Review Practice Exercise 4

Skin integrity and wound healing > Fundamentals

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Practice Exercise 4

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Total Questions : 5

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Question 1:

Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client:

A. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). B. It will be acceptable to leave the pad in place if the temperature is reduced. C. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed. D. It will be acceptable to leave the pad in place as long as it is moist heat.

Answer and Explanation

Choice A:

Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). Prolonged heat application beyond 20–30 minutes causes a rebound phenomenon, where vasoconstriction replaces the initial vasodilation. This can decrease blood flow, increase tissue damage, and lead to burns or ischemia. Therefore, heating devices should not be used for more than 20–30 minutes at a time.

Choice B:

It will be acceptable to leave the pad in place if the temperature is reduced: Lowering the temperature does not prevent the rebound effect or reduce the risk of burns. The duration, not just temperature, is critical in preventing tissue injury.

Choice C:

It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed: Even if the skin looks normal, prolonged exposure can still damage deeper tissues. Heat should be removed after 30 minutes, then reapplied later if prescribed, with rest periods in between.

Choice D:

It will be acceptable to leave the pad in place as long as it is moist heat: Moist heat penetrates more deeply and increases the risk of burns. It should still be limited to 20–30 minutes to avoid tissue injury.

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Question 2:

Which of the following items are used to perform wound irrigation? Select all that apply

A. Clean gloves B. Sterile gloves C. Refrigerated irrigating solution D. 60-mL syringe E. Forceps

Answer and Explanation

Choice A:

Clean gloves: Clean gloves are acceptable for chronic or non-surgical wounds that are already colonized with bacteria, as irrigation is considered a clean (not sterile) procedure in these cases. They protect both nurse and client from contamination.

Choice B:

Sterile gloves: Sterile gloves are used when irrigating acute, surgical, or open wounds where sterility must be maintained. The nurse must follow facility policy and wound classification to determine whether sterile technique is necessary.

Choice C:

Refrigerated irrigating solution: Irrigation solutions should be at room temperature to prevent vasoconstriction, tissue damage, or discomfort. Cold solutions reduce blood flow to the wound, delaying healing.

Choice D:

60-mL syringe: A 60-mL syringe with an irrigation tip (often 19-gauge) is standard equipment. It delivers the right amount of pressure (4–15 psi) to remove debris and bacteria without damaging granulation tissue.

Choice E:

Forceps: They may be used in other wound care tasks (like debridement or dressing changes), but not specifically for irrigation.

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Question 3:

Which of the following indicates proper use of a triangle arm sling?

A. The elbow is kept flexed at 90 ° or more. B. The knot is placed on either side of the vertebrae of the neck. C. The sling extends to just proximal of the hand. D. The sling is removed every 2 hours to check for circulation and skin integrity.

Answer and Explanation

Choice A:

The elbow is kept flexed at 90° or more: The elbow should be flexed slightly less than 80°, not 90° or more. This allows the hand to be elevated above the elbow, preventing dependent swelling and promoting venous return. Overflexion can cause discomfort and impede circulation.

Choice B:

The knot is placed on either side of the vertebrae of the neck: The knot must be positioned off-center, either in front of or behind the neck, to avoid pressure on the spinal processes. Pressure directly on the vertebrae can cause pain, skin irritation, and possible nerve compression.

Choice C:

The sling extends to just proximal of the hand: The sling should extend beyond the wrist, fully supporting the entire hand and wrist. This prevents venous pooling and reduces swelling. A sling ending before the hand fails to provide adequate support.

Choice D:

The sling is removed every 2 hours to check for circulation and skin integrity: While assessment of circulation, motion, and sensation (CMS) is necessary, every 2 hours is unnecessarily frequent and impractical for routine use. Checks are typically done at regular intervals (e.g., during nursing rounds or if swelling or discomfort is reported).

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Question 4:

The nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates the patient understands the explanation?

A. “I can expect to have more discomfort in the area where the cold is applied.” B. “I should expect more drainage from the incision after the ice has been in place.” C. “I should see less swelling and redness with the cold treatment.” D. “My incision may bleed more when the ice is first applied.”

Answer and Explanation

Choice A:

“I can expect to have more discomfort in the area where the cold is applied.” Cold application should reduce discomfort by numbing nerve endings and decreasing pain perception, not increase it.

Choice B:

“I should expect more drainage from the incision after the ice has been in place.” Cold causes vasoconstriction, which reduces blood flow and drainage, not increases it.

Choice C:

“I should see less swelling and redness with the cold treatment.” Cold therapy causes vasoconstriction, which limits inflammation, reduces capillary permeability, and minimizes swelling, redness, and pain.

Choice D:

“My incision may bleed more when the ice is first applied.” Bleeding is reduced, not increased, because vasoconstriction limits blood flow to the area.

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Question 5:

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? Select all that apply

A. Collection of wound drainage B. Provision of support to abdominal tissues when coughing or walking C. Reduction of abdominal swelling D. Reduction of stress on the abdominal incision E. Stimulation of peristalsis (return of bowel function) from direct pressure

Answer and Explanation

Choice A:

Collection of wound drainage: Binders do not collect drainage. Drainage is managed by surgical drains or dressings, not by external compression devices.

Choice B:

Provision of support to abdominal tissues when coughing or walking: The binder provides gentle, even pressure that supports weakened abdominal muscles, decreasing discomfort and the risk of wound dehiscence during movement or coughing.

Choice C:

Reduction of abdominal swelling: While a binder provides mild compression, it is not primarily used to treat edema or swelling; excessive compression could impair circulation.

Choice D:

Reduction of stress on the abdominal incision: The binder stabilizes the incision area, reducing tension on sutures and promoting healing by preventing wound separation.

Choice E:

Stimulation of peristalsis (return of bowel function) from direct pressure: Binders do not stimulate peristalsis. Early ambulation and adequate hydration are the preferred methods for promoting bowel function postoperatively.

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Practice Exercise 4

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