VNSG 1323 Chapter 28 Prep U Questions || with 100% Verified Solutions.
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Course
VNSG 1323
Institution
VNSG 1323
The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? correct answers Assess the wound for active bleeding
Explanation: Negative-pressure woun...
VNSG 1323 Chapter 28 Prep U Questions || with 100%
Verified Solutions.
The health care provider prescribes negative-pressure wound therapy for a client with a pressure
injury. Before initiating the treatment, it is important for the nurse to implement which nursing
assessment? correct answers Assess the wound for active bleeding
Explanation: Negative-pressure wound therapy (NPWT) promotes wound healing and wound
closure through the application of uniform negative pressure on the wound bed. NPWT is not
considered for the use in the presence of active bleeding. The nurse needs to assess for the use of
anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the
presence of claustrophobia are not significant when initiating negative-pressure wound therapy.
A nurse is caring for a client with dehydration at the health care facility. The client is receiving
glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
correct answers Transparent
Explanation: The nurse should use a transparent dressing to cover the IV insertion site because
such dressings allow the nurse to assess a wound without removing the dressing. In addition,
they are less bulky than gauze dressings and do not require tape, since they consist of a single
sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to
bleed, or wounds that exude drainage. A hydrocolloid dressing helps keep the wounds moist. A
bandage is a strip or roll of cloth wrapped around a body part to help support the area around the
wound.
The nurse and client are looking at a client's heel pressure injury. The client states, "Why is there
a small part of this wound that is dry and brown?" What is the nurse's appropriate response?
correct answers "Necrotic tissue is devitalized tissue that must be removed to promote healing."
Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is
necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray,
or green. Undermining is tissue erosion from underneath intact skin at the wound edge.
Upon review of a postoperative client's medication list, the nurse recognizes that which
medication will delay the healing of the operative wound? correct answers Corticosteroids
Explanation: Clients who are taking corticosteroids or require postoperative radiation therapy are
at high risk for delayed healing and wound complications. Corticosteroids decrease the
inflammatory process, which may delay healing. Antihypertensive drugs, Potassium
supplements, and laxatives, do not delay wound healing.
Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced.
Initial nursing management includes calling the physician and: correct answers Covering the
wound area with sterile towels moistened with sterile 0.9% saline.
, Explanation: If dehiscence occurs, cover the wound area with sterile towels moistened with
sterile 0.9% saline. The client should also be placed in the low-Fowler's position, and the
exposed abdominal contents should be covered with sterile saline and not hydrogen peroxide.
Notify the physician immediately because this is a medical emergency. Do not leave the client
alone but the nurse does not need to hold the wound together until the physician arrives.
During a dressing change, the nurse assesses protrusion of intestines through an opened wound.
What would the nurse do after covering the wound with towels moistened with sterile 0.9%
sodium chloride solution? correct answers Notify the physician and prepare for surgery.
Explanation: Protrusion of the intestines through an opened wound indicates evisceration. After
covering the wound with towels soaked in sterile normal saline, the nurse should immediately
notify the physician. Immediate surgical repair is required. Pain medication and documentation
are also important. If necessary, the nurse should reinforce the dressing while waiting for
surgery.
The nurse is caring for a client who has reported to the emergency department with a steam burn
to the right forearm. The burn is pink and has small blisters. The burn is most likely: correct
answers Second degree or partial thickness
Explanation: Partial-thickness burns may be superficial or moderate to deep. A superficial
partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild
sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or
deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with
blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may
vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or
bullae may be present. The full-thickness burn appears dry and leathery.
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies,
which dressing will the nurse select to cover the site where the needle was inserted to gather
blood? correct answers Gauze
Explanation: Gauze dressings absorb blood or drainage. Transparent dressings like OpSite are
used to protect intravenous insertion sites. Hydrocolloid dressings like Duoderm and Tegasorb
are used to used keep a wound moist.
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary
care provider placed the client on bed rest. Which action should the nurse perform to prevent a
pressure injury? correct answers Use pillows to maintain a side-lying position as needed.
Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change
position to alleviate and alternate pressure on client's bony prominences. The client's position
should be changed a minimum of every 2 hours. In addition, incontinent care should be
performed a minimum of every 2 hours and as needed to decrease moisture and irritation to the
skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure injury.
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