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Review Questions 47 (copy)


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Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss
There are three phases of wound healing. The nurse observes granulation tissue in a client ’s pressure ulcer. What phase of wound healing is represented by granulation tissue?
A. Maturation phase
B. Proliferative phase
C. Inflammator
The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest, particularly in surgical wounds?
A. During the first 24 to 48 hours after surgery
B. Between 48 and 60 hours after surgery
C. Between 60 and 72
Often occurring during wound management, autolylic, chemical, and surgical are all methods of what?
A. Cleansing
B. Dressings
C. Debridement
D. Growth factors
A 40-year-old client is a new paraplegic. The client is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the client’s education. Regarding that education, the nurse should have included
During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:
A. Placing the client in Fowler’s position and returning in 2 ho
The nurse is to collect a specimen for culture after assessing the client’s wound drainage. The best technique for obtaining the culture is:
A. Collecting the specimen from accumulated drainage
B. Swabbing from the outside skin edge inward
The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why was the hydrogel dressing the best choice for this client?
A. It is soothing and reduces pain in the wound.
B. It can be used as a preventative dressing for h
The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?
A. Reflex vasoconstriction occurs.
B. Refl
When repositioning an immobile client the nurse notices redness over a bony prominence. When the area is assessed the red spot blanches with fingertip touch, indicating:
1. a local skin infection requiring antibiotics
2. this client has sensiti
4. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
This type of pressure ulcer has an observable pressure related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature, tissue consistency,
1. stage I
When obtaining a wound culture to determine the presence of a wound infection, the specimen should be taken from the
1. necrotic tissue
2. drainage on the dressing
3. wound drainage
4. wound after it has first been cleansed with norma
4. wound after it has first been cleansed with normal saline
Postoperatively the client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. the
3. Cover the areas with sterile saline-soaked towels and immediatly notify the surgical team; this is likely to indicate a wound evisceration
Serous drainage from a wound is defined as:
1. fresh bleeding
2. clear watery plasma
3. thick and yellow
4. beige to brown and foul smelling
2. clear watery plasma
for a client who has a muscle sprain, localized hemorrhage or hematoma, this helps prevent edema formation, control bleeding and anesthetize the body part.
1. binder
2. ice bag
3. ace bandage
4. absorptive diaper
2. ice bag
Interventions to manage a client who is experiencing fecal and urinary incontinence include:
1. Use of a large absorbent diaper, changing when saturated
2. keeping the buttocks exposed to air at all times
3. utilization of an incontinence
3. utilization of an incontinence cleanser, followed by application of a moisture barrier ointment
The best description of a hydrocolloid dressing is
1. a seaweed derivative that is highly absorptive
2. premoistened gauze placed over the granulating wound
3 a debriding enzyme that is used to remove necrotic tissue
4. a dressing tha
4. a dressing that forms a gel that interacts with the wound surface
A binder placed around a surgical client with a new abdominal wound is indicated for:
1. collection of wound drainage
2. reduction of abdominal swelling
3. reduction of stress on the abdominal incision
4. stimulation of peristalsis (r
3. reduction of stress on the abdominal tissue
Application of a warm compress is indicated
1. to relieve edema
2. For a client who is shivering
3. to promote healing by simulating blood flow
4. to protect bony prominences from pressure ulcers
1. to relieve edema

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