_____ a. Blood clots form
_____ b. Approximation of wound edges _____ c. Avascular, pale, mature scar present _____ d. Enzymes from neutrophils digest fibrin _____ e. Epithelial cells migrate across wound surface _____ f. Fibroblasts migrate to site and secrete collagen
_____ g. Budding capillaries result in pink, vascular friable wound _____ h. Healing area contracts by movement of myofibroblasts
_____ i. Macrophages ingest and digest cellular debris and red blood cells
_____ j. Fibrin clot serves as meshwork for capillary growth and epithelial cell migration 9. What is the primary difference between healing by primary intention and healing by secondary
intention?
a. Primary healing requires surgical debridement for healing to occur.
b. Primary healing involves suturing two layers of granulation tissue together.
c. Presence of more granulation tissue in secondary healing results in a larger scar.
d. Healing by secondary intention takes longer because more steps in the healing process are necessary.
10. A patient had abdominal surgery 3 months ago and calls the clinic with complaints of severe abdominal pain and cramping, vomiting, and bloating. What should the nurse most likely suspect as the cause of the patient's problem?
a. Infection b. Adhesion c. Contracture d. Evisceration
11. A patient had a complicated vaginal hysterectomy. The student nurse provided perineal care after the patient had a bowel movement. The student nurse tells the nurse there was a lot of light brown, smelly drainage seeping from the vaginal area. What should the nurse suspect when assessing this patient?
a. Dehiscence b. Hemorrhage c. Keloid formation d. Fistula formation
12. Which nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing?
a. Fats b. Proteins c. Vitamin C d. Vitamin A
13. What role do the B-complex vitamins play in wound healing?
a. Decrease metabolism
b. Protect protein from being used for energy
c. Provide metabolic energy for the inflammatory process d. Coenzymes for fat, protein, and carbohydrate metabolism
14. The patient is admitted from home with a clean stage II pressure ulcer. What does the nurse expect to observe when she does her wound assessment?
a. Adherent gray necrotic tissue b. Clean, moist granulating tissue c. Red-pink wound bed, without slough
d. Creamy ivory to yellow-green exudate
15. What type of dressing will the nurse most likely use for the patient in Question 14?
a. Hydrocolloid b. Transparent film c. Absorptive dressing
d. Negative pressure wound therapy
16. The patient's wound is not healing, so the HCP is going to send the patient home with negative pressure wound therapy. What will the caregiver need to understand about the use of this device?
a. The wound must be cleaned daily.
b. The patient will be placed in a hyperbaric chamber.
c. The occlusive dressing must be sealed tightly to the skin.
d. The diet will not be as important with this sort of treatment.
17. Priority Decision: During care of patients, what is the most important precaution for preventing transmission of infections?
a. Wearing face and eye protection during routine daily care of the patient
b. Wearing nonsterile gloves when in contact with body fluids, excretions, and contaminated items
c. Wearing a gown to protect the skin and clothing during patient care activities likely to soil clothing
d. Hand washing after touching fluids and secretions, removing gloves, and between patient contacts
18. Which patient is at the greatest risk for developing pressure ulcers?
a. A 42-yr-old obese woman with type 2 diabetes b. A 78-yr-old man who is confused and malnourished c. A 30-yr-old man who is comatose following a head injury d. A 65-yr-old woman who has urge and stress incontinence
19. Priority Decision: What is the most important nursing intervention for the prevention and treatment of pressure ulcers?
a. Using pressure-reduction devices b. Repositioning the patient frequently c. Massaging pressure areas with lotion
d. Using lift sheets and trapeze bars to facilitate patient movement
20. The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcer does the nurse expect to see on admission?
a. Stage I b. Stage II c. Stage III d. Stage IV
21. A patient's documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the patient's right hip?
a. Exposed bone, tendon, or muscle b. An abrasion, blister, or shallow crater
c. Deep crater through subcutaneous tissue to fascia d. Persistent redness (or bluish color in darker skin tones)
22. Teamwork and Collaboration: Which nursing interventions for a patient with a stage IV sacral pressure ulcer are most appropriate to assign or delegate to a licensed practical/vocational nurse
(LPN/LVN) (select all that apply)?
a. Assess and document wound appearance.
b. Teach the patient pressure ulcer risk factors.
c. Choose the type of dressing to apply to the ulcer.
d. Measure the size (width, length, depth) of the ulcer.
e. Assist the patient to change positions at frequent intervals.
Case Study
Inflammation
(©Ivan_Kochergin/iStock/Thinkstock)
Patient Profile
G.K., a 28-yr-old female patient who has type 1 diabetes, is admitted to the hospital with cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chills.
Subjective Data
• States that she has severe pain and heaviness in her leg
• States she cannot bear weight on her leg and has been in bed for 3 days
• Lives alone and has not had anyone to help her with meals Objective Data
Physical Examination
• Irregular shape, 2-cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick, yellow drainage
• Left leg red and swollen from ankle to knee
• Calf measurement on left 3 inches larger than on right
• Temp: 102° F (38.9° C) Laboratory Tests
• White blood cell (WBC) count: 18,300/µL (18.3 × 103/L; 80% neutrophils, 12% bands)
• Wound culture: Staphylococcus aureus
• Blood glucose: 204 mg/dL Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. What clinical manifestations of inflammation are present in G.K.?
2. What type of exudate is draining from the open wound?
3. Is G.K. more likely have a venous or arterial ulcer? Why?
4. What is the significance of her WBC count and differential?
5. What factors are present in G.K.'s situation that could delay wound healing?
6. Her HCP orders acetaminophen to be given PRN for a temperature above 102° F (38.9° C). How does the acetaminophen act to interfere with the fever mechanism? Why is the acetaminophen to be given only if the temperature is above 102° F? To prevent cycling of chills and diaphoresis, how should the nurse administer the acetaminophen?
7. What type of wound dressing would promote healing of G.K.'s open wound?
8. Priority Decision: What are the priority precautions to prevent transmission of infection in the care of G.K.?
9. Priority Decision: Based on the assessment data provided, what are the priority nursing diagnoses? Are there any collaborative problems?