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Skin integrity and wound healing > Fundamentals
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Showing 15 questions, Sign in for moreWhich statement, if made by the client or family member, would indicate the need for further teaching?
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient’s nursing care plan?
A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? (Arrange from first to last.)
Explanation
Wound dehiscence and evisceration is a postoperative emergency in which internal organs protrude through a surgical incision. The priority nursing actions include reducing intra-abdominal pressure (low Fowler’s position), protecting exposed organs with sterile saline-moistened dressings, and immediately notifying the surgeon. Prompt recognition and correct sequence of interventions prevent tissue necrosis, infection, and further complications while preparing the patient for surgical repair.
Rationale for correct answer:
3. Place the patient in the low Fowler’s position: The immediate action is to reduce strain on the abdominal wound. Placing the patient in a low Fowler’s or semi-recumbent position with the knees slightly flexed decreases tension on the incision and prevents further evisceration of abdominal contents. This position also enhances comfort and reduces intra-abdominal pressure.
2. Cover the exposed tissue with sterile towels moistened with sterile NSS: Once the client is positioned safely, the nurse should protect the protruding organs. Sterile normal saline–moistened dressings or towels keep the viscera from drying out and reduce the risk of infection. Using sterile technique is essential to prevent contamination of the abdominal contents.
1. Notify the physician immediately of the situation: After protecting the wound and ensuring the patient’s safety, the nurse must promptly contact the surgeon for emergency surgical intervention. Dehiscence with evisceration is a surgical emergency, and rapid communication ensures the client is prepared for operative repair.
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?
The nurse is performing a sterile irrigation of an open abdominal wound. Which intervention should be done first?
The nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?
An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of what factor?
The nurse assesses a stage III pressure ulcer manifested as:
In which sequence should the nurse implement the interventions to clean a surgical wound with dehisced edges?
Explanation
Proper wound cleaning requires starting from the cleanest area (the center) and moving outward to avoid introducing contaminants. Preparing sterile equipment, using the prescribed solution, and maintaining patient understanding are critical steps. For dehisced wounds, meticulous technique prevents infection and promotes healing by maintaining a clean wound environment and protecting surrounding skin.
Rationale for correct answer:
4. Explain the procedure to the patient: The nurse should always begin by explaining the procedure to ensure informed cooperation, reduce anxiety, and promote patient comfort and understanding.
2. Moisten sterile gauze or swab with prescribed cleansing agent: Preparing sterile supplies ensures that cleaning is performed under aseptic conditions and with the appropriate solution (e.g., normal saline or antiseptic as ordered).
1. Clean the wound in full or half circles, beginning in the center and working toward the outside: This cleaning method moves from least contaminated to most contaminated areas, reducing the risk of introducing microorganisms into the wound bed.
3. Clean to at least 1 inch beyond the end of the new dressing: This ensures that the surrounding skin is clean and that the new dressing adheres to uncontaminated tissue, helping prevent infection.
Take home points:
- Always explain before you clean - patient cooperation and aseptic preparation are essential first steps.
- Clean from center to periphery to prevent contamination and always extend cleaning beyond dressing borders for full protection.
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? Select all that apply
Place the steps when performing wound irrigation of a large open wound in the correct sequence.
Explanation
Safe, effective irrigation requires preparation (equipment and waste disposal), aseptic technique, correct fluid and device assembly, proper positioning, and controlled irrigation pressure and direction. Following the correct sequence reduces contamination, prevents injury to granulating tissue, and promotes wound healing.
Rationale for correct answer:
4. Place biohazard bag near bed: First step (preparation). Set up a safe work area and disposal for contaminated fluid and materials before starting the procedure.
3. Fill syringe with irrigation fluid: Preparation step that must occur before attaching the catheter and irrigating. Use prescribed solution (usually normal saline) and the correct volume.
2. Attach 19-gauge angiocatheter to syringe: Must be done after the syringe is filled and before positioning. The angiocatheter (or irrigation tip) converts the syringe into an effective irrigator for appropriate pressure and flow.
5. Position angiocatheter over wound: Do this immediately prior to irrigation. Proper positioning (slight distance above wound, directing flow from least to most contaminated areas or as ordered) ensures effective cleansing and minimizes tissue trauma.
1. Use slow, continuous pressure to irrigate wound: After preparation and positioning, irrigation is done using a steady, controlled pressure (often a 35-mL syringe with appropriate catheter or a pressurized system) to remove debris without damaging healthy tissue.
Take home points
- Prepare before you flush: set up disposal, fill syringes with the correct solution, and assemble the irrigation device before positioning and irrigating.
- Irrigate with controlled, continuous pressure and correct direction to remove debris while protecting healthy tissue (avoid high-pressure streams that damage tissue).
What is the removal of devitalized tissue from a wound called?
Which of the following nursing activities apply to a Medical Device–Related Pressure Injuries (MDRPI)? Select all that apply
The main functions of the skin include:
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