Surgical Wound care Quiz

1. Gentle washing of an area with a stream of solution delivered through a syringe.

Sterilization

Irrigation

Innundation

Effleurage

p. 321

Explanation

p. 321

2. Definition of a Keloid

A painful disease involving tissue damage

This is another phase of wound healing

Same as an eschar only with a lighter color

Overgrowth of a collagenous scar tissue at the site of the wound

p. 311

Explanation

p. 311

3. A one day postoperative patient is scheduled to have an initial wound dressing. What would be an appropriate thing to do before doing the intervention?

Provide an analgesic while doing wound care

Give an analgesic 30 minutes before exposing the wound

Offer an analgesic after changing the dressing

Do not offer any analgesic because it is contraindicated

p. 316

Explanation

p. 316

4. Best Definition of EXUDATE

Exactly the same as Drainage

It is a noun derived from the verb "to exude"

That which emerges from an injured tissue

p. 311

Explanation

p. 311

5. When a post-operative patient states that something has given way and the feeling is brought on by periods of sneezing, coughing or vomiting, what could have possibly happened?

Early symptoms of flu

Patient is having a running nose

A wound dehiscence occurred

The patient is just hungry

p. 324

Explanation

p. 324

6. Which of the following groups are not a factor that could impair wound healing?

Obesity, malnutrition and age

Impaired oxygenation, radiation and smoking

Height, weight and body mass

Drugs, diabetes mellitus and wound stress

p. 313

Explanation

p. 313

7. A patient who had an appendicitis removed early in the morning is having a hard time going to sleep because of coughing. What is the best non-pharmacological intervention that a nurse could provide him?

Apply a pillow, rolled blanket, or the palms of the hands to the incisional area to lessen intraabdominal pressure

Administer a PRN pain medication

Call the surgeon and tell him to intervene

Bind the wound with a Montgomery wrap

p. 312

Explanation

p. 312

8. Wire sutures are removed by physician

True

False

Wire sutures are typically used in surgical procedures to hold together tissues or close incisions. These sutures are made of wire and require a physician to remove them after a certain period of time. This is because wire sutures are more durable and can cause more discomfort if left in for too long. Therefore, it is true that wire sutures are removed by a physician.

Explanation

Wire sutures are typically used in surgical procedures to hold together tissues or close incisions. These sutures are made of wire and require a physician to remove them after a certain period of time. This is because wire sutures are more durable and can cause more discomfort if left in for too long. Therefore, it is true that wire sutures are removed by a physician.

9. Steri-strips are not removed and are allowed to loosen and peel off gradually

True

False

p. 326

Explanation

p. 326

10. A cut produced surgically by a sharp instrument creating an opening into an organ or space in the body

Puncture

Incision

Stoma

Abrasion

p. 310

Explanation

p. 310

11. Stab wound for a drainage system

Puncture

Incision

Stoma

Abrasion

p. 310

Explanation

p. 310

12. Since it is not an invasive procedure, a Wound Vacuum Assisted Closure (Wound VAC) device does not require a Physician's order.

True

False

p. 331

Explanation

p. 331

13. A chronic disease that impairs wound healing because it causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. An effect of this disease alters ability of leukocytes to perform phagocytosis needed for wound healing. This same effect will also support overgrowth of fungal and yeasts infection which are both contraindicated for wound healing

Multiple sclerosis

Diabetes insipidus

Diabetes mellitus

Myocardial infection

p. 313

Explanation

p. 313

14. During the first day after surgery, how often would you inspect the dressings?

Every 2 to 4 hours for the first 24 hours

Every 8 to 10 hours for the first 42 hours

Every 6 to 8 hours for the first 30 hours

Every 2 to 4 hours for the first 12 hours

p. 314

Explanation

p. 314

15. When doing wound care, in order to prevent fluid from being retained in the wound, how should a patient be positioned?

The patient should stand while receiving wound care

The patient should be an a dorsal recumbent position

The patient should be supine for comfort

Position the patient to his/her side to encourage the irrigant to flow away from the wound

p. 323

Explanation

p. 323

16. Which of the following is not an evidence of infection?

Elevated WBC

Purulent drainage

Primary intention

Increased leukocytes

p. 314

Explanation

p. 314

17. During hemostasis, termination of bleeding begins and blood clots are formed. What is in the blood clot that helps hold the wound together?

Granulation

Hemes

Fibrin

Leucocytes

p. 311

Explanation

p. 311

18. What is granulation tissue?

Composed of small microscopic grains of epithelial cells

A group of cells that form a grain

The tissue that remains after a scar is healed

Soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen.

p. 311

Explanation

p. 311

19. Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection

Adhesion

Abscess

Cellulitis

Dehiscence

p. 323

Explanation

p. 323

20. Without a physician's order, what do you do with a dressing that is saturated with exudate?

Wait for an order before doing anything

Go ahead and replace it. Then inform the physician later

Do nothing until the order has arrived

p. 338

Explanation

p. 338

21. A device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. It accelerates wound healing by promoting the formation of granulation tissue, collagen, fibroblasts, and inflammatory cells in order to close or improve the condition of a wound in preparation for a skin graft.

Hemivac

Wound Vacuum-assisted closure (Wound VAC)

Jackson Pratt

Davol

p. 330

Explanation

p. 330

22. Removal of fluids from a body cavity, wound or other source of discharge by one or more methods.

Exudate

Extravasation

Drainage

Cellular suction

p. 325

Explanation

p. 325

23. What is the primary purpose of wet-to-dry dressing?

To mechanically debride a wound

To perform aseptic cleansing

To protect the wound from further injury

To provide an aesthetic appearance to wound dressing

p. 318

Explanation

p. 318

24. After an abdominal surgery, abdominal muscles contract and cause intraabdominal pressure. If the incisional area is weak, what is possible to happen?

Dehiscence

Evisceration

Decubitus

Shearing

p. 310

Explanation

p. 310

25. If hemorrhage is not detected or stopped, what is most likely to happen?

Hypervolemic shock leading to an excessive dehydration

Hypovolemic shock leading to a cardiac infection

Hypovolemic shock leading to a collapsed circulatory system

Hypervolemic shock leading to water retention

p. 324

Explanation

p. 324

26. A moist environment may damage the wound edges (peri-wound skin). It is classified as moisture-associated skin damage (MASD). What do you call this damage?

Laceration

Maceration

Incision

Evisceration

p. 333

Explanation

p. 333

27. A strip or roll of cloth or other material can be wound around a part of the body in a variety of ways for multiple purposes.

Scarf

Bandage

Gauze

Bandana

p. 333

Explanation

p. 333

28. When using an occlusive dressing, where will the tape strips be attached?

Several inches apart

On all sides of the dressing

One on top of the other

On the four corners

p. 315

Explanation

p. 315

29. Match the terms used in wound care on the left with wound complications on the right.

adhesion

cellulitis

dehiscence

evisceration

p. 323

Explanation

p. 323

Submit

30. Match the following wound drainage on the left with its appearance on the right

serous

purulent

serosanguineous

sanguineous

p. 314

Explanation

p. 314

Submit

31. After applying a transparent dressing, it is labeled with which information? Select all that apply:

Date

Initials

Location

Time

p. 321

Explanation

p. 321

Submit

32. Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery or injury

Cellulitis

Evisceration

Extravasation

Hematoma

A hematoma is a collection of extravasated blood that becomes trapped in the tissues or an organ due to incomplete hemostasis after surgery or injury. This can occur when blood vessels are damaged and blood leaks out into the surrounding area, forming a localized clot. Hematomas can vary in size and severity, and may cause swelling, pain, and discoloration of the skin. Treatment for a hematoma may involve monitoring, applying ice or heat, elevating the affected area, or in some cases, draining the blood.

Explanation

A hematoma is a collection of extravasated blood that becomes trapped in the tissues or an organ due to incomplete hemostasis after surgery or injury. This can occur when blood vessels are damaged and blood leaks out into the surrounding area, forming a localized clot. Hematomas can vary in size and severity, and may cause swelling, pain, and discoloration of the skin. Treatment for a hematoma may involve monitoring, applying ice or heat, elevating the affected area, or in some cases, draining the blood.

33. Which of the following four phases of wound healing are arranged accordingly

Hemostasis, inflammatory phase, maturation, reconstruction

Hemostasis, inflammatory phase, reconstruction, maturation

Hemostasis, reconstruction, maturation, inflammatory phase

Inflammatory phase, hemostasis, maturation, reconstruction

p. 311

Explanation

p. 311

34. It is a factor that impairs wound healing by interfering with normal cellular mechanisms that promote release of oxygen to tissues. It reduces the amount of functional hemoglobin in blood.

Obesity

Radiation

Smoking

Malnutrition

p. 319

Explanation

p. 319

35. When changing a sterile dry dressing, which of the following is a proper way of cleaning a wound?

Cleanse wound and surrounding area with regular swab, starting from incision and moving outward, using one stroke per swab

Cleanse wound and surrounding area with antiseptic swab, starting from incision and moving outward, using one stroke per swab.

Cleanse wound and surrounding area with alcohol, starting from incision and moving outward

Cleanse wound and surrounding area with antiseptic swab, starting from the edges of the wound towards the incision

p. 317

Explanation

p. 317

36. In a Wound VAC assisted closure procedure, foams are used, Match the type of foam on the left with its properties on the right

Black foam (PU - polyurethane)

White soft foam (PVA - polyvinyl alcohol)

p. 332

Explanation

p. 332

Submit

37. How long does the outer edge of a wound appear inflamed?

First 2 to 3 weeks

First 2 to 3 hours

First 2 to 3 days

First 20 to 30 minutes

p. 338

Explanation

p. 338

38. Upon doing wound care of a patient who had an abdominal surgery this morning , nurse observes 325 mL of exudate extracted from patient's Hemovac. What would she do next?

Assess the patient for complication

Empty the Hemovac and clean appropriately

Report the findings to the physician immediately

Change the patient dressing

p. 327 - Treat exudate or drainage in quantities greater than 300 mL in the first 24 hours as abnormal and report it immediately

Explanation

p. 327 - Treat exudate or drainage in quantities greater than 300 mL in the first 24 hours as abnormal and report it immediately

39. When doing wound irrigation for a deep wound with small opening (deep ulcers), which of the following devices should you use?

13-gauge needle with a 25 mL syringe

Tuberculin needle

19-gauge needle (or angiocath) with a 35 mL syringe

Same needle as insulin

p. 332

Explanation

p. 332

40. The process of applying a pillow, rolling a bath blanket, or the palms of the hands to an incisional area to decrease intraabdominal pressure is called what?.

Binding

Wrapping

Splinting

Dressing

p. 312

Explanation

p. 312

41. A nurse is removing a suture. Which of the following would be a sign that this nurse needs further training?

Grasps and elevates knotted end of suture with hemostat or forceps.

Grasps continuous suture and removes loop of suture, pulling contaminated stitch through tissue

Documents the number of staples or sutures removed

Removes one to three sutures at a time

pages 326-327

Explanation

pages 326-327

42. When doing a wound irrigation, how should the syringe be positioned?

1 finger-length above the wound

1 cm above the wound

1 inch above the wound

1 mm above the wound

p. 322

Explanation

p. 322

43. When doing wound care, which of the following should not be done?

Wash hands before donning sterile gloves

Use sterile gloves while removing wound dressing

If drains are present, remove dressings one layer at a time

Cover wound with appropriately sized dry sterile dressing and use drain dressing, if applicable

p. 317. Don clean gloves and remove dressing and discard

Explanation

p. 317. Don clean gloves and remove dressing and discard

44. Existence of a wound indicates what kind of nursing diagnosis?

Risk for infection

Impaired skin integrity

Loss of self image

Powerlessness

p. 338

Explanation

p. 338

45. When are sutures and staples generally removed?

In 1 to 2 weeks after surgery or sooner if healing is adequate

In 48 to 60 hours after surgery or sooner if healing is adequate

In 7 to 10 days after surgery or sooner if healing is adequate

In 5 to 8 days after surgery or sooner if healing is adequate

Sutures and staples are typically removed 7 to 10 days after surgery once the wound has sufficiently healed to maintain closure. Removing them too early can risk wound reopening, while removing them later may cause unnecessary scarring.

Explanation

Sutures and staples are typically removed 7 to 10 days after surgery once the wound has sufficiently healed to maintain closure. Removing them too early can risk wound reopening, while removing them later may cause unnecessary scarring.

46. A system of tubing and other apparatus attached to the body to remove fluid in an airtight circuit that prevents environmental contaminants from entering the wound.

Open drainage system

Closed drainage system

Suction drainage

Vacuum drainage

p. 328

Explanation

p. 328

47. After opening and partially using a 10 ml bottle of a normal saline wetting agent for wound care, what should be done next?

Wetting solutions should always be refrigerated 24 hours after opening and to prevent harboring microorganism growth.

Wetting solutions should be discarded 24 hours after opening and replaced with fresh solution because they can harbor microorganism growth.

Wetting solutions should be discarded an hours after opening and replaced with fresh solution because they can harbor microorganism growth.

Wetting solutions should be sealed after after opening and used as often as needed

p. 320

Explanation

p. 320

48. Classification of wound according to the CDC. Select all that apply:

Clean

Clean-contaminated

Contaminated

Dirty or infected

Aseptic or sterile

p. 311

Explanation

p. 311

Submit

49. Passage or escape into the tissues, usually of blood, serum or lymph

Adhesion

Evisceration

Extravasation

Hematoma

p. 323

Explanation

p. 323

50. In changing a wet-to-dry dressing, what happens when you apply dry dressing over wet gauze?

Pulls microbes from the wounds and allows termination of pathogens

Pulls moisture from the wound and allows for absorption of excess moisture

Pulls ischemic tissue and removes excess drainage

Pulls necrotic tissue from the wound and accelerates healing

p. 319

Explanation

p. 319

51. How often should a Davol or Hemovac systems be observed?

Every hour

Every 2 to 4 hours

Once every shift

At least once a day

p. 329

Explanation

p. 329

52. Unless otherwise directed by physician, how often do you remove and reapply elastic bandage?

Once every 8 hours

Every 6 to 8 hours

Every two hours

Before and after meals

p. 337

Explanation

p. 337

53. A type of bandage that is made of large pieces of material to fit a specific body part mostly made of elastic, cotton, muslin or flannel

Tie

Gauze

Binder

Bandana

p. 334

Explanation

p. 334

54. When applying a triangular blinder (Sling), where do you tie the square knot?

At the lateral area of neck on the affected side

Right where the elbow is

At the lateral area of neck on uninjured side

At the dorsal area of neck close to the occiput

p. 334

Explanation

p. 334

55. Match the wound classification on the left with an example on the right

Clean

Clean-contaminated

Contaminated

Dirty or Infected

Submit

56. What should be the position of a Wound VAC system for it to work?

Place VAC on a level surface or hang from the foot of the bed

Place VAC parallel to the patient while sleeping

Place VAC on the ground to avoid contamination

Place VAC wherever the patient finds it convenient to reach

p. 333 - Note: The VAC system will alarm and deactivate therapy if the unit is tilted beyond 45 degrees.

Explanation

p. 333 - Note: The VAC system will alarm and deactivate therapy if the unit is tilted beyond 45 degrees.

57. Before applying a steri-srip, what is applied to make the skin tacky and cause the steri-strip to adhere more securely?

Vaseline

Iodine

Tincture of benzoin

Cold cream

p. 326 - Apply this to skin on each side of suture line over an area 1.5 to 2 inches wide, and allow to dry for a few minutes

Explanation

p. 326 - Apply this to skin on each side of suture line over an area 1.5 to 2 inches wide, and allow to dry for a few minutes

58. Fluid that have slowly discharged from cells or blood vessels through small pores or breaks in cell membrane.

Drainage

Exudate

Edema

Interstitial fluid

p. 325

Explanation

p. 325

59. When a patient has steri-strips, what would be the recommended form of body hygiene?

Instruct a patient to take a shower

Instruct patient to soak in bath tub

Instruct patient not to take a bath

Instruct patient just to wash face for a while

p. 326

Explanation

p. 326

60. When bandaging extremities, how do you apply them?

When bandaging extremities, it is important to measure the distance between turns.

When bandaging extremities, begin with the part that is proximal to the heart and then go distal.

When bandaging extremities, apply bandage first at the distal end and progress toward the trunk (heart)

When bandaging extremities, it does not matter which end to start

p. 337

Explanation

p. 337

61. When doing wound care, which of the following should be the first thing to do?

Introduce yourself

Explain the procedure

Refer to medical record, care plan or kardex

Identify patient

p. 314

Explanation

p. 314

62. How long would a normally healing wound fill withe epithelial cells and edge closely

Around 5 days

Within a week or less

Within 7 to 10 days

Almost a month

p. 338

Explanation

p. 338

63. A nurse was asked to document the amount of exudate from a post-op patient who does not have a wound vacuum bag. She observes that the dressing was soaked in blood. After weighing the dressing, she noted that it weighed 2 oz. What is the proper amount of exudate that should be documented?

60 g

2 oz.

60 ml

2 g.

p. 328 - Documenting the amount of exudate should be according to volume and not according to weight. There are 2 conversions in this problem:
a) 1 oz = 30 g
b) 1 g = 1 ml

If it weights 2 oz, therefore it weights 60 g (30g x 2 oz)
If for every gram, there is 1 ml. then the answer follows that it is 60 ml

Explanation

p. 328 - Documenting the amount of exudate should be according to volume and not according to weight. There are 2 conversions in this problem:
a) 1 oz = 30 g
b) 1 g = 1 ml

If it weights 2 oz, therefore it weights 60 g (30g x 2 oz)
If for every gram, there is 1 ml. then the answer follows that it is 60 ml

64. When does wound dehiscence primarily take place?

Maturation phase

Reconstruction phase

Inflammatory phase

Mitotic phase

p. 311

Explanation

p. 311

65. Use _ _ rather than _ ____ to fasten bandages on small children or infants.

Loose clips, adhesive tapes

Permanent glue, steel staples

Rubber band, iron wire

Adhesive tapes, loose clips

p. 337

Explanation

p. 337

66. When evisceration follows dehiscence, what interventions are needed? Select all that apply:

The patient is to remain bed bound in a low Fowler's position with knees flexed to reduce pressure on wound.

Keep patient on NPO status, and cover wound and contents with warm, sterile saline dressing

Change patient position every 2 hours to avoid decubitus

Notify surgeon immediately

p. 324

Explanation

p. 324

Submit

67. Match the process of wound healing on the left with a definition, description or example on the right

Primary Intention

Secondary Intention

Tertiary intention

p. 312

Explanation

p. 312

Submit

68. Which of the following is not an appropriate response to wound evisceration?

Raise the gatch near the foot of the bed and keep the patient into a sitting position with knees straight.

Stay calm and monitor patient closely.

Use clean towels or dressings if there are no sterile dressings available

p. 324 - Help the patient into a low Fowler's position with knees slightly flexed. This will ease pressure on the wound and prevent further tearing of the wound edges.

Explanation

p. 324 - Help the patient into a low Fowler's position with knees slightly flexed. This will ease pressure on the wound and prevent further tearing of the wound edges.

69. Often the choice for management of wound with little exudate or drainage such as abrasions and non-draining postoperative incisions.

Semi-occlusive

Wet-to-dry dressing

Dry dressing

Occlusive

p. 316

Explanation

p. 316

70. Match the type of dressing on the left with its specific purpose on the right

Gauze dressings

Semiocclusive dressings

Occlusive dressings

Montgomery straps

p. 315

Explanation

p. 315

Submit

71. A method and a trend that allows atmospheric oxygen to circulate above the wound, aiding in the healing process

Use Montgomery straps without binders

Protect sutured, clean wounds with occlusive dressing after surgery.

Leave sutured, clean wounds undressed after surgery or use loose dressings

Allow dry to dry dressings using occlusive gauze

p. 316

Explanation

p. 316

72. What is the appropriate way of removing sutures or staples?

First, all sutures or staple are removed and then replaced with a steri-strip.

p. 324

Explanation

p. 324

73. For best results, when or how should transparent dressings be used? Select all that apply;

On clean debrided wounds that are not actively bleeding

Apply it so not wrinkles form, but do not stretch it over the skin

On eschar or over non-stagale decubitus

Ideal for small superficial wounds and as a dressing over an IV catheter site

p. 320

Explanation

p. 320

Submit

74. In a Wound VAC system, what is the negative pressure required for it to work?

Between 10 - 100 mm Hg, average of 100 mm Hg

Between 5 - 200 mm Hg, average of 125 mm Hg

Between 25 - 75 mm Hg, average 50 mm Hg

Between 40 - 60 mm Hg, average 50 mm Hg

p. 332

Explanation

p. 332

75. How often should a Wound Vac dressing be changed for a patient with a clean wound?

Once a week

Every other day

Three times a week

Every other week

p. 330

Explanation

p. 330

76. Also known as separate sutures characterized with knots that are lined up on the same side of incision.

Interrupted sutures

Continuous Sutures

Blanket sutures

Retention sutures

p. 325 and 326

Explanation

p. 325 and 326

77. When Montgomery straps are soiled, when do they get replaced?

Every 2 hours

Once every shift

At least once a week

Every 2 to 3 days

p. 316

Explanation

p. 316

78. A patient who recently suffered a vehicular accident is using a Wound Vac device. Due to the severity of the accident, the patient has purulent drainage. How often should his dressing be changed?

Every hour

Every 42 hours

Every 24 hours

Once a shift

p. 330

Explanation

p. 330

79. What kind of dressings promote healing by keeping wounds moist yet sterile?

Binders and steri-strips

Transparent and permeable dressings

Occlusive and semi-occlusive dressings

Wet and dry dressings

p. 315

Explanation

p. 315

80. Which of the following statements about wound healing are true? Select all that apply:

The stages for wound healing provide a model for acute wound healing and not necessarily chronic.

The stages of wound healing are not necessarily linear

The least amount of scar after healing would be in the primary intention wound

Tertiary intention healing produces the smallest scar

p. 312

Explanation

p. 312

Submit

81. When are dressings over closed wound usually removed?

The day after surgery

On the third day

A week after surgery

When the physician gives the order

p. 315

Explanation

p. 315

82. How are wounds classified? Select all the apply:

Cause

Severity of injury

Amount of contamination

Skin's integrity

Color and shape

p. 310

Explanation

p. 310

Submit

83. When does wound dehiscence most frequently take place?

Between the second and third week after surgery.

Between the 5th and 12th postoperative days.

Between 24 to 48 hours after surgery

Between the 3rd and 10th postoperative days

p. 324

Explanation

p. 324

84. In order to determine whether a patient is hemorrhaging, what do you need to observe? Select all that apply:

Increased thirst and restlessness

Cool, clammy skin

Rapid thready pulse

Decreased blood pressure and urinary output

Paresthesia on lower extremities

p. 324

Explanation

p. 324

Submit

85. How long do retention sutures remain in place?

Less than 14 days

14 days or more

Between 10 and 14 days

Not more than 2 weeks

p. 325 - Retention sutures are covered with rubber and used primarily for obese patients who have had an abdominal surgery

Explanation

p. 325 - Retention sutures are covered with rubber and used primarily for obese patients who have had an abdominal surgery

86. What are the advantages of a transparent dressing? Select all that apply:

Adheres to undamaged skin to contain exudate and minimize wound contamination

Promotes a moist environment that speeds epithelial cell growth

Accelerates wound healing by providing fibroblast stimulators

Serves as a barrier to external fluids and bacteria yet still allows the wound to breathe

Allows wound assessment without removing the film, as well as remove the film without damaging underlying tissue

p. 320

Explanation

p. 320

Submit

87. Which of the following are commonly used wetting agents? Select all that apply:

Normal Saline

Distilled Water

Sodium Hypochlorite Solution

Isotonic Solutions and Lactated Ringer

Dakin

p. 318

Explanation

p. 318

Submit

88. Dressing selection will be done according to agency policy and traditional universal care plans.

True

False

Dressing selection needs to be individualized to the type of wound and wound-healing goals. (p. 333 - evidence based practice)

Explanation

Dressing selection needs to be individualized to the type of wound and wound-healing goals. (p. 333 - evidence based practice)

89. Wound irrigation promotes wound healing through the following reasons. Select all that apply:

By removing debris from wound surface

By loosening and removing eschar

By moistening the wound

By decreasing bacterial counts

p. 322

Explanation

p. 322

Submit

90. When assessing the drainage of a T-Tube Drainage System, which of the following should be expected? Select all that apply:

Amount varies from 250 to 500 mL / 24 hours

Slightly blood tinged in the first 24 hours

Yellowish and dark brown after a day

Color is normally greenish brown and thick

p. 330

Explanation

p. 330

Submit

91. Common solutions used for irrigation. Select all that apply

Warm water

Hydrogen peroxide

Mild detergent

Saline

p. 322

Explanation

p. 322

Submit

92. The principles of basic wound irrigation include the following. Select all that apply

After irrigation, dry the wound with a clean gauze

Cleanse in a direction from the least contaminated to the most contaminated

During irrigation, apply cold compress

When irrigating, make sure all the solution flows from the least contaminated to the most contaminated

p. 321

Explanation

p. 321

Submit

93. Match the draining system on the left with its purpose on the right

Penrose drain

Hemovac or Redi Vac

Jackson Pratt and Davol evacuators

Suction drainage

pages 328-329

Explanation

pages 328-329

Submit

94. Which of the following statements about dry dressing are true? Select all that apply

Keeps initial bleeding to a minimum, protects wound from injury and prevents introduction of bacteria

If dry dressing adheres to a wound, moisten dressing with distilled water before removing the gauze

Prevents deeper tissue from drying out by keeping wound surface moist

Does not debride wounds

p. 316 - If dry dressing adheres to a wound, moisten dressing with NORMAL SALINE OR STERILE (not distilled) water before removing the gauze.

Explanation

p. 316 - If dry dressing adheres to a wound, moisten dressing with NORMAL SALINE OR STERILE (not distilled) water before removing the gauze.

Submit

95. Which of the following is NOT a characteristic of a healthy healing surgical wound?

Pink granulation tissue

Minimal exudate (drainage)

Well-approximated edges

Purulent discharge (pus)

Purulent discharge, or pus, is a sign of infection in a wound. A healthy healing wound should have pink granulation tissue (new connective tissue), minimal exudate (clear or slightly bloody drainage), and well-approximated edges (wound edges that are closed together).

Explanation

Purulent discharge, or pus, is a sign of infection in a wound. A healthy healing wound should have pink granulation tissue (new connective tissue), minimal exudate (clear or slightly bloody drainage), and well-approximated edges (wound edges that are closed together).

96. Which of the following are effective antimicrobial agents either for Psuedomonas Aeruginosa or other pathogens but are toxic to fibroblasts in standard solutions?

Povidone-iodine

Lactated Ringer

Hypertonic Solutions

Acetic Acid

pages 318 and 320

Explanation

pages 318 and 320

Submit

97. Match the basic bandage turns on the left with their specific purpose on the right

circular

spiral

spiral-reverse

figure of 8

recurrent

p. 336

Explanation

p. 336

Submit

98. The following are steps on applying a triangular binder (sling). Rearrange by matching them with the number on the right according to the order of their priority.

Fold triangle end neatly around elbow and secure with safety pins

Use square know to tie two ends together at lateral area of neck an uninjured side

Place end of triangular binder over shoulder of the uninjured side, anterior to posterior

Support wrist well with binder; do not allow it to extend over end of binder

Have patient flex arm at approximately 80-degree angle depending on purpose of binder

Grasp other end of binder and bring it up and over injured arm to shoulder of injured arm

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Surgical Wound care Quiz

1. Gentle washing of an area with a stream of solution delivered through a syringe.

2.

What first name or nickname would you like us to use?

2. Definition of a Keloid

3. A one day postoperative patient is scheduled to have an initial wound dressing. What would be an appropriate thing to do before doing the intervention?

4. Best Definition of EXUDATE

5. When a post-operative patient states that something has given way and the feeling is brought on by periods of sneezing, coughing or vomiting, what could have possibly happened?

6. Which of the following groups are not a factor that could impair wound healing?

7. A patient who had an appendicitis removed early in the morning is having a hard time going to sleep because of coughing. What is the best non-pharmacological intervention that a nurse could provide him?

8. Wire sutures are removed by physician

9. Steri-strips are not removed and are allowed to loosen and peel off gradually

10. A cut produced surgically by a sharp instrument creating an opening into an organ or space in the body

11. Stab wound for a drainage system

12. Since it is not an invasive procedure, a Wound Vacuum Assisted Closure (Wound VAC) device does not require a Physician's order.

14. During the first day after surgery, how often would you inspect the dressings?

15. When doing wound care, in order to prevent fluid from being retained in the wound, how should a patient be positioned?

16. Which of the following is not an evidence of infection?

17. During hemostasis, termination of bleeding begins and blood clots are formed. What is in the blood clot that helps hold the wound together?

18. What is granulation tissue?

19. Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection

20. Without a physician's order, what do you do with a dressing that is saturated with exudate?

22. Removal of fluids from a body cavity, wound or other source of discharge by one or more methods.

23. What is the primary purpose of wet-to-dry dressing?

24. After an abdominal surgery, abdominal muscles contract and cause intraabdominal pressure. If the incisional area is weak, what is possible to happen?

25. If hemorrhage is not detected or stopped, what is most likely to happen?

26. A moist environment may damage the wound edges (peri-wound skin). It is classified as moisture-associated skin damage (MASD). What do you call this damage?

27. A strip or roll of cloth or other material can be wound around a part of the body in a variety of ways for multiple purposes.

28. When using an occlusive dressing, where will the tape strips be attached?

29. Match the terms used in wound care on the left with wound complications on the right.

30. Match the following wound drainage on the left with its appearance on the right

31. After applying a transparent dressing, it is labeled with which information? Select all that apply:

32. Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery or injury

33. Which of the following four phases of wound healing are arranged accordingly

34. It is a factor that impairs wound healing by interfering with normal cellular mechanisms that promote release of oxygen to tissues. It reduces the amount of functional hemoglobin in blood.

35. When changing a sterile dry dressing, which of the following is a proper way of cleaning a wound?

36. In a Wound VAC assisted closure procedure, foams are used, Match the type of foam on the left with its properties on the right

37. How long does the outer edge of a wound appear inflamed?

38. Upon doing wound care of a patient who had an abdominal surgery this morning , nurse observes 325 mL of exudate extracted from patient's Hemovac. What would she do next?

39. When doing wound irrigation for a deep wound with small opening (deep ulcers), which of the following devices should you use?

40. The process of applying a pillow, rolling a bath blanket, or the palms of the hands to an incisional area to decrease intraabdominal pressure is called what?.

41. A nurse is removing a suture. Which of the following would be a sign that this nurse needs further training?

42. When doing a wound irrigation, how should the syringe be positioned?

43. When doing wound care, which of the following should not be done?

44. Existence of a wound indicates what kind of nursing diagnosis?

45. When are sutures and staples generally removed?

46. A system of tubing and other apparatus attached to the body to remove fluid in an airtight circuit that prevents environmental contaminants from entering the wound.

47. After opening and partially using a 10 ml bottle of a normal saline wetting agent for wound care, what should be done next?

48. Classification of wound according to the CDC. Select all that apply:

49. Passage or escape into the tissues, usually of blood, serum or lymph

50. In changing a wet-to-dry dressing, what happens when you apply dry dressing over wet gauze?

51. How often should a Davol or Hemovac systems be observed?

52. Unless otherwise directed by physician, how often do you remove and reapply elastic bandage?

53. A type of bandage that is made of large pieces of material to fit a specific body part mostly made of elastic, cotton, muslin or flannel

54. When applying a triangular blinder (Sling), where do you tie the square knot?

55. Match the wound classification on the left with an example on the right

56. What should be the position of a Wound VAC system for it to work?

57. Before applying a steri-srip, what is applied to make the skin tacky and cause the steri-strip to adhere more securely?

58. Fluid that have slowly discharged from cells or blood vessels through small pores or breaks in cell membrane.

59. When a patient has steri-strips, what would be the recommended form of body hygiene?

60. When bandaging extremities, how do you apply them?

61. When doing wound care, which of the following should be the first thing to do?

62. How long would a normally healing wound fill withe epithelial cells and edge closely

63. A nurse was asked to document the amount of exudate from a post-op patient who does not have a wound vacuum bag. She observes that the dressing was soaked in blood. After weighing the dressing, she noted that it weighed 2 oz. What is the proper amount of exudate that should be documented?

64. When does wound dehiscence primarily take place?

65. Use _____ _______ rather than _____ ______ to fasten bandages on small children or infants.

66. When evisceration follows dehiscence, what interventions are needed? Select all that apply:

67. Match the process of wound healing on the left with a definition, description or example on the right

68. Which of the following is not an appropriate response to wound evisceration?

69. Often the choice for management of wound with little exudate or drainage such as abrasions and non-draining postoperative incisions.

70. Match the type of dressing on the left with its specific purpose on the right

71. A method and a trend that allows atmospheric oxygen to circulate above the wound, aiding in the healing process

72. What is the appropriate way of removing sutures or staples?

73. For best results, when or how should transparent dressings be used? Select all that apply;

74. In a Wound VAC system, what is the negative pressure required for it to work?

75. How often should a Wound Vac dressing be changed for a patient with a clean wound?

76. Also known as separate sutures characterized with knots that are lined up on the same side of incision.

77. When Montgomery straps are soiled, when do they get replaced?

78. A patient who recently suffered a vehicular accident is using a Wound Vac device. Due to the severity of the accident, the patient has purulent drainage. How often should his dressing be changed?

79. What kind of dressings promote healing by keeping wounds moist yet sterile?

65. Use _ _ rather than _ ____ to fasten bandages on small children or infants.