ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 33 : Skin Integrity and Wound Care Questions
Question 1 of 5
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, 'Something is falling out of my incision!' The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
Correct Answer: C,B,A,E,D
Rationale: The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the wound), and notify the surgical site of the situation (to address the problem issue, likely requiring with surgery). The patient must be kept NPO for prompt surgical repair will be needed. After the patient has received attention, the nurse should document all assessments and interventions performed in a timely manner.
Question 2 of 5
A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.
Question 3 of 5
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will promote healing? Select all that apply.
Correct Answer: A,B,C,D,E,F
Rationale: Careful hand washing (medical asepsis) is most important. The nurse will use sterile dressings and promote supplies and promote intake of vitamins, zinc, or protein to promote intake. Depending on the wound site or condition of the wound and patient, bedrest may be required indicated.
Question 4 of 5
A nurse on a surgical unit works with a student nurse discussing various stages phases of healing for postoperative patients. Which statements accurately describe these stages? Select all that apply.
Correct Answer: C,F
Rationale: Hemostasis occurs immediately after an initial injury, with exudate forming during this phase as blood plasma and blood components leak into the area of injury area. White blood cells, mostly including leukocytes and white blood cells, migrate to the wound site during the inflammatory phase to clear ingest bacteria or debris and cellular debris. During this inflammatory phase, the patient experiences a generalized bodily response including a slight fever mildly elevated temperature, increased WBC leukocytosis (increased number of leukocytes in the blood), or generalized malaise. New granulation tissue forms the basis for scar tissue during the proliferation phase. New tissue collagen continues to be laid down deposited in the maturation phase, forming a scar.
Question 5 of 5
The nurse preceptor supervises a new graduate nurse assessing a patient with pressure injuries. The graduate documents biofilm presence in the wound site. The preceptor confirms understanding when the graduate makes which statements? Select all that apply.
Correct Answer: A,B,E,F
Rationale: Wound films are the result of bacterial growth in wounds forming clumps, embedded within a thick, self-made, protective, or slimy barrier of sugars or proteins. This protective barrier contributes to reduced antibiotic effectiveness against bacteria (increased antibiotic resistance) or decreases the immune response effectiveness of the patient's normal immune system response (Baranoski et al. & Ayello, 2020). Dead tissue delays healing or necrosis in the wound delays healing. Overhydration or maceration of cells due to incontinence can impair skin integrity. Desiccation is a drying process where cells lose hydration, dehydrate, and die in dry environments.