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What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
What is the substance in the clot that holds the wound together?
What is the substance in the clot that holds the wound together?
What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?
What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?
What marked advantage does primary intention have over other phases of wound healing?
What marked advantage does primary intention have over other phases of wound healing?
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Which type of wound healing involves the edges of the wound being brought together?
Which type of wound healing involves the edges of the wound being brought together?
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What is the first response of the body to a surgical injury?
What is the first response of the body to a surgical injury?
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During which phase do inflammatory cells migrate into the wound site?
During which phase do inflammatory cells migrate into the wound site?
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What is typically observed at a wound site during the inflammatory response?
What is typically observed at a wound site during the inflammatory response?
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Which of the following best describes a clean-contaminated wound?
Which of the following best describes a clean-contaminated wound?
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What is the appearance of serous drainage?
What is the appearance of serous drainage?
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Which type of drainage indicates active bleeding?
Which type of drainage indicates active bleeding?
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How would one describe the characteristics of purulent drainage?
How would one describe the characteristics of purulent drainage?
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What is the correct documentation for drainage that is pale, red, and watery?
What is the correct documentation for drainage that is pale, red, and watery?
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Which of the following describes sanguineous drainage?
Which of the following describes sanguineous drainage?
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What kind of drainage would be described as a mixture of serous and sanguineous drainage?
What kind of drainage would be described as a mixture of serous and sanguineous drainage?
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If a nurse observes thick drainage that is predominantly yellow, how should it be classified?
If a nurse observes thick drainage that is predominantly yellow, how should it be classified?
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What indicates that the wound may be healing if drainage changes to pale red and watery?
What indicates that the wound may be healing if drainage changes to pale red and watery?
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Which type of drainage is NOT characterized by being watery?
Which type of drainage is NOT characterized by being watery?
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What color is sanguineous drainage typically described as?
What color is sanguineous drainage typically described as?
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Which of the following are phases of wound healing?
Which of the following are phases of wound healing?
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Which solutions are appropriate for use on a wet-to-dry dressing?
Which solutions are appropriate for use on a wet-to-dry dressing?
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What are benefits of using a transparent dressing?
What are benefits of using a transparent dressing?
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What is the primary component formed that leads to the purple, raised, immature scar?
What is the primary component formed that leads to the purple, raised, immature scar?
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Which elements contribute to wound healing, as per the established steps?
Which elements contribute to wound healing, as per the established steps?
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What does not describe the features of a transparent dressing?
What does not describe the features of a transparent dressing?
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How often should a nurse assess for bleeding under the dressing during the first 24 hours following surgery?
How often should a nurse assess for bleeding under the dressing during the first 24 hours following surgery?
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When should the nurse administer an analgesic to promote comfort for a dressing change after a total hip replacement?
When should the nurse administer an analgesic to promote comfort for a dressing change after a total hip replacement?
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What is the primary purpose of a wet-to-dry dressing when it is removed?
What is the primary purpose of a wet-to-dry dressing when it is removed?
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Which findings could indicate internal hemorrhage in a postoperative patient?
Which findings could indicate internal hemorrhage in a postoperative patient?
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What is the recommended action for a nurse assessing a post-surgery patient with a dressing?
What is the recommended action for a nurse assessing a post-surgery patient with a dressing?
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What should be considered before performing a dressing change to enhance patient comfort?
What should be considered before performing a dressing change to enhance patient comfort?
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What is a potential risk when a wet-to-dry dressing adheres to the wound?
What is a potential risk when a wet-to-dry dressing adheres to the wound?
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What vital sign changes may signal a concern in a postoperative patient that needs to be reported?
What vital sign changes may signal a concern in a postoperative patient that needs to be reported?
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What should a nurse do after discovering a patient has a dry dressing post-surgery?
What should a nurse do after discovering a patient has a dry dressing post-surgery?
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What is the expected outcome of the wet-to-dry dressing technique?
What is the expected outcome of the wet-to-dry dressing technique?
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What patient problem is identified as a priority for a morbidly obese patient with a foot injury and diabetes that is healing?
What patient problem is identified as a priority for a morbidly obese patient with a foot injury and diabetes that is healing?
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Which assessment finding would rule out infection in the patient with a stage 2 foot injury?
Which assessment finding would rule out infection in the patient with a stage 2 foot injury?
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In the context of the patient needing to follow an ADA diet, which problem is least likely to be a priority?
In the context of the patient needing to follow an ADA diet, which problem is least likely to be a priority?
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What is a key feature of the vacuum-assisted closure (VAC) device in wound therapy?
What is a key feature of the vacuum-assisted closure (VAC) device in wound therapy?
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Which of the following is NOT a benefit of using a VAC device for wound therapy?
Which of the following is NOT a benefit of using a VAC device for wound therapy?
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What should nurses focus on when determining the priority problem for a patient with a healing foot injury and obesity?
What should nurses focus on when determining the priority problem for a patient with a healing foot injury and obesity?
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What impact does decreasing local and peripheral edema have in wound healing?
What impact does decreasing local and peripheral edema have in wound healing?
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Why is compliance with an ADA diet particularly important for a patient with insulin-dependent diabetes mellitus?
Why is compliance with an ADA diet particularly important for a patient with insulin-dependent diabetes mellitus?
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Which of the following promotes healing in a wound?
Which of the following promotes healing in a wound?
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What is typically observed within 3 to 4 days of applying a VAC device to a wound?
What is typically observed within 3 to 4 days of applying a VAC device to a wound?
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Study Notes
Wound Classification
- An uninfected surgical wound with less than a 5% chance of becoming infected is classified as a "clean" wound.
Hemostasis
- During hemostasis, the substance fibrin in a clot holds the wound together.
Wound Healing Phases
- The inflammatory phase involves fluid leakage from blood vessels into the vascular space leading to edema, erythema, heat, and pain.
- Primary intention healing results in minimal scarring.
Wound Care - Postoperative
- Nurses should assess for bleeding under the dressing every 2 to 4 hours in the first 24 hours post-surgery.
- To promote patient comfort during dressing changes, consider administering analgesics at least 30 minutes before exposing the wound.
Wet-to-Dry Dressings
- Wet-to-dry dressings are applied wet and allowed to dry, adhering to the wound.
- The drying process facilitates mechanical débridement when the dressing is removed.
Wound Assessment & Signs of Internal Hemorrhage
- Signs of internal hemorrhage include rapid pulse, decreased blood pressure, decreased urinary output, and a dry dressing.
Wound Drainage
- Serous drainage is clear and watery.
- Purulent drainage is thick and yellow, green, tan, or brown.
- Sanguineous drainage is bright red, indicating active bleeding.
- Serosanguineous drainage is pale red and watery, a mixture of serous and sanguineous drainage.
Vacuum-Assisted Closure (VAC) Device
- VAC devices apply negative pressure, increasing drainage.
- They promote granulation tissue formation, reduce local and peripheral edema, and decrease bacterial levels in the wound.
Phases of Wound Healing
- The phases of wound healing are hemostasis, inflammation, reconstruction, and maturation.
Wet-to-Dry Dressing Solutions
- Normal saline, sterile water, lactated Ringer, acetic acid, and Dakin solution are suitable for use on wet-to-dry dressings.
Transparent Dressings
- Transparent dressings adhere to undamaged skin, contain exudate, reduce contamination, act as a barrier to external bacteria, and speed epithelial growth.
Scar Formation
- Collagen formation is responsible for the formation of the purple, raised, immature scar over new surgical wounds.
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Description
Test your knowledge on wound classification, phases of healing, and effective wound care practices. This quiz covers essential nursing responsibilities postoperatively, the science of hemostasis, and the techniques for dressing changes. Perfect for nursing students and professionals focused on surgical care.
