 5.

9. The nurse prepares to remove the patient’s sutures and staples. Which step does the nurse implement before proceeding with the removal?

ANS: A

The nurse determines the type of material used for wound closure before removing the staples or sutures for efficient time management and proper preparation for removal. To avoid patient exposure, discomfort, and dissatisfaction, the nurse avoids starting the procedures without suitable supplies. The nurse avoids snipping off both ends of the suture material to keep the sutures visible at all times, ensuring that he or she always has an end to grasp for removal. Hydrogen peroxide is avoided for wound care or removal of staples or sutures because it is too harsh for topical use. Generally postoperative day 5 is too early for staple removal; staples are more typically removed on days 7–10.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Replace the Hemovac drain when full. b. Attach the tubing to the patient’s gown. c. Compress the Hemovac on a flat surface after emptying. d. Apply high continual suction to the Hemovac plug.

10. A patient has an abdominal wound with a Hemovac drain in place. Which technique does the nurse implement to maintain optimal suction in the drain?

ANS: C

To maintain the gentle suction designed into the Hemovac drainage system, the nurse empties the drainage into a measuring cup; compresses the Hemovac on a firm, flat surface; and reinserts the plug into its opening on the Hemovac. The surgeon places the drain in surgery so the unit is removable but not replaceable. The Hemovac container is attached to the patient’s gown for activity; if the nurse fails to attach it, the weight of the drain creates excessive tension on the tubing and increases the risk of accidental removal. Suction is never applied to a Hemovac without a specific order for the amount and type of suction. If the amount of suction is not specified, the nurse uses low suction.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Apply strips of transparent film to repair the leak. b. Change the patient’s negative-pressure wound therapy dressing. c. Patch the leaks with an adhesive dressing. d. Contain leakage with a large ABD dressing.

11. The nurse assesses a patient’s wound and notices leakage at the edge of the transparent film of the negative-pressure wound therapy. Which does the nurse implement to promote wound healing and prevent infection?

ANS: B

If the nurse notes a leak from the transparent dressing, he or she repairs it with pieces of transparent dressing. Unless the leak cannot be controlled, the nurse would not need to change the entire system. Adhesive dressing is avoided because it can irritate the skin and is too porous for establishing negative pressure. Likewise, an ABD pad is too porous to allow negative pressure to be reestablished.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. An incisional ridge continues to be present. b. The patient experiences less discomfort. c. There is a lack of new drainage. d. The patient states, “My wound smells funny.”

12. The nurse is performing a wound assessment after removing the soiled dressing. What finding would indicate a problem requiring additional assessment?

ANS: D

The nurse would need to evaluate the wound for clinical indicators for infection since an odd smell may indicate a developing infection. A wound culture may be required. Ridge formation, decreased discomfort, and lack of drainage are consistent with clinical indicators of a healing surgical incision without infection.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Assess the wound for sinus tracts and tunneling. b. Provide the patient with supplemental oxygen. c. Pack the wound lightly with a dry gauze dressing. d. Provide a well-balanced diet with high-quality protein.

13. The nurse prepares to apply a dressing for a patient who has a full-thickness wound with moderate exudate and necrosis. Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound?

ANS: D

Improving the patient’s nutrition is imperative for wound healing. A well-balanced diet with high-quality protein is required to maintain an adequate supply of substrate for wound healing. Assessing the wound is an important function, but does not help achieve the desired outcome. There is nothing in the stem that indicates the patient needs oxygen. The type of wound care will be specified by the provider, but a dry gauze dressing will not promote healing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Applying a hydrocolloid dressing b. Assessing the dimensions of the wound c. Reporting visible drainage on dressing d. Changing the first postoperative dressing

14. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care task can the nurse assign to NAP?

ANS: C

The nurse assigns reporting visible drainage on the dressing to the NAP because the NAP is trained to perform that wound care task. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse the wound with sterile saline solution. d. Prepare the sterile field for supplies.

15. The nurse needs to apply a dry sterile dressing. Which does the nurse implement first?

ANS: A

After removing the old dressing, the nurse assesses the wound for color, size, depth, drainage, and edema and compares the findings with baseline data. The nurse uses the conclusions from the assessment to plan follow-up nursing care. After the assessment the nurse creates the sterile field to maintain the integrity of sterile supplies in preparation for the dressing change. He or she then cleanses the wound using sterile saline or an antiseptic swab and blots the excess moisture to reduce the risk of infection.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Dark pink wound with undermining at 2 o’clock b. Wound clean and without odor with slight undermining toward patient’s head c. See photograph of wound taken today d. Pale pink wound 2 cm  3 cm  2 cm deep with undermining at 12 o’clock

16. While cleaning a wound, the nurse determines that undermining is at the top of the wound. Which documentation of the wound by the nurse is best?

ANS: D

The best documentation is “Pale pink wound 2 cm  3 cm  2 cm deep with undermining at 12 o’clock.” This entry contains the size, color, and location of the undermining of the wound. The other entries omit key information.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Be prepared to use skin glue on the edges of the wound. b. Have Steri-Strips ready to use after the staples are removed. c. Increase the amount of protein in the patient’s diet. d. Assess the skin edges before the patient is discharged.

17. The nurse is preparing to remove the skin staples from an older adult’s incision. Which action will the nurse take to prevent a complication as a result of age and its effect on healing?

ANS: B

Steri-Strips can help support tissues after the staples are removed. Skin glue can be irritating to older tissue. Increased protein aids skin health, but the need is immediate, and additional protein won’t help right now. The skin edges should be assessed frequently during the remainder of the patient’s hospitalization.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. A 10-mL syringe with a 20-gauge needle b. A 35-mL syringe with a 19-gauge angiocatheter c. A 50-mL syringe with a 27-gauge needle d. A 60-mL syringe with a 24-gauge angiocatheter

18. The nurse is irrigating a wound with a wide opening. What equipment would be appropriate for the nurse to use?

ANS: B

The 19-gauge catheter lumen and the volume of the syringe provide the ideal pressure for cleaning the wound and removing debris. A 10-mL syringe is too small. The 20-gauge needle is similar to the size of the angiocatheter and could be used. A 27-gauge needle and a 24-gauge angiocatheter are both too small.

N

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Restrain the child because. b. Have the parents leave the room. c. Describe the wound irrigation in detail. d. Use a doll to show how you will irrigate the wound.

19. The nurse is preparing to perform a wound irrigation on a 7-year-old child who is uncooperative. Which of the following will be the most helpful in alleviating the child’s fear?

ANS: D

Some pediatric patients may become frightened and may verbally or physically attempt to prevent the wound irrigation. Describing the wound irrigation using a doll may help to alleviate the fear. When possible, include parents in the procedure.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

20. The nurse is caring for a patient who has a Jackson-Pratt drain in place on postoperative day a. Notify the health care provider. b. Inspect the area around the drain. c. Ask the patient to rate his or her pain level. d. Administer pain medication.

1. The NAP reports there is no drainage and the patient is complaining of pain at the site. What will the nurse do first?

ANS: B

In order to plan and implement care the nurse first assesses the situation. The nurse would assess the area around the drain, then ask the patient to rate the pain. The patient may or may not need pain medication and the nurse might or might not need to notify the provider.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Add another layer of transparent dressing to the leak. b. Inform the provider that the system is not working. c. Notify the wound, ostomy, and continence nurse. d. Replace the transparent film over the filler gauze.

21. The nurse is assessing the negative-pressure wound therapy system and notes a large leak. The previous nurse had already attempted to repair the leak by applying more transparent dressing three different times. What action by the nurse is most appropriate?

ANS: D

Multiple layers of transparent dressing are not placed over the filler gauze because they can cause maceration of tissue. The nurse would replace the entire film. This may or may not require the nurse to remove the entire system and start over. The system is not the problem, it is the leak. The nurse should attempt to fix the problem prior to consulting other care team members.

N

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Administer the ordered antibiotic. b. Obtain wound cultures. c. Assess the patient’s pain. d. Change the dressing.

22. The provider suspects a patient has a wound infection. What action does the nurse take first?

ANS: B

Antibiotics will be given if the wound is indeed infected, but to determine if it is infected (and with which microorganism), the nurse collects cultures first, then administers the antibiotic. Assessing pain and changing the dressing are not the priorities.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Blood glucose 126 mg/dL b. Hemoglobin 8.2 g/dL c. Hematocrit 32% d. White blood cell count 8500/mm3

23. A patient’s wound does not seem to be healing. What assessment finding would the nurse correlate with this situation?

ANS: B

A low hemoglobin (less than10 g/dL) leads to impaired tissue oxygenation, which is needed for healing. The other values are within normal limits. The blood sugar does not specify whether it is fasting, post prandial, or random.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Consult the wound, ostomy, and continence nurse. b. Document the findings in the patient’s chart. c. Prepare to obtain wound cultures. d. Educate the patient on wound packing.

24. A nurse assesses the patient’s wound and notes the following appearance. What action by the nurse is most appropriate?

ANS: B

This is a wound healing by primary intention. Wound-healing edges are pulled together and approximated with sutures, staples, or adhesive, and healing occurs by connective tissue deposition. This is a normal appearance, so the only action needed is to document an assessment in the patient’s chart.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Snip first suture distal to knot, then snip second suture on the same side. b. Snip suture distal to knot and pull through skin in one smooth motion. c. Place end of suture extractor under suture and pull upwards. d. Pull the exposed suture through the skin and out through the other side.

25. The nurse is preparing to remove a patient’s sutures. What technique demonstrates correct technique?

ANS: A

N

These are blanket continuous sutures. The nurse first snips the first suture distal to the knot and close to the patient’s skin. Next the nurse snips the second suture on the same side. Then the nurse will grasp the knotted end and gently pull with continuous smooth action, removing suture from beneath skin. The nurse repeats this process until the entire line of sutures is removed. Pulling a single knotted suture is done for interrupted sutures. There is no suture extractor. Never pull the exposed suture material through the epidermis as it is considered contaminated.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use a cotton-tipped applicator to measure any undermining. b. Lightly palpate the edges for a healing ridge. c. Determine if the wound is able to be closed by sutures. d. Assess and treat the patient’s pain.

26. The nurse is caring for a patient whose wound looks like the following. What wound care does the nurse prepare to implement for this wound?

ANS: A

This is a wound healing by secondary intention and is left open to heal by scar formation. Appropriate wound care includes measuring any undermining with a sterile cotton-tipped applicator. A healing ridge would be felt with an incision healing by primary intention. Closing a wound after it has been left open for a time is tertiary intention. All patients with wounds need their pain assessed and treated.

N

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

MULTIPLE RESPONSE a. Inflammatory phase b. Hemostasis c. Primary intention d. Proliferation e. Remodeling f. Secondary intention

1. The nursing student is listing the phases of full-thickness wound healing to the nursing mentor. Which of the following phases listed indicate the needs further education? (Select all that apply.)

ANS: C, F

Wound healing occurs in four stages. (1) Hemostasis: Blood vessels constrict; clotting factors activate coagulation to stop bleeding. Clot formation seals disrupted vessels so blood loss is controlled and acts as a temporary bacterial barrier. Growth factors are released, which attract cells needed to begin tissue repair. (2) Inflammatory phase: Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (WBCs) arrive in the wound to begin cleanup. Macrophages appear and regulate the wound repair. (3) Proliferation/rebuilding phase: New capillaries are created, restoring the delivery of oxygen and nutrients to the wound bed. At the same time new granulation tissue is formed. Collagen is synthesized and begins to provide strength and structural integrity to a wound. Contraction reduces the size of the wound. Epithelial resurfacing (the construction of new epidermis) begins to cover the wound. (4) Maturation/remodeling phase: Collagen is remodeled to become stronger and provide tensile strength to the wound. Outer appearance in an uncomplicated wound will be that of a well-healed scar. Healing by primary intention occurs when the wound edges of a clean surgical incision remain close together. Wounds left open and allowed to heal by scar formation are classified as healing by secondary intention.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Wound dimensions b. Tissue type c. Wound edges d. Periwound skin e. Presence of sutures f. Undermining

2. The nurse is assessing a wound that is healing by secondary intention. Which of the following assessments are important to address? (Select all that apply.)

ANS: A, B, C, D, F

When assessing a wound that is healing by secondary intention (e.g., pressure ulcer or contaminated surgical or traumatic wound), it is important to assess the anatomical location of the wound, the wound dimensions, undermining, the extent of tissue loss, the tissue type, the presence of exudate, the wound edges, and the periwound skin. Sutures are not used on a wound healing by secondary intention.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. “I can set the psi between 15 and 17.” b. “I should never use this on exposed blood vessels.” c. “It is okay to use this on skin grafts.” d. “I should not use this on exposed muscles or tendon.” e. “I should never use this on patients with a coagulation disorder.”

3. The nurse is preparing to use high-pressure pulsatile lavage to irrigate a necrotic wound. Which of the following statements indicate a need for further education on this type of irrigation? (Select all that apply.)

ANS: A, C, E

Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. Pressure settings should be set per provider order (usually between 4 and 15 psi) and should not be used on skin grafts, exposed blood vessels, muscle, tendon, or bone. Use with caution if the patient has coagulation disorder or is on anticoagulants.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Nutrition b. Age c. Obesity d. Racial differences e. Medications

4. The nurse is listing factors that affect wound healing to a student nurse. What factors does the nurse include? (Select all that apply.)

ANS: A, B, C, E

Factors that influence wound healing include nutrition, age, obesity, and medications. Racial differences do not play a part.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment