Nursing Chapter 36 Clean-contaminated wounds are surgical wounds

Kozier & Erb’s Fundamentals of Nursing, 10/E

Chapter 36

Question 1

Type: MCSA

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which

operative wound would be excluded from this study?

1. Gastric resection

2. Uncomplicated abdominal hysterectomy

3. Breast biopsy

4. Lung resection

Question 2

Type: MCSA

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the

abdominal cavity during the client’s bowel resection. For which category of wound should the receiving nurse

plan care for this client?

1. Clean-contaminated

2. Contaminated

3. Dirty

4. Infected

Question 3

Type: MCSA

A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for

this client’s care?

1. Obtain ice packs to apply to the wounds.

2. Request gauze to pack the wounds.

3. Organize suture material to close the wounds.

4. Notify the surgical staff that a surgical client will soon be arriving.

Question 4

Type: MCSA

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened

area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the

nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?

1. Reactive hyperemia

2. Stage I pressure ulcer

3. Stage II pressure ulcer

4. Stage III pressure ulcer

Question 5

Type: MCSA

The nurse assesses an open area over a client’s greater trochanter that is approximately 10 cm in diameter. The

tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which

additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

1. There is undermining of adjacent tissues.

2. The crater extends into the subcutaneous tissue.

3. The joint capsule of the hip is visible.

4. The ulcer has thick dark eschar over the top.

Question 6

Type: MCSA

The UAP reports a small skin tear on the client’s forearm that occurred during a routine turn. After assessing the

wound the nurse should take which action?

1. Obtain a transparent dressing for the UAP to place on the wound.

2. Request a consult with the wound care nurse.

3. Cleanse the wound and apply a dressing.

4. Tell the UAP to reevaluate the wound in 20 minutes.

Question 7

Type: MCSA

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all

new admissions. Before using this scale the nurse

1. should receive specific training.

2. must be certified.

3. is required to ask the client’s permission.

4. has to obtain special assessment equipment.

Question 8

Type: MCSA

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the

nurse determine as the significance of the trending of these scores?

1. Trending can only be accurate if the same scale is used.

2. There is a definite trend of low risk for pressure ulcer development.

3. Trending would be more accurate if the same scale was used.

4. The scores indicate opposite risks for pressure ulcer development.

Question 9

Type: MCSA

A client’s laceration has been closed with tissue adhesive. What instruction should the nurse provide the client

about wound healing?

1. Primary intention

2. Open approximation

3. Secondary healing

4. Delayed closure

Question 10

Type: MCSA

A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include

information about infection control because steroids cause

1. decreased oxygen supply to tissues.

2. suppression of the inflammatory process necessary for healing.

3. a decrease in the amount of nutrients such as glucose in the blood.

4. blood vessel constriction, which impairs waste product removal.

Question 11

Type: MCSA

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that “something

popped” in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing

action should be taken first?

1. Notify the client’s surgeon.

2. Cover the area with a large saline-soaked dressing.

3. Position the client in bed with knees bent.

4. Pack the wound with nonadherent gauze.

Question 12

Type: MCSA

A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client’s legs?

1. Defer the assessment because the stockings are in place.

2. Remove the stockings for this assessment.

3. Review the morning assessment, but don’t repeat it unless a problem occurs.

4. Assess the skin when the client removes the stockings at bedtime.

Question 13

Type: MCSA

Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes

that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is

otherwise stable. What action should the nurse take?

1. Place a tourniquet above the wound.

2. Remove the dressing and place direct pressure on the wound.

3. Add an additional dressing to the wound without removing the original.

4. Remove the dressing and replace it with a new sterile dressing.

Question 14

Type: MCSA

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the

specimen be collected?

1. Clean areas of granulation tissue

2. Exudate in the bottom of the wound

3. A pus-coated area on the side of the wound

4. Intact skin at the edge of the wound

Question 15

Type: MCSA

The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem

statement is most appropriate for use with this client?

1. Altered Tissue Perfusion

2. Impaired Skin Integrity

3. Impaired Tissue Integrity

4. Risk for Injury

Question 16

Type: MCSA

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention.

What principles should the nurse use in choosing this dressing?

1. Materials used in dressing this wound should keep the wound bed moist.

2. The dressing should allow good air circulation through the wound.

3. Dressings should be simple as they will be changed at least every 4 hours.

4. Absorbent material to wick exudates away and support drying should be used.

Question 17

Type: MCSA

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has

developed in the perianal area. What care should the nurse provide?

1. Wash the area with soap and hot water at every brief change.

2. Apply a petroleum-based cream to the area after cleaning.

3. Wipe the skin with an alcohol-free barrier film agent after cleaning.

4. Keep the client in bed on absorbent pads until the area clears.

Question 18

Type: MCSA

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to

help reduce the effects of shearing forces on the client’s skin?

1. Keep the head of the client’s bed at 30 degrees.

2. Coat the client’s back and buttocks with baby powder after bathing.

3. Use a turn sheet lifted by two staff members to move the client in bed.

4. Dust the linens with cornstarch each morning to allow for easier movement.

Question 19

Type: MCSA