3.Which of the following generally occur dur-
ing normal wound healing? (Select all that
apply.)
a.The edges of a healing surgical wound ap-
pear clean and well approximated, with a
crust along the edges.
b.It takes approximately 2 weeks for the
edges of the wound to appear normal and
heal together.
c.Increased swelling and drainage may occur
during the first 5 days of the wound.
d.The wound should not feel hot upon
palpation.
e.The inflammatory response results in the
formation of exudate in the wound.
f.Incisional pain during wound healing is
usually most severe for the first 3 to 5 days
and then progressively diminishes.
4.Which of the following statements describe
the proper use of the various types of
dressings? (Select all that apply.)
a.A Surgipad is often used to cover an
incision line directly.
b.Transparent dressings are applied over
ABDs to help keep the wound dry.
c.Op-Site is often used over intravenous
sites, subclavian catheter insertion sites,
and noninfected healing wounds.
d.Using appropriate aseptic techniques when
changing dressings is crucial.
e.Gauze dressings are commonly used to
cover wounds.
f.Telfa is applied to the wound to keep
drainage from passing through and being
absorbed by the outer layer.
5.Which of the following interventions might
a nurse be expected to perform when provid-
ing competent care for a patient with a drain-
ing wound? (Select all that apply.)
a.Administer a prescribed analgesic 30 to
45 minutes before changing the dressing,
if necessary.
b.Change the dressing midway between
meals.
c.Apply a protective ointment or paste, if ap-
propriate, to cleaned skin surrounding the
draining wound.
d.Apply another layer of protective ointment
or paste on top of the previous layer when
changing dressings.e.Apply an absorbent dressing material as
the first layer of the dressing.
f.Apply a nonabsorbent material over the
first layer of absorbent material.
6.Which of the following are characteristics of
Y (yellow) wounds? (Select all that apply.)
a.They reflect the color of normal granula-
tion tissue.
b.They are characterized by oozing from the
tissue covering the wound.
c.They should be cleansed by irrigating the
wound and using wet-to-moist dressings
and absorptive dressings.
d.The nurse should consult with the physi-
cian about using a topical antimicrobial
medication to decrease the growth of
bacteria.
e.They are covered with thick eschar.
f.They are usually treated by using sharp,
mechanical, or chemical débridement.
7.Which of the following statements accurately
describe a factor in the development of a
pressure ulcer? (Select all that apply.)
a.Pressure ulcers usually occur over bony
prominences where body weight is distrib-
uted over a small area without much sub-
cutaneous tissue.
b.Most pressure ulcers occur over the
trochanter and calcaneus.
c.Generally, a pressure ulcer will not appear
within the first 2 days in a person who has
not moved for an extended period of time.
d.The major predisposing factor for a pressure
ulcer is internal pressure applied over an
area, which results in occluded blood capil-
laries and poor circulation to the tissues.
e.The skin can tolerate considerable pressure
without cell death, but for short periods
only.
f.The duration of pressure, compared to the
amount of pressure, plays a larger role in
pressure ulcer formation.
8.Which of the following statements accurately
describe the formation of pressure ulcers?
(Select all that apply.)
a.Reactive hyperemia is considered a stage I
pressure ulcer.
b.A stage II pressure ulcer is superficial and
may present as a blister or abrasion.196 UNIT VII PROMOTING HEALTHY PHYSIOLOGIC RESPONSES
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