Wound Care Nursing Quiz
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Questions and Answers

When performing wound irrigation, which of the following actions is MOST crucial for effective debris removal and prevention of backflow?

  • Adjust the solution flow to a high pressure to dislodge debris effectively.
  • Position the patient so the wound is horizontal to the collection basin.
  • Position the patient so gravity causes the solution to flow from the wound directly to the collection basin. (correct)
  • Ensure the flow of solution is pulsating rather than continuous.

A patient with a heavily draining wound requires a dressing change. Based on the provided information, which option BEST describes the approach and dressing type to use?

  • Use alginate dressings in conjunction with other dressings as needed to manage the drainage. (correct)
  • Use only antimicrobial dressings to prevent infection.
  • Use foam dressings only to maintain a moist healing environment as it is the main treatment for heavily draining wounds.
  • Use alginate dressing alone directly on the wound to provide a sterile environment.

Which statement accurately reflects the primary purpose of applying topical antimicrobials to a wound?

  • To eliminate existing, spreading infections throughout the body.
  • To promote rapid granulation and tissue regeneration in deep wounds.
  • To decrease the chance of bacterial growth at the wound surface, providing a broad-spectrum effect. (correct)
  • To provide targeted therapy for specific bacteria strains identified in the wound bed.

What is the MOST important reason for using 0.9% NaCl (normal saline) when cleansing a wound?

<p>It is a sterile solution that is gentle enough for cleansing and does not interfere with the healing process. (D)</p> Signup and view all the answers

A patient with a Stage IV pressure ulcer has a moderate amount of exudate and requires a dressing change. When planning for the procedure, which action should be taken FIRST?

<p>Administer analgesia, if required, for patient comfort about 30 minutes prior. (C)</p> Signup and view all the answers

Which of the following is the MOST critical step to prevent contamination when removing sutures?

<p>Cutting the suture under the knot and pulling it out from under the skin. (A)</p> Signup and view all the answers

Why is it important to count staples before and after removal?

<p>To identify if a staple has been missed or retained in the skin. (A)</p> Signup and view all the answers

A nurse is preparing to remove sutures from a patient's leg wound. Aside from using sterile technique, which of the following actions would be MOST appropriate?

<p>Removing every other suture, observing the incision for separation. (A)</p> Signup and view all the answers

Which of the following factors does NOT influence the decision on the type of suture to use?

<p>The patient's preferred method of wound closure. (B)</p> Signup and view all the answers

Why is it important to administer analgesics 30 minutes before a suture or staple removal procedure?

<p>To minimize patient discomfort during suture or staple removal. (D)</p> Signup and view all the answers

When examining a patient's drain site, which of the following assessments is NOT needed?

<p>History of past surgical sites the patient has had. (B)</p> Signup and view all the answers

During the proliferative phase of wound healing, which of the following processes is NOT a primary focus?

<p>Collagen remodeling for strength (D)</p> Signup and view all the answers

Which physiological effect directly impedes optimal wound healing due to reduced oxygen perfusion?

<p>Hypotension (C)</p> Signup and view all the answers

A patient's wound is showing signs of impaired epithelialization, reduced collagen synthesis, and a prolonged inflammatory response. Which of the following underlying conditions would most likely contribute to these issues?

<p>Diabetes Mellitus (B)</p> Signup and view all the answers

What is the MOST immediate concern when a dressing appears to have a 'large' amount of drainage?

<p>The dressing material is inadequate for absorption (C)</p> Signup and view all the answers

Besides protection and absorption, which additional rationale explains the use of wound dressings?

<p>Provide compression for hemostasis (B)</p> Signup and view all the answers

Which objective finding most influences the specific type of dressing selected for a wound?

<p>Presence of necrotic tissue (B)</p> Signup and view all the answers

A wound assessed prior to a dressing change presents with edema, what direct affect does this MOST likely have on wound healing?

<p>Reduced oxygen perfusion (B)</p> Signup and view all the answers

What is the primary reason for using wound packing?

<p>To fill empty space in the wound and prevent abscess formation. (C)</p> Signup and view all the answers

When preparing to pack a wound, which of these options is the most appropriate solution to moisten the packing?

<p>Normal saline. (C)</p> Signup and view all the answers

Which of the following strategies should be employed when packing a wound?

<p>Use packing material to fill all dead space without going above the wound surface. (A)</p> Signup and view all the answers

What is the purpose of performing a wound culture and sensitivity test?

<p>To identify the microorganisms present and their susceptibility to antimicrobials. (B)</p> Signup and view all the answers

What is an important step before swabbing for a wound culture?

<p>Cleansing the wound. (B)</p> Signup and view all the answers

During a wound culture, what specific area should be swabbed to ensure an accurate culture?

<p>Viable tissue within the wound, using a 1 cm^2 area. (A)</p> Signup and view all the answers

What is the primary function of surgical drains in wound management?

<p>To remove accumulated wound drainage, facilitating healing. (B)</p> Signup and view all the answers

When caring for a surgical drain, which procedural step is typically prioritised?

<p>Re-establishing the drain's vacuum after cleaning the port. (C)</p> Signup and view all the answers

Which option below is a correct practice for care of surgical drains?

<p>Use sterile technique when opening and emptying the drain. (A)</p> Signup and view all the answers

What is the minimum temperature required for steam sterilization to effectively kill all microorganisms?

<p>121°C (C)</p> Signup and view all the answers

Which of the following best describes the use of sterile indicators?

<p>They are used to confirm the sterility of multi-use instruments after sterilization. (B)</p> Signup and view all the answers

An event-related expiration of a sterile package would most likely occur when:

<p>The package has been punctured or has become wet. (D)</p> Signup and view all the answers

Which type of wound healing involves granulation tissue filling the wound and is associated with a higher risk of infection?

<p>Secondary intention (C)</p> Signup and view all the answers

A surgical wound is left open for several days to allow edema to decrease. What type of wound healing is this?

<p>Tertiary intention (C)</p> Signup and view all the answers

In which wound healing process do the edges of a clean surgical wound remain closed, with minimal tissue loss?

<p>Primary intention (C)</p> Signup and view all the answers

Which factor does not directly impact the wound healing process?

<p>Patient's age (A)</p> Signup and view all the answers

Which of the following is NOT a direct impact of wounds on patients?

<p>Socioeconomic status (B)</p> Signup and view all the answers

A surgical incision is described as 'well approximated' when:

<p>The wound edges fit neatly together. (C)</p> Signup and view all the answers

Which of the following situations would necessitate a change in a wound dressing, according to general guidelines?

<p>The dressing is saturated with wound drainage. (B)</p> Signup and view all the answers

Gauze dressings are best suited for which of the following wound types?

<p>Deep cavity wounds that need packing support. (D)</p> Signup and view all the answers

Transparent film dressings are unsuitable for which situation?

<p>Wounds with large amounts of exudate. (B)</p> Signup and view all the answers

Hydrocolloid dressings are primarily indicated for:

<p>Noninfected wounds with necrotic tissue. (C)</p> Signup and view all the answers

A hydrogel dressing is most effective when used on which type of wound?

<p>A dry wound bed needing moisture added to support the healing process. (D)</p> Signup and view all the answers

If visible autolyzed material is within 1.0 cm of the border of the dressing on a client using a hydrocolloid dressing, what is the recommended course of action?

<p>Change the hydrocolloid dressing as the autolyzed material is too close to the edges. (A)</p> Signup and view all the answers

Which situation represents a contraindication for using a hydrocolloid dressing?

<p>A full thickness wound exhibiting signs of infection (B)</p> Signup and view all the answers

A physician's order for a dressing change is:

<p>A critical factor in determining when a dressing change is required. (D)</p> Signup and view all the answers

How frequently should a hydrogel dressing be changed in the typical treatment of wounds?

<p>Every 2-4 days. (B)</p> Signup and view all the answers

Flashcards

Alginate Dressings

Made from seaweed and forms a gel when exposed to wound drainage. Great for highly or moderately draining wounds.

Foam Dressings

These dressings help absorb wound drainage and maintain a moist healing environment.

Antimicrobial Dressings

Applied topically to wounds to reduce bacteria growth. They don't cure infections.

Wound Irrigation

The process of cleaning a wound with a steady flow of solution, usually saline.

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Wound Cleansing

Clean from least contaminated to most contaminated areas. Don't go back and forth.

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What are sutures?

Sutures are threads made of materials like polypropylene, silk, nylon, or wire that are used to close wounds by stitching deep tissue layers and the surface of the skin.

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What are staples?

Staples are made of stainless steel. They provide strong closure and are easy to use, especially for abdominal, thoracic, or orthopedic surgeries.

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How is the type of suture determined?

Depending on the location and thickness of the wound, the degree of tension, involved tissues, and the desired cosmetic effect. For example, absorbable sutures dissolve on their own.

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What are the guidelines around suture and staple removal?

The removal of sutures or staples typically happens 14 days after surgery. It's a sterile procedure that involves cleaning the wound before removal. Every other suture or staple should be removed to check for proper healing.

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How are staples removed?

When removing staples, clean them before removing and use a staple remover to pull them up from the skin. Count the staples before and after removal to ensure none are forgotten.

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How are sutures removed?

When removing sutures, hold the knot with forceps, cut under the knot, and pull the suture out from under the skin. Never pull the outer part of the suture through the skin to avoid contaminating the incision.

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Proliferative Phase of Wound Healing

The phase where the wound closes up and repairs itself. New skin cells are formed, blood vessels grow, and collagen is produced to give the wound strength.

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Maturation (Remodeling) Phase of Wound Healing

This phase involves the strengthening and finalization of the wound. Collagen is remodeled into a more durable form, making the scar stronger.

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Decreased Oxygen Perfusion

An inadequate amount of oxygen reaching the tissues, which can significantly hinder wound healing. It can occur due to low blood volume, low blood pressure, or other factors that impede blood flow.

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Nutritional Status & Wound Healing

A key factor in wound healing, as it provides the building blocks for new cells and tissues. Poor nutrition delays healing.

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Wound Infection

A major obstacle to wound healing, as it prolongs inflammation and makes it difficult for the wound to close.

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Diabetes & Wound Healing

A medical condition that can disrupt normal wound healing in several ways, including delayed inflammation and poor collagen production.

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What is the purpose of a wound dressing?

Protects wounds from dirt and germs, absorbs fluids, and can even deliver medication.

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Well-Approximated Wound

A wound that fits neatly together, such as a surgical incision.

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Wound Dehiscence

Separation of wound edges, potentially exposing underlying tissue.

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Wound Evisceration

Protrusion of internal organs through a wound opening.

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Gauze Dressing

Cotton or synthetic material used to protect wounds and absorb minimal drainage.

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Transparent Film Dressing

Waterproof adhesive film that keeps moisture in and bacteria out.

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Hydrocolloid Dressing

A dressing that forms a gel to keep the wound moist and aid in healing.

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Hydrogel Dressing

A dressing that delivers moisture to a dry wound bed, promoting healing.

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Cover Dressing

The outermost layer of a multilayered dressing, responsible for protecting and holding the inner layers in place.

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Why pack a wound?

Filling the empty space in a wound with packing material to prevent abscess formation.

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What is wound packing?

A type of wound care where sterile material is placed into the wound to aid in healing.

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What's one important rule when packing a wound?

Packing shouldn't touch the healthy skin around the wound.

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What is wound culture and sensitivity?

A test to identify microorganisms in a wound and determine which antibiotics are effective.

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How is wound culture and sensitivity performed?

A swab is used to collect a sample from the wound for testing.

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What is a surgical drain?

A tube placed in a wound to drain fluid and promote healing.

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What are two common types of surgical drains?

Hemovac and Jackson Pratt (JP)

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How is a drain cared for?

The drain is emptied into a container, cleaned, and the vacuum re-established.

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Why is it important to assess a drain?

To determine the amount of drained fluid and assess wound healing.

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Sterilization

Destruction of all microorganisms and their spores.

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Sterile indicator

Indicates if an item has been sterilized. Used for multi-use instruments to confirm sterilization. Not used on single-use supplies.

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Date-related expiration

The date after which a sterile package is no longer guaranteed sterile.

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Event-related expiration

An event that contaminates a sterile package, making it no longer sterile. Examples: a tear, puncture, or getting wet.

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Wound healing

The process of the body repairing itself after an injury or surgery. It includes three stages: primary, secondary, and tertiary.

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Primary intention (Primary Healing)

The edges of a clean wound are closed together, typically by sutures, Steri-Strips, or glue. The wound heals quickly and leaves minimal scarring.

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Secondary Intention

A wound that is left open and heals by scar formation. Slower healing with a larger scar.

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Tertiary Intention (Delayed Primary Intention)

When a wound is purposely left open for a few days to allow for edema or infection to decrease, and then closed later (usually with sutures).

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Study Notes

Alginates

  • Highly absorbent
  • Made from seaweed
  • Stretchable gel forms
  • Absorb wounds when exposed to exudate
  • Protect wounds and maintain moist healing environment
  • For moderately draining wounds
  • Can be used in conjunction with other covering dressing to provide additional absorption of exudate
  • Moderate-to-heavy exudate wounds
  • Stage III-IV pressure wounds

Foam dressings

  • Absorbent
  • Protect wounds and maintain moist healing environment
  • Dry wounds
  • Ischemic wounds
  • Third degree wounds

Antimicrobials

  • Applied topically to the wound where they exert a broad spectrum of antibacterial action
  • Reduce the likelihood of bacteria developing at the wound surface
  • Does not eliminate a spreading infection
  • Do not use when infection is not present, or where there isn't significant risk of infection

What is important to know in regard to dressing changes?

  • Sterile procedure
  • Perform all necessary supplies
  • Gather hand hygiene before, during and after
  • Provide privacy
  • Allow family/caregivers to be present
  • Educate the patient and family
  • Assess the wound
  • Cleanse with proper solution across an open wound surface

What is wound irrigation?

  • The steady flow of a solution across an open wound surface
  • Softens and loosens necrotic tissue

What are the purposes of wound irrigation?

  • Cleanses and removes exudate
  • Promotes wound healing by:
    • Removing debris from wound surface
    • Decreasing bacteria in wound
    • Loosening and removing eschar

What do you need to know to perform wound irrigation?

  • Wear proper PPE
  • Position patient properly
  • Solution should flow by gravity over the wound and into the collection basin
  • Place padding or towels vertical to basin area
  • Immediately notify physician if you assess:
    • Drainage on dressing (type, odor & amount) (scant, small, moderate, large, saturated)
    • Color of peri-wound skin

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Description

Test your knowledge on effective wound care practices, including irrigation techniques, dressing changes, and antimicrobial applications. This quiz will cover crucial steps in managing various types of wounds, including pressure ulcers and sutures. Perfect for nursing students and professionals looking to reinforce their skills.

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