Test Bank For High Acuity Nursing 7th Edition Wagner

Test Bank for High-Acuity Nursing 7th Edition Wagner
Test Bank for High-Acuity Nursing 7th Edition

Wagner
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High Acuity Nursing, 7e (Wagner)
Chapter 10 Complex Wound Management
1) Assessment of the patient's sternal surgical incision reveals that the skin between sutures is
opened. There is a small amount of drainage present on the dressing. The nurse would anticipate
caring for this wound as it heals in which manner?
1. Tertiary intention
2. Primary intention
3. Secondary intention
4. Recurrent surgical debridement
Answer: 3
Explanation: 1. Tertiary intention combines primary and secondary intention, often requiring the
wound to be left open for a period of time, such as a few days.
2. Primary intention healing occurs when the wound is closed and heals without interruption.
3. This wound has dehisced, which means that it has not healed as expected and the suture line is
opened. This may occur because of stretching of the skin, poor skin integrity, or because the
wound is infected. Dehisced sternal wounds can heal by second intention.
4. Future surgical debridement may be necessary if the wound does not heal, but this is not an
expected part of the plan of care.
Page Ref: 258
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity : Physiological Adaptation
Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and
standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement
holistic, patient-centered care that reflects an understanding of human growth and development,
pathophysiology, pharmacology, medical management, and nursing management across the
health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies:
Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and
safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning
LO & MNL LO: LO02: Explain wound physiology, including the physiologic events that occur
in each phase of wound repair and the methods of wound closure.
1
Copyright © 2019 Pearson Education, Inc.
2) A patient is to receive lavage treatments for a chronic ulcer on the left heel. Which
explanation would the nurse provide for this treatment?
1. "This treatment is a form of autolytic debridement to remove dead tissue from your heel."
2. "Your foot will be submersed in a whirlpool tub for this treatment."
3. "This treatment will help cleanse the wound bed."
4. "This treatment will inject medications into the deep crevices of your wound."
Answer: 3
Explanation: 1. Lavage is not a form of autolytic debridement.
2. A whirlpool tub would not be used to lavage this wound. Whirlpool treatments increase risk of
cross-contamination of the wound.
3. Lavage is used to clean materials out of the wound bed.
4. Lavage is not used to inject medications into the wound.
Page Ref: 265
Cognitive Level: Applying
Client Need/Sub: Safe Effective Care Environment : Management of Care
safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
LO & MNL LO: LO05: Discuss treatment modalities used in wound management and their
rationale.
2
3) The surgical wound of a patient recovering from an appendectomy has several steri-strips
across it with a small amount of dried blood over the incision line. How would the nurse dress
this wound?
1. Hydrocolloid dressing
2. Wet-to-dry dressing
3. Alginate dressing
4. Dry, sterile dressing
Answer: 4
Explanation: 1. Hydrocolloid dressings are used on mild to moderate exudating wounds. This
wound is dry.
2. Wet-to-dry dressings are used for wounds that require mechanical debridement.
3. Alginate dressings are used to absorb secretions and form a covering for the wound bed. This
wound bed is dry.
4. The patient's wound is healing by primary intention. Dry, sterile dressings are the standard for
wounds healing by this method, offering protection from contamination and the absorption of the
minimal amount of exudate expected.
Page Ref: 267
rationale.
3
4) A patient presents to the emergency department with a large leg wound. The nurse identifies
which factors as increasing this patient's risk of complications with wound healing?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. The patient smokes eight cigarettes a day.
2. The patient has cardiac disease.
3. The patient has osteoarthritis in his knees.
4. The patient's average blood sugar measurements are over 200 mcg/dL.
5. The patient lost some blood during the injury but the loss was not excessive.
Answer: 1, 2, 4
Explanation: 1. Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide
reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet
adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also
associated with significantly higher infection rates.
2. Cardiac disease decreases oxygenation of the tissues, increasing risk of complications.
3. The presence of osteoarthritis is related to overuse of the joint and is not a significant risk
factor for problems healing.
4. Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is
a factor in healing problems.
5. Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues,
leading to difficulties with healing.
Page Ref: 259
standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct
comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessment of health and illness parameters in patients, using developmentally
and culturally appropriate approaches. | NLN Competencies: Knowledge and Science:
Knowledge: Relationships between knowledge/science and quality and safe patient care. |
Nursing/Integrated Concepts: Nursing Process: Assessment
LO & MNL LO: LO03: Discuss physiologic and environmental factors that affect wound
healing.
4
5) There is dead tissue throughout the patient's nonhealing abdominal wound. The nurse prepares
for which intervention needed to encourage this wound to heal?
1. Diet analysis for protein adequacy
2. Keeping the wound covered to increase oxygen to the wound bed
3. Debridement of devitalized tissue
4. Introduction of air into the wound for drying
Answer: 3
Explanation: 1. The patient does need adequate protein for healing to occur, but this is not the
most problematic issue at present.
2. Keeping the wound covered does help to maintain oxygen levels in the wound bed, but this is
not the most problematic issue present.
3. The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is
tissue that has been separated from the circulation and the body's antimicrobial defenses.
Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is
essential to prevent an environment conducive to bacterial growth.
4. The wound bed should be kept moist.
Page Ref: 265
rationale.
5
6) The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness
and has more swelling around the wound edges. Which nursing intervention is indicated?
1. Encourage the patient to ingest more fluids.
2. Assess for pain and warmth.
3. Cover the wound with a sterile dry dressing.
4. Dress the wound as prescribed.
Answer: 2
Explanation: 1. Encouraging fluids will not reduce the inflammation that is occurring in the
wound.
2. The cardinal signs of an inflammation exist in a wound that is infected and include redness,
edema, pain, and warmth. Since the patient's wound is demonstrating redness and edema, the
nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and
infected.
3. Covering the wound with a sterile dry dressing will not address the potential for infection that
exists.
4. Simply dressing the wound according to previous order will not address the change that has
occurred.
Page Ref: 263
LO & MNL LO: LO04: Identify the common clinical assessments used to evaluate wound
healing.
6
7) The nurse manager has noted an increase in wound infections in a postoperative unit. What
instruction to the unit staff is the most important?
1. Wear gloves at all times.
2. Administer antibiotics as prescribed.
3. Assess patients for infection risk upon admission.
4. Follow hand hygiene protocols.
Answer: 4
Explanation: 1. Wearing gloves at all times could increase infection rate by creating a false
sense of security among staff.
2. Antibiotics should be given as prescribed, but this is not the most important intervention.
3. Knowing which patients are at highest risk for infection is helpful, but is not the most critical
intervention.
4. Correct hand hygiene is still considered one of the most important methods of preventing
wound infections.
Page Ref: 271
LO & MNL LO: LO06: Explain wound infections, including conditions that predispose a patient
to developing an infection, diagnostic criteria, and treatment interventions.
7
8) A patient has a wound on his thigh that is swollen and red. The nurse assesses that the
surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment
findings would cause the nurse to alert the healthcare provider about possible necrotizing
fasciitis (NF)?
1. Blood pressure is 140/90 mm Hg.
2. The patient reports recently taking steroids for a severe ear infection.
3. The patient works in an elementary school.
4. The patient reports pain as a 9 on the 1 to 10 pain scale.
5. The patient's body mass index is 31.
Answer: 2, 4, 5
Explanation: 1. If the patient is in pain this blood pressure would not be unexpected.
2. Steroid use increases the risk for necrotizing fasciitis.
3. Exposure to young children is not a risk factor for developing necrotizing fasciitis.
4. Pain that is out of proportion to the physical clinical presentation is an important warning sign
of NF.
5. A body mass index (BMI) over 30 indicates obesity. Obesity is a risk factor for development
of NF.
Page Ref: 271
LO & MNL LO: LO07: Describe necrotizing soft-tissue infections, including pathophysiology,
signs and symptoms, risk factors, and treatment strategies for necrotizing fasciitis and Fournier
gangrene.
8
9) A male patient tells the nurse that he has "excruciating pain" in his perineal region that started
a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees
a dime-sized reddened area on the patient's perineum below the scrotal sac. What nursing
intervention is priority?
1. Have the wound further evaluated for possible Fournier's gangrene.
2. Apply ice to the region.
3. Give the patient prn acetaminophen.
4. Place a scrotal support on the patient.
Answer: 1
Explanation: 1. The one clinical symptom of Fournier's gangrene is pain out of proportion to the
wound. The other clinical symptom is that this type of disorder affects males more than females.
These two pieces of information should lead the nurse to contact the patient's physician for
further evaluation of the wound for possible Fournier's gangrene. The patient did have an
indwelling urinary catheter removed a few days ago, and this type of disorder is associated with
genitourinary procedures or manipulation.
2. Applying ice to the region is not indicated.
3. The nurse would treat the patient's pain, but a different intervention is the priority.
4. There is no indication that use of a scrotal support would relieve this patient's pain or change
the underlying reason for the pain.
Page Ref: 275
gangrene.
9
10) A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a
large abdominal wound. The nurse anticipates providing which care for this patient's wound?
1. Irrigating the wound twice daily before applying dry dressing
2. Caring for a split thickness skin graft
3. Applying wet-to-dry dressings
4. Caring for a suture line created by surgical closure of the wound
Answer: 2
Explanation: 1. Granulation tissue should be kept moist.
2. Once systemic manifestations of the infectious process associated with necrotizing fasciitis
disappear, healthy granulation tissue appears. The next phase is to restore dermal and fascial
integrity, and the best way to achieve wound closure rapidly and safely is with split thickness
skin grafts. Skin is taken from a donor site and placed on healthy granulation tissue to cover the
defect.
3. The wounds associated with necrotizing fasciitis are large and would not easily be treated with
wet-to-dry dressings.
4. This wound will be extensive and is not closed in the normal manner of creating a suture line.
Page Ref: 274
gangrene.
10
11) A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment
finding would the nurse evaluate as indicating this patient is at increased risk for developing an
enterocutaneous fistula (ECF)?
1. Diagnosis of type 2 diabetes mellitus
2. Daily use of nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis symptoms
3. Diagnosis of peripheral vascular disease
4. History of radiation therapy to treat colon cancer
Answer: 4
Explanation: 1. While diabetes mellitus can result in impaired healing, it is not a specific risk for
development of ECF.
2. There is no specific connection between use of NSAIDs and increased risk for ECF.
3. Peripheral vascular disease can result in problems with skin integrity, but is not a specific risk
for development of ECF.
4. Radiation therapy to the abdomen increases the patient's risk for development of ECF.
Page Ref: 277
LO & MNL LO: LO08: Discuss enterocutaneous fistula, including pathophysiology, risk
factors, clinical presentation, and collaborative management.
11
12) The patient's colectomy incision is red and the skin around the sutures is taut and shiny.
What nursing intervention is indicated?
1. Assess for the presence of drainage or odor.
2. Clean this healing wound and redress as ordered.
3. Collaborate with the healthcare provider regarding suture removal.
4. Instruct the patient to use additional splinting for deep breathing and coughing.
Answer: 1
Explanation: 1. Since this patient's surgical wound is closed with sutures, the nurse should
assess for the odor of GI contents or for seepage around the sutures. If this finding is present, an
enterocutaneous fistula may be present.
2. These findings do not indicate a healing wound.
3. These findings are not those normally associated with a wound ready for suture removal.
4. These findings do not indicate stress from coughing, and they will not be changed by
additional splinting.
Page Ref: 277
LO & MNL LO: LO08: Discuss enterocutaneous fistula, including pathophysiology, risk
factors, clinical presentation, and collaborative management.
12
13) A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care
for this wound with the knowledge that it has penetrated to which skin level?
1. Epidermis
2. Hypodermis
3. Dermis
4. Cartilage
Answer: 2
Explanation: 1. The epidermis, the outermost layer, contains epithelial cells.
2. The hypodermis contains blood vessels, nerves, muscle, and adipose tissue.
3. The dermis contains connective tissue and elastic fibers, sensory and motor nerve endings, and
a complex network of capillary and lymphatic vessels and muscles.
4. Cartilage is not a layer of the skin.
Page Ref: 254
Nursing/Integrated Concepts: Nursing Process: Planning
LO & MNL LO: LO01: Describe the anatomic structures and functions of the skin and the
effects of wounds on skin integrity.
13
14) The nurse measures a patient's wound diameter and notes that it has reduced in size. The
nurse evaluates this information to indicate the wound has entered which phase?
1. Remodeling
2. Inflammatory
3. Maturation
4. Proliferative
Answer: 4
Explanation: 1. The remodeling phase is the third phase of the wound healing process, which
occurs after the wound has closed.
2. The inflammatory phase prepares the wound environment for subsequent tissue development.
This sign is recognized by the four cardinal signs of inflammation: heat, redness, swelling, and
pain.
3. The maturation stage is also known as the remodeling stage.
4. Wound contraction occurs during the proliferative phase of wound healing.
Page Ref: 256
14
15) A patient with several burn scars tells the nurse that the scars are prone to injury and don't
seem as tough as the rest of his skin. Which nursing response is indicated?
1. "Even when healed, the scar will only regain about 80% of the strength of normal skin."
2. "Your body is still making new blood vessels for the wound."
3. "Your body is trying to remove additional bacteria from the wound area."
4. "Your healing process hasn't been completed."
Answer: 1
Explanation: 1. Remodeling/maturation is the final repair process and can last months to years.
The final product of remodeling is the scar, which has covered the defect and restored the
protective barrier against the external environment. Even when the wound is completely healed,
only about 80% of the tensile strength of normal skin is regained and the patient is at risk for
recurrent breakdown.
2. Angiogenesis takes place in the proliferative stage of wound healing, not after scars have
developed.
3. Bacteria are normally removed from the wound during the inflammatory phase.
4. The patient's healing process may take months or years, but this is not the best answer to
address the patient's concerns.
Page Ref: 257
Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect
for the diversity of human experience. | AACN Competencies: IX.3 Implement holistic, patient-
centered care that reflects an understanding of human growth and development,
15
16) The nurse is assessing a wound using the technique shown in this picture. How would the
nurse document this assessment?
1. The wound is macerated.

2. The wound is tunneled.
3. The wound is deep.
4. The wound is filled with exudate.
Answer: 2
Explanation: 1. Maceration is a white, pale, or boggy appearance or texture caused by prolonged
contact with moisture.
2. The nurse has inserted a sterile applicator under the rim of the wound and a significant
distance into the surrounding tissue. This is called tunneling.
3. The nurse is not measuring depth of wound in this picture.
4. The nurse is not measuring amount of exudate in this picture.
Page Ref: 262
Cognitive Level: Remembering
safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
healing.
16
17) A nurse documents a stage 1 pressure ulcer on a patient's lateral malleolus. What assessment
findings would indicate that this ulcer has progressed to stage II?
1. The subcutaneous fat layer is exposed.
2. A fluid-filled blister is present.
3. A shallow open ulcer is present.
4. There is an area of boggy purple skin on the bony prominence.
5. There is an area of skin that does not turn white with pressure.
Answer: 2, 3
Explanation: 1. Exposure of the subcutaneous fat layer occurs in stage III ulcers.
2. Presence of a fluid-filled blister indicates a stage II ulcer.
3. Shallow open ulcers are stage II ulcers.
4. Boggy purple skin over a bony prominence is a deep-tissue injury.
5. Nonblanchable erythema indicates a stage I ulcer.
Page Ref: 280
LO & MNL LO: LO09: Review pressure ulcers, including etiology, risk factors, assessment
tools, and collaborative management.
17
18) The wound care specialist has assessed a patient's pressure ulcer and recommends using a
hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions
associated with which stage pressure ulcer?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
Answer: 4
Explanation: 1. Stage I ulcers are treated with turning and removal of pressure.
2. Stage II ulcers need a moist environment but not debridement.
3. Stage III ulcers need a moist environment but not debridement.
4. Stage IV ulcers may require debridement as well as packing to fill dead space and to absorb
exudate.
Page Ref: 267
LO & MNL LO: LO09: Review pressure ulcers, including etiology, risk factors, assessment
tools, and collaborative management.
18
19) During initial assessment, the nurse notes that the edges of a wound are hard to palpation.
The nurse would continue assessment for which conditions?
1. Infection
2. Necrosis
3. Osteomyelitis
4. Deep tissue injury
5. Maceration
Answer: 1, 2, 4
Explanation: 1. Indurated wound edges may indicate infection.
2. Indurated edges may indicate necrosis.
3. Osteomyelitis is considered when bone is visible or palpable.
4. Indurated wound edges may occur when there is deep tissue injury.
5. Maceration is softening of the skin associated with chronic exposure to moisture.
Page Ref: 263
healing.
19
Test Bank for High-Acuity Nursing 7th Edition Wagner
20) The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative
wound infection. Which nursing intervention is indicated?
1. Draw peak and trough concentrations as indicated.
2. Give the medication over a 2-hour period.
3. Hold the medication if the patient experiences nausea.
4. Monitor for increase in creatinine clearance.
Answer: 1
Explanation: 1. Gentamicin has a narrow therapeutic range. Peak and trough concentrations
should be drawn.
2. There is no indication that it is necessary to give this medication over 2 hours.
3. There is no indication that nausea will require interrupting therapy.
4. Decreased creatinine clearance is the adverse effect associated with gentamicin.
Page Ref: 274
Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies
LO & MNL LO: LO06: Explain wound infections, including conditions that predispose a patient
to developing an infection, diagnostic criteria, and treatment interventions.
20
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