Chapter 27: Dressings, Bandages, and Binders Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition

Multiple Choice

1. The nurse applies a circumferential gauze dressing to a patient’s amputated leg. Which method should the nurse use to decrease edema in the extremity?

a. Montgomery straps b. An adhesive tape wrap c. A figure-eight wrap d. A circular turns dressing

ANS: C

The nurse applies a dressing around the extremity using the figure-eight method to avoid restriction of blood flow and main venous return. This allows the dressing to be anchored by wrapping gauze in alternating directions that ascend and descend with oblique, overlapping turns. The terminal end of the dressing is secured with a short piece of tape, taking care not to restrict blood flow in any manner. Montgomery straps are contraindicated for dressing an extremity because the circumference is usually too small to make them practical. Adhesive tape potentially constricts blood flow to the extremity if it is wrapped tightly over itself in a circumferential manner. Circular turns dressings are used on small parts like fingers or toes, but are too constricting to use on larger body parts.

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

TOP: Nursing Process: Planning a. Apply the hydrocolloid dressing. b. Assess dimensions of the wound. c. Report visible drainage on the dressing. d. Change the first postoperative dressing.

2. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care tasks should the nurse assign to this staff member?

ANS: C

The nurse assigns reporting visible drainage on the dressing to the NAP because this individual is trained to perform this wound care task. It is essential to review what needs to be looked for and what to report back to the nurse. 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. The patient states that the dressing feels cold. b. The dressing is dry and intact. c. The dressing has bright red drainage. d. The patient states that the pain level is 8 on a scale of 1–10.

3. The nurse plans care for the patient’s wound that requires a moist-to-dry dressing. Which should the nurse use for an expected patient outcome several hours after applying a new dressing?

ANS: B

The nurse uses a moist-to-dry dressing for wound débridement and exudate collection because cellular debris and exudate in a wound bed delay healing. The nurse expects the dressing to absorb wound drainage and to be dry and intact. The dressing should feel cold as the nurse applies the moist gauze, not later. It should absorb drainage, not cause drainage to increase and penetrate the layers of dressing material. Pain rated as 8 on a scale of 1–10 is severe and warrants further investigation by the nurse because a dressing should provide patient comfort.

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

TOP: Nursing Process: Evaluation a. A clean, superficial laceration b. A deep leg ulcer with infection c. A puncture wound with bleeding d. A large laceration over the eyebrow

4. The wound care nurse prepares to dress the wounds of four patients. Which wound should receive a transparent film dressing?

ANS: A

An indication for a transparent film dressing includes a clean, superficial laceration because transparent dressings adhere to wounds and are nonabsorbent. A transparent dressing is contraindicated for a deep ulcer because the dressing is adherent; in addition, a deep ulcer most likely drains exudate or requires débridement, contraindicating the use of the dressing. The nurse avoids using the transparent dressing for the bleeding puncture wound because he or she first applies a pressure dressing to stop the bleeding and then dresses the wound with an absorbent dressing to collect subsequent drainage. Because the dressing is adherent, the nurse avoids using a transparent dressing over a large laceration. The laceration is likely to require sutures or Steri-Strips to close the wound; thus the nurse avoids using a dressing that can pull on the fragile wound edges.

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

TOP: Nursing Process: Planning a. The skin around the binder is dry without redness or edema. b. The patient experiences difficulty moving around in bed. c. The patient’s pain level has changed from 8 to 6 on a scale of 1–10. d. The respiratory rate has decreased from 17 to 15 breaths per minute.

5. The nurse is caring for a patient with a history of chronic respiratory problems who has an abdominal binder in place. Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome?

ANS: B

The patient’s activity should not be hampered by the binder. The nurse needs to assess the patient’s ability to move in bed before the binder is applied and reassess after the binder has been in place for a short time. The binder may be too tight, and loosening it may be enough to allow more mobility by the patient. Assessing the skin around the binder and evaluating trends in data are nursing tasks requiring nursing assessment skills and nursing judgment and evaluation; thus the nurse avoids delegating skin assessments and data analysis. Determining the patient’s pain level is a nursing function requiring assessment skills. The nurse expects the NAP to report the respiratory rate, even if normal, and the nurse draws conclusions about the data reported.

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

TOP: Nursing Process: Evaluation a. Start the binder right under the axilla. b. Place the patient in a semi-Fowler’s position. c. Secure the binder with metal fasteners. d. Remove the old dressing and apply a binder.

6. The nurse delegates applying a binder over the patient’s abdominal incision to nursing assistive personnel (NAP). Which does the nurse include in the NAP’s instructions?

ANS: C

The nurse instructs the NAP to secure the binder with metal fasteners, Velcro strips, or safety pins to keep the dressing in place. This prevents the binder from opening accidentally and increasing the risk of patient infection. If the NAP starts right under the axilla, the binder will encase the thorax, potentially impairing the patient’s ability to oxygenate, ventilate, cough, and deep breathe thereby increasing the risk of hypoxia, acidosis, atelectasis, and pneumonia. The NAP is instructed to place the patient in the supine position to apply the binder because in that position the patient may assist the NAP by rolling from side to side. This allows the NAP to place the fanfolded binder under the patient so it may be drawn around the abdomen. The nurse instructs the NAP to apply the binder after the sterile dressing change is completed to prevent patient infection and protect the wound.

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

TOP: Nursing Process: Planning a. The dead space found in an ulcer should be packed tightly. b. The wound should be débrided using multiple dry gauze pads. c. The dressing should absorb exudate without damaging the wound bed. d. The wound bed should be dried to stimulate granular tissue.

7. The nurse prepares to perform a dressing change on an ulcerated area. Which principle does the nurse apply while performing a dressing change?

ANS: C

The dressing should absorb drainage but, when removed, should not interfere with the healing that has occurred in the wound bed. The dead space in a wound is lightly packed to absorb exudate. The purpose of a dry dressing is protection for wounds with minimal drainage. Dry dressings do not interface with the wound, and débridement uses a wet-to-dry or moist-to-dry dressing. If exudate saturates a dry dressing, the nurse removes and changes it quickly or reinforces it. The nurse keeps the wound bed moist to promote healing, because a moist wound bed stimulates formation of granulation tissue, and keeps the area around the wound dry to keep it clean.

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

TOP: Nursing Process: Evaluation a. Alginate nonwoven b. Adhesive transparent dressing c. Hydrocolloid adhesive d. Foam nonadherent pad

8. The nurse is preparing to dress an open, shallow wound with a moderate amount of drainage. Nursing care is correct if the nurse chooses which dressing material?

ANS: C

Hydrocolloid dressings are the best choice for this wound. They are adhesive dressings composed of gelatin, pectin, and absorbent material suitable for stages 1–4 pressure ulcers with minimal-to-moderate exudate. Although hydrocolloid adhesive is a versatile product, the nurse considers its propensity for skin maceration if left in place beyond its recommended time. Alginate dressings are absorbent and indicated for use with partial- and full-thickness wounds that drain moderate-to-heavy amounts of exudate. This dressing is expensive and needs to be changed daily. Transparent film dressing is appropriate for shallow wounds with minimal exudate to protect the wound and promote autolytic débridement. Foam pads are used for partial- and full-thickness wounds that drain moderate-to-heavy amounts of exudate; a secondary dressing is required.

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

TOP: Nursing Process: Planning a. Evaluate for leukocytosis. b. Change to foam dressing. c. Collaborate with the health care provider. d. Document serous drainage.

9. The nurse removes the patient’s hydrocolloid dressing and observes minimal clear, watery drainage. Which action should the nurse take at this time?

ANS: D

The nurse documents that there is serous drainage after the dressing change to record the wound drainage accurately. Serous drainage is a benign finding. Leukocytosis indicates infection, inflammation, or malignancy. If the patient has leukocytosis, the nurse determines that the wound is probably not the cause because serous drainage is a benign finding and inconsistent with clinical indicators of infection. The nurse uses a dressing indicated for wounds with minimal exudate and does not need to collaborate with the health care provider because serous drainage from the wound is consistent with a successful wound care protocol.

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

TOP: Nursing Process: Planning a. Foam pad b. Wet-to-dry c. Transparent film d. Dry sterile gauze

10. The nurse prepares to change the patient’s dressing over a surgical incision without drainage but palpates a ridge along the suture line. Which dressing should the nurse apply to this wound?

ANS: D

The nurse uses a dry sterile gauze dressing over the surgical incision because a nondraining incision with a healing ridge is consistent with clinical indicators of a properly healing surgical incision. The nurse chooses this dressing because the incision needs protection. The surgical incision has no drainage; thus a foam pad dressing is contraindicated because it is intended for use with partial- to full-thickness wounds with moderate-to-heavy drainage. A wet-to-dry dressing is contraindicated for use with a nondraining surgical incision but is indicated for mechanical débridement of wounds. A transparent film dressing is a reasonable choice to protect the wound because the wound may be observed through it; however, the nurse avoids choosing this dressing to cover a surgical incision because removing the dressing pulls on the fragile borders of the incision.

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

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

11. The nurse needs to apply a dry sterile dressing. Which should 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 takes 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 cleanses the wound using sterile saline or an antiseptic swab and blots the excess moisture to reduce the risk of infection.

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

TOP: Nursing Process: Planning a. Applies a dry absorbent outer dressing. b. Packs flat gauze into the wound bed. c. Soaks the wound packing with antiseptic. d. Moistens the old dressing before removal.

12. The nurse is caring for a patient who requires a moist-to-dry dressing. Which action by the nurse is appropriate during the procedure?

ANS: A

The nurse applies a dry secondary dressing over the wound for protection and infection control and to contain the moist packing. He or she squeezes excess moisture from the fine mesh gauze and packs the wound with the gauze compressed from squeezing to facilitate drainage and debris collection. The gauze used for packing is soaked with sterile saline solution or another isotonic solution. To facilitate débridement, the nurse removes the old dressing without dampening it.

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

TOP: Nursing Process: Implementation a. Call for assistance. b. Place a sterile moist dressing on the wound. c. Apply direct pressure over the wound dressing. d. Apply a pressure dressing over the open area.

13. The nurse inspects a patient’s surgical incision and notes dehiscence several inches long. Which is the most important intervention for the nurse to implement?

ANS: B

The most important interventions for the nurse to take are to have the patient lie still, place moist sterile dressings over the area and cover it with dry pads, and notify the health care provider. The nurse should not put any pressure on the area that has dehisced. A pressure dressing is contraindicated for this type of opening. A pressure dressing would be used over a bleeding wound or puncture area after a procedure.

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

TOP: Nursing Process: Implementation a. Record the observation in the patient’s record. b. Remove the white exudate carefully. c. Obtain an order for a wound culture. d. Apply a light absorbent dressing.

14. The nurse assesses the patient’s transparent film dressing and observes white opaque exudate and reddened and edematous wound edges. Which is the priority intervention for the nurse to implement?

ANS: C

The nurse suspects an infected wound because exudate can indicate wound debris from an infection. Although all of these implementations may be performed, the priority is to start effective treatment for the suspected infection, so the culture must be obtained as soon as possible. The nurse notifies the health care provider so an order can be written for the culture then obtains a wound specimen sample for testing. The nurse must obtain the culture before antimicrobial therapy begins. The wound assessment is recorded after completing wound care and obtaining the culture.

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

TOP: Nursing Process: Implementation a. Montgomery straps b. A 7.6-cm (3-inch) bandage wrapped proximal to distal c. A 2-inch bandage using the spiral wrap technique d. A loosely wrapped elastic bandage using a recurrent turn

15. The nurse is applying a gauze bandage to hold a dressing on a patient’s wrist since the patient is allergic to tape. Which technique would be most appropriate for the nurse to use?

ANS: C

The nurse needs to secure the dressing in place using a small bandage because the wrist is small and a spiral wrap covers the area effectively without compression. A Montgomery strap is inappropriate because of its large size and adhesive backing. A 7.6-cm (3-inch) bandage is most commonly used for the adult leg and should be wrapped distal to proximal to promote venous return. An elastic bandage is generally used for simple intermittent compression. The recurrent turn is used to cover uneven body parts such as the head or the residual limb after an amputation.

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

TOP: Nursing Process: Implementation a. Semi-Fowler’s b. Supine c. Prone d. High-Fowler’s

16. The nurse is assisting a patient with putting on an abdominal binder. In which position does the nurse place the patient?

ANS: B

The nurse positions the patient in supine position with head slightly elevated and knees slightly flexed. None of the other positions would allow the nurse to secure the binder correctly.

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

TOP: Nursing Process: Planning a. Assesses the wound for sinus tracts and tunneling. b. Applies roller gauze over the gauze pads on the extremity using a figure-eight pattern. c. Obtains sterile gauze and sterile gloves. d. Has nursing assistive personnel (NAP) apply the pressure dressing.

17. The patient started bleeding profusely from a surgical wound on the thigh. Nursing care is appropriate if the nurse takes which action to care for this patient?

ANS: B

Assessing the wound for sinus tracts and tunneling would increase the hemorrhaging. Since this is a fresh wound there is no need to do this. The figure-eight pattern of wrapping acts as a pressure dressing, exerting even pressure over the extremity. Assessment has indicated that the patient is hemorrhaging. Pressure needs to be applied to the area to prevent blood loss and patient deterioration. Sterile technique is not the priority at this time. As long as the dressings are clean, they can be applied. The nurse needs only clean gloves. The skill of applying a pressure bandage in an emergent situation should not be delegated to the NAP. If the application requires more than one person, the NAP can assist the nurse as directed.

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

TOP: Nursing Process: Planning a. Heavy exudate b. Deep laceration c. Femoral dressing d. Wound dehiscence

18. The wound care nurse prepares wound care supplies. Which patient assessment datum cues the nurse to provide Montgomery straps to promote wound healing?

ANS: A

The patient with heavy exudate will need repeated dressing changes and Montgomery ties will allow access to the wound while protecting the skin. The repeated removal of an adhesive bandage in this situation could damage the skin. A deep laceration often requires varying amounts of surgical repair after cleansing. After approximating the laceration with sutures or staples, the nurse would apply a dry dressing. A femoral dressing usually covers the crease created by the hip and thigh; thus the area does not lend itself to Montgomery straps. Because of leg movement and the close proximity to the groin, a simple dressing works best. Wound dehiscence requires surgical repair. If tension on the suture line is an issue, the patient can benefit from a binder to support the incision.

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

TOP: Nursing Process: Planning a. Spiral b. Circular c. Recurrent d. Figure-eight

19. The nurse dresses the surgical incision on the patient’s elbow. Which method of securing the bandage should the nurse use with this patient?

ANS: D

The nurse uses a figure-eight bandage to cover the patient’s elbow dressing because it involves oblique, overlapping turns of the gauze roll, lending itself to use on a joint. By alternating the oblique turns around the humorous and radial and ulnar bones, the bandage anchors the dressing and immobilizes the joint. Overlapping, ascending turns of the spiral dressing effectively anchor a dressing to the upper or lower arm separately but do not secure the dressing at the elbow effectively because the dressing anchors at the beginning and the end. Bandage turns overlapping one another are as effective for the elbow as the spiral dressing. The recurrent dressing is most effective on the skull or a stump because the bandage folds back on it to cover the region. The nurse avoids choosing this bandage for an elbow because the bandage needs to cover a center portion of the arm versus the terminal end of an extremity.

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

TOP: Nursing Process: Implementation a. Assess patient/family’s knowledge of the purpose of the dressing change. b. Assess the dressing for the presence of drainage. c. Ask the patient to rate his or her wound pain. d. Review the order for the type of dressing.

20. The nurse is preparing to change a moist-to-dry dressing on a patient. After correctly identifying the patient, what is the next most appropriate step for the nurse to perform?

ANS: C

The first step the nurse should do after identifying the patient is to determine if the patient is having any wound pain. It is important to administer prescribed analgesic as needed 30 minutes before the dressing change because giving pain medication before dressing change achieves peak effect of the drug during the procedure. Assessing the dressing for drainage, reviewing the orders, and assessing the patient’s knowledge are important but can be done after the pain has been assessed and treated so that the pain medication can have time to reach peak effect when the dressing change begins.

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

TOP: Nursing Process: Assessment a. Every 6 days b. Every day c. Every 3–4 days d. Every 12 hours

21. The nurse has applied a transparent dressing to facilitate débridement of the pressure ulcer. How often should the nurse change that dressing?

ANS: B

Transparent dressings are normally changed every 3 or 4 days or as needed; however, if using the dressing to facilitate autolytic débridement, it should be changed every 24 hours.

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

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is working with a student nurse to provide care to a patient with a pressure injury. The student nurse describes characteristics of an ideal dressing. Which of the following statements indicate the student needs more education? (Select all that apply.)

a. The dressing should keep the wound bed dry.

b. The dressing can be removed without causing trauma.

c. The dressing should conform to the body to allow for movement.

d. Cost should not be a consideration.

e. Should be easy for the patient to change after discharge.

ANS: A, D

The characteristics of an ideal dressing include a dressing that is able to absorb exudate yet keep the wound bed moist but the surrounding periwound area dry and intact, be appropriate for infected wounds, conform to the body for ease of movement, maintain physiological wound environment, and be cost-effective. If the patient cannot change the dressing, assistance can be obtained such as a visiting nurse.

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

TOP: Nursing Process: Implementation a. Pain intensity is reduced during dressing changes. b. The depth of wound is reduced. c. The amount of exudate increases. d. The amount of necrotic tissue decreases.

2. The nurse is caring for a patient with a pressure injury. The nurse would expect which of the following outcomes if the patient’s wound is healing? (Select all that apply.)

ANS: A, B, D

Outcomes of wound healing include a reduction in the volume of exudate and amount of necrotic tissue. In addition, periwound erythema resolves, there is a reduction in wound dimensions or depth, and there is a reduction in pain intensity during dressing changes.

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

TOP: Nursing Process: Assessment

Completion

1. A highly absorbent nonwoven material that forms a gel when exposed to wound drainage is called a(n) __________ dressing.

ANS: alginate

This product is derived from brown seaweed and used for moderate-to-heavy exudating wounds.

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

TOP: Nursing Process: Implementation

2. A _______ is a fungal or bacteria-embedded slimy matrix of proteins and sugars that adhere to the surface of a wound bed.

ANS: biofilm

These biofilms are known to contribute to infections, especially in chronic wounds. Biofilms contribute to inflammation and an increased production of exudates and slough.

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

TOP: Nursing Process: Implementation

3. A ______dressing is contraindicated in ischemic wounds with dry eschar and third-degree burns or wounds that tunnel.

ANS: foam

Foam dressings are used to protect wounds and maintain a moist healing environment. They are contraindicated in ischemic wounds with dry eschar and third-degree burn wounds.

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

TOP: Nursing Process: Implementation