Practice Exam (Sterile Dressing Change)

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Questions and Answers

What is the primary purpose of a sterile dressing?

To absorb drainage (correct)

To reduce pain

To prevent allergic reactions

To improve circulation

Which of the following is an appropriate cleansing solution for most sterile dressing changes?

Alcohol

Hydrogen peroxide

0.9% Sodium Chloride (normal saline) (correct)

Distilled water

Which of the following describes a wound healing by secondary intention?

Surgical incision with approximated edges

Burn with considerable tissue loss (correct)

Fracture without skin breakage

Sutured wound

A postoperative patient reports a sudden feeling of "pulling" in the abdominal wound. What complication does this indicate?

Dehiscence Signup and view all the answers

What is the correct order of wound cleansing for a closed wound?

Center, side, side Signup and view all the answers

Which dressing is primarily used for wound debridement?

Wet-to-dry dressing Signup and view all the answers

What is the normal exudate that may be expected from a healing wound?

Serous Signup and view all the answers

Which assessment finding would indicate a possible wound infection?

Redness, warmth, and purulent drainage Signup and view all the answers

What should a nurse do if a wound dressing adheres to the wound?

Moisten the dressing with saline before removal Signup and view all the answers

What type of drainage is a pale, pink mixture of clear and red fluid?

Serosanguineous Signup and view all the answers

When packing a wound, which of the following principles should be followed?

Pack lightly to avoid pressure on the wound bed Signup and view all the answers

Which of the following is a priority action if evisceration occurs?

Notify the surgeon immediately Signup and view all the answers

What is a normal finding 48 hours after surgery?

Slight redness and mild edema at the wound site Signup and view all the answers

Which of the following wounds heals by primary intention?

Surgical wound with approximated edges Signup and view all the answers

How should a nurse measure the depth of a wound?

Placing a sterile cotton swab at the deepest part of the wound Signup and view all the answers

When should sterile gloves be applied?

After setting up a sterile field Signup and view all the answers

What is considered a violation of sterile technique?

Reaching across a sterile field to get supplies Signup and view all the answers

Why must fluids be poured carefully onto a sterile field?

To avoid splashing and contaminating the field Signup and view all the answers

What is the correct action when pouring a sterile solution?

Pour a small amount into a waste container first Signup and view all the answers

Which part of a sterile field is considered unsterile?

The outer 1-inch border Signup and view all the answers

In which setting is sterile technique always required?

Operating room procedures Signup and view all the answers

Which of the following areas cannot be sterilized?

Skin Signup and view all the answers

What should a nurse do when the sterile field becomes contaminated?

Discard the entire sterile field and start over Signup and view all the answers

What is the correct action when opening a sterile package?

Open the package away from the nurse first Signup and view all the answers

What is the correct sequence when applying sterile gloves?

Apply the first glove and then the second glove by holding the cuff Signup and view all the answers

What is the primary sign of evisceration in a postoperative wound?

Protrusion of internal organs Signup and view all the answers

Which of the following increases the risk of wound dehiscence?

Poor wound care Signup and view all the answers

What action is most appropriate if a wound dressing becomes saturated with drainage?

Change the dressing immediately Signup and view all the answers

Which of the following conditions is indicative of a wound infection?

Foul-smelling purulent drainage Signup and view all the answers

Which of the following interventions promotes healing by secondary intention?

Applying wet-to-dry dressings Signup and view all the answers

Which is the correct technique for removing a soiled dressing?

Remove the dressing with clean gloves Signup and view all the answers

Which of the following describes appropriate hand hygiene before donning sterile gloves?

Washing hands with soap and water for 20 seconds Signup and view all the answers

What should a nurse do if they touch a non-sterile object while wearing sterile gloves?

Replace the contaminated glove with a new sterile glove Signup and view all the answers

In which direction should a nurse clean a wound to maintain sterility?

From the least contaminated area to the most Signup and view all the answers

Which of the following actions contaminates the sterile field during a dressing change?

Reaching over the sterile field to grab an instrument Signup and view all the answers

Which part of a sterile glove is considered sterile?

The outer surface only Signup and view all the answers

What action is necessary when setting up a sterile field?

Maintain sterile objects within the nurse’s field of vision Signup and view all the answers

What is the purpose of a wound vac in wound healing?

Using negative pressure to promote granulation tissue formation Signup and view all the answers

How should a nurse dispose of soiled dressings after a dressing change?

Place the soiled dressings in a biohazard bag Signup and view all the answers

What should be included in the documentation after performing a sterile dressing change?

Condition of the wound, type of dressing applied, and patient response Signup and view all the answers

When applying a new sterile dressing, what must the nurse document on the dressing?

Date, time, and nurse’s initials Signup and view all the answers

What should a nurse do immediately after performing a sterile procedure?

Ensure the patient is comfortable and ask if anything else is needed Signup and view all the answers

Which sign would indicate delayed wound healing?

Wound edges separating and increasing drainage after 5 days Signup and view all the answers

What is the proper method for measuring the length of a wound?

Measure from the longest point of the wound Signup and view all the answers

A nurse is preparing to perform a sterile dressing change on a patient with an abdominal wound that is healing by secondary intention. Which action is most appropriate when cleaning the wound?

Use one gauze pad for each stroke, cleaning from the wound center outward. Signup and view all the answers

A patient is two days post-surgery with a well-approximated incision. On assessment, the nurse observes mild erythema and slight edema at the incision site. What is the most appropriate nursing action?

Document the findings as a normal expectation of healing. Signup and view all the answers

When performing wound irrigation on a patient with a draining wound, which of the following techniques is essential to maintain a sterile field?

Position the patient so that fluid flows from the cleanest to the most contaminated area. Signup and view all the answers

During a sterile dressing change, the nurse notices that the patient’s wound has developed purulent drainage with a strong odor and increased warmth around the incision site. What is the nurse’s priority action?

Obtain a wound culture with a physician’s order. Signup and view all the answers

A nurse is caring for a patient whose abdominal incision has dehisced. The patient reports feeling a “tearing” sensation. What should the nurse do immediately?

Apply a sterile saline-soaked dressing over the wound and notify the physician. Signup and view all the answers

Study Notes

Sterile Dressings and Wound Care

Primary Purpose of Sterile Dressing: To protect a wound from contamination and promote healing.
Appropriate Cleansing Solution: Normal saline is the most commonly used cleansing solution for sterile dressing changes.
Wound Healing by Secondary Intention: This occurs when a wound is left open and the body heals from the bottom up. This happens when a wound is left open to drain or when there is a significant amount of tissue loss.
Sudden "Pulling" Sensation in Abdominal Wound: This indicates wound dehiscence, a partial or complete separation of the wound edges.
Wound Cleansing Order: The correct sequence is:
- Cleanse the wound from least contaminated to most contaminated, typically starting with the surrounding skin and then moving toward the center of the wound.
Dressing for Debridement: Wet-to-dry dressings are primarily used for wound debridement.
Normal Wound Exudate: Serous exudate, a clear, watery fluid, is expected in a healing wound.
Indicators of Wound Infection: Signs include:
- Erythema (redness)
- Edema (swelling)
- Pain
- Warmth
- Purulent drainage (thick, yellow or green pus).
Adherent Dressing: If a dressing adheres to the wound, gently moisten it with saline solution to loosen it. Do not pull or force the dressing off as this can damage delicate healing tissue.
Serosanguineous Drainage: This is a pale, pink mixture of clear (serous) and red (sanguineous) fluid, commonly observed during wound healing.
Wound Packing Principles:
- Pack loosely.
- Do not overpack the wound as this can impede circulation and healting.
- Ensure drainage can escape easily.
Evisceration Priority Action: Immediately cover the wound with sterile saline-soaked gauze, notify the provider, and prepare the patient for surgery. This is a medical emergency requiring immediate intervention.
Normal Finding After Surgery: Some mild swelling and slight redness around the incision site are considered normal 48 hours after surgery.
Healing by Primary Intention: This occurs when a wound is closed directly with sutures, staples, or adhesive strips. Examples include surgical incisions.
Measuring Wound Depth: Use a sterile cotton-tipped applicator and mark the length on the applicator with a sterile marker.
Sterile Glove Application: Sterile gloves should be applied immediately before the procedure.
Violation of Sterile Technique: Touching a non-sterile object is considered a violation of sterile technique.
Pouring Fluids onto a Sterile Field: Pour fluids carefully to avoid splashing or contaminating the sterile area.
Pouring Sterile Solution: Place the bottle cap face up on a flat surface and pour the solution from a distance to avoid contaminating the lip of the bottle.
Unsterile Area of Sterile Field: The edges of the sterile field and anything below the table level are considered unsterile.
Sterile Technique Setting: Sterile technique is always required in surgical settings.
Non-Sterilizable Areas: Body cavities and the inside of the gastrointestinal system cannot be sterilized.
Contaminated Sterile Field: If the sterile field becomes contaminated:
- Discard the contaminated items and start over with new sterile equipment.
- Do not attempt to reuse contaminated items.
Opening Sterile Package:
- Open the package away from you.
- Avoid touching the inner surfaces of the package.
Applying Sterile Gloves:
- Don the dominant hand glove first.
- Use the gloved hand to put on the other glove.
- Do not touch the outside of the gloves with bare hands.
Evisceration Sign: Protrusion of internal organs through the wound is the primary sign of evisceration.
Wound Dehiscence Risk Factors:
- Obesity
- Malnutrition
- Poor wound healing
- Excessive coughing or straining.
Saturated Wound Dressing: Change the dressing immediately to prevent infection.
Wound Infection Indicators:
- Increased redness, pain, swelling, warmth, and purulent drainage.
Promoting Healing by Secondary Intention: Wound packing with moist dressings should be employed.
Removing Soiled Dressing:
- Wear clean gloves.
- Remove the dressing in a single fluid motion.
- Avoid touching the wound.
Hand Hygiene Before Donning Sterile Gloves:
- Wash hands thoroughly with soap and water for at least 20 seconds and dry them completely.
Touching Non-Sterile Object: Discard the contaminated gloves and apply a new pair.
Wound Cleaning Direction: Cleanse the wound from the least contaminated area to the most contaminated area.
Contamination of Sterile Field: Touching the sterile field with an ungloved hand or a non-sterile instrument contaminates the sterile field.
Sterile Glove Area: The inner surface of the sterile glove is considered sterile.
Setting up a Sterile Field:
- The sterile field must be completely dry prior to placement of sterile equipment.
Wound Vac Purpose: Negative pressure wound therapy (wound vac) promotes wound healing by removing wound exudate, reducing edema, and improving blood flow.
Soiled Dressing Disposal:
- Dispose of soiled dressings in a biohazard waste container.
Dressing Change Documentation:
- Record:
  - The type and amount of drainage
  - The wound appearance (size, color, odor)
  - Any complications encountered.
New Dressing Documentation:
- Document the date and time of application of the new sterile dressing.
Post-Sterile Procedure Action:
- Wash hands thoroughly with soap and water.
Delayed Wound Healing Sign: Persistent inflammation or increased exudate can suggest delayed wound healing.
Wound Length Measurement: Measure the length of the wound with a sterile ruler from end to end.

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Description

This quiz explores the primary purpose and functions of sterile dressings in medical practice. You'll learn about wound care principles and the importance of maintaining asterility to prevent infection. Test your knowledge on this critical aspect of healthcare.