NSG 106 with a focus on Tissue Integrity &
Wound Care Post Assessment Actual Final Exam
Questions with all Questions Accurately
Answered 2024/2025
Wound Vacuum - correct answer - Helps stimulate cell proliferation, blood
flow to wounds & growth of new blood flow
- Types of wounds: pressure ulcers, arterial venous, & diabetic ulcers,
dehisced surgical wounds, skin graft sites, infected wounds, & burns
- Caution: poor nutrition status, anticoagulation status & immunosuppressant
therapy
Heat Application does what ? - correct answer Promotes relaxation &
relieves muscle spasms & joint stiffness
Cold Application does what ? - correct answer Relieves muscle spasms &
pain through numbness, decreases edema & inflammation
Do NOT apply heat to an open wound when ? - correct answer Immediately
after trauma; during hemorrhage; over inflammatory edema; to an acute
inflamed area, a localized malignant tumor, the testes, or abdomen of a
pregnant woman; or over metallic implants
Do NOT use cold when ? - correct answer On open wounds or for patients
with impaired peripheral circulation or an allergy to cold
When heat is applied, what should you assess for? - correct answer For
undesired responses, including localized redness, blistering & pain (symptoms
of burning), along with possible systemic responses, such as hypotension &
changes in consciousness
,When cold is applied, what should you assess for? - correct answer For
localized response, including pallor, cyanosis, numbness, and pain
The order for heat & cold applications should include what? - correct answer
- Type of application
- Body area to be treated
- Frequency & length of time for application
Patients response to heat or cold suggest possible nursing diagnosis -
correct answer - Acute pain
- Ineffective tissue perfusion
- Chronic pain
- Risk for injury
Patient outcomes from applying heat or cold - correct answer - Verbalize
increased comfort
- Demonstrate evidence of wound healing, decreased muscle spasms,
decreased edema, & increased comfort
- Verbalize and demonstrate safe hot and cold application
Ice Bags - correct answer - Easy & inexpensive
- Fill bag with small pieces about 2/3 full
- Remove air
- Secure cap, test bag for leaks and wipe excess moisture
- Place cover
- Apply for 30 minutes, then remove for an hour
, Cold Packs - correct answer - Sealed containers filled with a chemical or a
nontoxic substance
- Some bags are frozen or squeezed to activate
- Remains pliable & can be easily molded
- Assess skin periodically for numbness & pain
Cold compresses might be used for ? - correct answer - Injured eye,
headache, tooth extraction, and sometimes for hemorrhoids
- Immerse material with clean basin that contains pieces of ice
- Wring out excess water
- Change frequently, continue for 20 minutes
- Repeat every 2-3 hours as ordered
Warm soaks - correct answer - Immersion of body area into warm water or
a medicated solution
- Purposes: increase blood supply to a locally infected area, to aid in cleaning
large, sloughing wounds, such as burns; to improve circulation; and to apply
medication to a locally infected area
Sitz Bath - correct answer Method of applying tepid or warm to pelvic,
perineal, or rectal areas by sitting in a tub, special chair, or basin filled with
sufficient water to reach the umbilicus
Warm moist compress - correct answer - Used to promote circulation and
healing to reduce edema
- Change compresses frequently because moist heat evaporates and cools
rapidly
- Cover them with a heating agent (hot water bottle, heating pad, AquaK pad)
