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Nur 204 exam 3 review.pdf
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Exam of 99 pages for the course NUR 204 at NUR 204 (Nur 204 exam 3)
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Nur 204 exam 3 reviewThe nurse knows which description would be classified as a closed wound?
a. A large bruise on the side of the face
b. A surgical incision that is sutured closed
c. A puncture wound that is healing
d. An abrasion on the leg – correct answer a. A large bruise on the side of the face
In a closed wound, as seen with bruising, the skin is still intact. An open wound is
characterized by an actual break in the skin's surface. For example, an abrasion, a puncture
wound, and a surgical incision are types of open wounds.
The nurse is educating the patient about the signs and symptoms of a wound infection. Which
statement indicates a need for further education?
a. "The wound will be red."
b. "The wound will have pus."
c. "The wound will be warm."
d. "The wound will need to be treated - correct answer b. "The wound will have pus."
An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage
that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105/g of
tissue sampled when cultured. The wound will need to be treated for the
,infection.
The nurse identifies which type of wounds heal by tertiary intention?
a. An acute wound in which the patient has sutures placed when it happened.
b. A pressure ulcer that was treated with dressing changes and is healed.
c. An acute wound in which surgical glue was used to close the wound.
d. A wound that was left open initially and closed later with sutures. - correct answer d. A wound that
was left open initially and closed later with sutures.
When a delay occurs between injury and closure, the wound healing is said to happen by tertiary
intention. Wounds such as surgical incisions or traumatic wounds in which the edges
of the wound can be approximated (brought together) to heal are examples of acute wounds. This type
of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue
must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as
a pressure ulcer.
The nurse is caring for a patient who is postoperative day one from an abdominal surgery.
When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse
immediately suspects which complication?
a. A wound infection
b. The stitches came loose
c. Wound dehiscence
d. Wound crepitus - correct answer c. Wound dehiscence
,Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete
separation of the tissue layers during the healing process. This is an emergency situation. Stitches can
come loose, but there is no popping sensation. Wound infections are
characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.
The nurse is caring for a postoperative patient who has had abdominal surgery and whose
wound has completely eviscerated when the nurse walks into the room. In addition to
notifying the surgeon, what should the nurse do?
a. Cover the wound with a sterile gauze pad.
b. Cover the wound with a transparent dressing.
c. Put pressure on the wound with a sterile gauze pad.
d. Cover the wound with gauze soaked with normal saline. - correct answer d. Cover the wound with
gauze soaked with normal saline.
If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline,
and notify the surgeon immediately. Putting pressure on the wound could cause further complications.
Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry
and cause further complications.
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3
pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?
a. Wound will be completely healed in 72 hours.
b. Wound will show signs of healing within 2 weeks.
c. Patient will develop no new pressure ulcers.
, d. Patient will ambulate twice a day. - correct answer b. Wound will show signs of healing within 2
weeks.
A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate
goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure
ulcers is good, but not the most appropriate, and ambulating twice a
day is more of an intervention.
A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the
new nurse causes the preceptor to intervene?
a. The nurse asks the UAP to assess the wound.
b. The nurse asks the UAP to report increased wound drainage.
c. The nurse asks the UAP to observe changes in dietary intake.
d. The nurse asks the UAP to change the dressing. - correct answer a. The nurse asks the UAP to assess
the wound.
Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the
treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive
personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in
temperature; complaints of pain; increased wound drainage or incontinence; and
observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.
The nurse recognizes which intervention is not a form of mechanical debridement?
a. Wet to dry dressings
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