A wound care nurse is assissing a pt. who presents to the ED w/a clean, full thickness wound. Which of the following solutions would be best for cleansing the wound?
Normal Saline
Povidone-iodine
Hydrogen peroxide
Sodium hypochlorite solution
Normal Saline
*
In the US, which of the following drugs is most commonly prescribed for venous disease and is an effective adjunct to compression therapy ? It reduces the aggregation of platelets & white blood cells, which diminshes capillary plugging, enhances microcirculatroy blood flow & decreases tissue ischemia.
Pentoxifylline
Aspirin
Horse chesnut seed extract (HCSE)
Micronized purified flavonoid fraction (MPFF)
Pentoxifylline
*Pentoxifylline is the drug most commonly prescribed for venous disease & is effective adjunct to compression therapy.
Pentoxifylline for treatment of Venous disease along w/compression therapy by-
reducing the aggregation of platelets & white blood cells, which diminshes capillary plugging, enhances microcirculatroy blood flow & decreases tissue ischemia.
Which legal principle must a wound care specialist consider when managing palliative care decisions for a patient?
Autonomy
Therapseutic privilege
Informed consent
Non-maleficence
Autonomy
* This priciniple is fundamental in palliative care, emphasizing the patient's right to make decisions about treatment. - This includes choices & requires that the patient's wishes be respected, especially when quality of life is the primary focus.
Hydrogel dressings should be used for wounds with which of the following levels of exudate?
Highly exudative wounds only
Dry to minimally exudative wounds
Moderate to highly exudative wounds
Minimally to moderate exudative wounds
Dry to minimally exudative wounds
* These dressings consist of hydrophilic polymers, typically glycerin- or water- based, designed to hydrate wounds & provide moisture.
The primary function of Hydrogel dressings to to
to support moist wound healing & facilitate autolytic debridement.
Autolytic debridement -
A natural wound-cleaning process that uses the body’s own enzymes & moisture to soften, liquefy, & remove dead (necrotic) tissue. It is considered the most conservative and selective method of debridement, meaning it breaks down only damaged or dead tissue while leaving healthy skin untouched
A compression stocking that provides 25-35 mm Hg of compression is considered to be in what compression class?
Class 1
Class 3
Class 2
Class 4
Class 3
* Class 3 compression stocking / hose provide a greaded compression from the ankle to below the knee to mobilize edema fluid.
The four classess of compression stockings based on the amount of compression they deliver:
Class: 1
14-19mm Hg
The four classess of compression stockings based on the amount of compression they deliver:
Class: 3
25-35 mm Hg
The four classess of compression stockings based on the amount of compression they deliver:
Class: 2
19-24 mm Hg
* remember the firs two phase are 5 mm Hg's apart. The last two phases are 10 mm Hgs apart!
The four classess of compression stockings based on the amount of compression they deliver:
Class: 4
40-50 mm Hg
The last two phases are 10 mm Hgs apart, w/phase 4 starting at 40 mm Hg
What class range of compression stockings does literature generally support that the range of compression is therapeutic, comfortable, and easy to use?
30-40mm Hg
A 38 YO female pt. w/a recent appendectomy surgical wound shows signs of increasing exudate & miled erythema at the incision site. Which evidence-based intervention is recommended to manage exudate & prevent infection?
Saline irrigation & application of an alginate dressing
Application of a topical steroid cream
Initiate systemic antibiotic therapy for ten to 14 days
Wet-to-dry dressing changes
Saline irrigation & application of an alginate dressing
* Saline irrigation gently cleanses the wound without damaging tissue. Alginate dressings are ideal for managing moderate-to-heavy exudate because they absorb excess fluid while maintaining a moist wound environment, which is crucial for optimal healing.
These dressings inhibit bacterial growth & reduces the risk of infection, and are recommend for moderate-to-heavy exudate wounds.
Alginate dressings
When should facial surtures generally be removed?
3 to 5 days
1 to 3 days
14 to 21 days
7 to 10 days
3 to 5 days
Sutures should be removed within __ to __ weeks of placement, depending on the anatomic location.
1 - 2
When should back, forearm, and foot sutures be removed?
10-14 days
Which locations on the body should sutures be removed with in 7 to 10 days?
Scalp, chest, fingers, hand, and lower extremity.
A pt.s laboratory values reveal increased serum osmolarity & serum creatinine, as well as elevated hematocrit levels. What condition does the most likely indicate?
Infection
Dehydration
Fluid overload
Malnutrition
Dehydration
Signs & Symptoms of dehydration (6):
- Weight loss
- Dry skin & cracked lips
- Poor skin turgor * thirst
- Fever or hypothermia
- Altered sensation, dizziness, and confusion
- Loss of appetite & nausea
In a patient that is dehydrated laboratory finding often show (4):
- Increased serum creatinine & hematocrit
- Elevated BUN, potassium, chloride, and osmolarity (sodium may be high, normal, or low depending on the cause)
- Decreased blood pressure and increased pulse rate (tachycardia)
- Concentrated urine & constipation
The below are all signs of.....
- Increased serum creatinine & hematocrit
- Elevated BUN, potassium, chloride, and osmolarity (sodium may be high, normal, or low depending on the cause)
- Decreased blood pressure and increased pulse rate (tachycardia)
- Concentrated urine & constipation
Laboratory results of a dehydrated person.
Regarding venous insufficiency, what is the gold standard in detecting blood flow & possible reflux in the outpatient setting?
Ambulatory venous pressure monitoring
Photoplethysmography (PPG)
Air plethysmography (APG)
Venous duplex scanning
Venous duplex scanning
* Also known as Color duplex ultrasound scanning, combines gray-scale ultrasound (revealing anatomic) details with pulsed Doppler (showing blood flow direction).
Venous duplex scan
Also known as the Color duplex US scanning. combines gray-scale ultrasound (revealing anatomic) details with pulsed Doppler (showing blood flow direction).
A wound on a patient's right hip shows red granulation tissue. The wound edges are firm and soft, and it is contracting into a rectangular shape. Which phase of healing is this wound in?
Proliferation
Maturation
Hemostasis
Inflammation
Proliferation
* The 3rd phase of acute full thickness wound healing is the PROLIFERATIVE PHASE.
- Restoration of skin color & contour symmetry as peri-wound edema resolves
- Formation of re granulation tissue at the wound perimeter
- Active wound contraction & epithelialization leading to scar formation.
Signs of healthy proliferation
Which phase in wound healing occurs immediately when plactelets seal vessels & initiate clotting, and inflammation.
Phase 1
Which phase in wound healing is marked by erythema & edema as phagoctyes remove debris.
Phase 2
The final ____________ or (remodeling) phase strengthens the scar & can continue for up to TWO years.
Maturation
In the context of evidence ranking, how do Randomized Controlled Trials (RCTs) compare to observational studies?
Both are considered equally reliable forms of evidence
Observations studies rank higher due to their real-world context
RCTs rank lower due to their limited real-world applicability
RCTs rank higher due to their control over confounding variables
RCTs rank higher due to their control over confounding variables
________ _______ an outside factor that influences both the independent variable and the dependent variable in a study. It distorts the true relationship between them, making it falsely appear that the independent variable caused a change in the dependent variable
confounding variables
Internal fistulas connect two internal organs for example-
Small bowel to bladder, OR from the bladder to vagina
EXTERNAL fistulas involve the skin for example -
from the small bowel to the skin
Skin and GI tract are the most commonly seen ______
fistulas
According to the American Burn Association's burn injury categories, which criterion defines a moderate burn?
A 10% TBSA burn injury for children & the elderly
A 15% to 25% TBSA burn injury for adults
A 30% TBSA burn injury for all patients
Any burn on any patient involving the face, eyes, ears, hands, or perineum
A 15% to 25% TBSA burn injury for adults
Impaired skin integrity is an appropriate nursing diagnosis for which stage of pressure ulcer?
Stage III
Unstageable pressure injury
Stage IV
Stage II
Stage II
* "Impaired Skun Integrity" applies to pressure ulcers that involve ONLY superficial damage to intact skin OR partial-thickness loss.
Which legal principle is essential to consider when making culturally sensitive wound care decisions?
Beneficence
Autonomy
Non-maleficence
Justice
Justice
* The principle of justice ensure that all patients receive equitable treatment regardless of cultural background.
The Principle - Justice
In wound care, this principle requires that no group is favored or disadvantaged and that care delivery respects cultural beliefs & practices.
Which tissue layer of the skin is the thickets?
Hypodermis
Basement membrane
Epidermis
Dermis
Dermis
* Also know as the true skin is the thickest layer of the skin. It is a richly vascularized & innervated connective tissue layer composed primarily of fibroblasts embedded in an extracellular matrix of collagen & elastin fibers.
What common foot lesion is caused by an infection with human papillomavirus?
Plantar warts
Tinea pedis
Callus
Hard and/or soft corn
Plantar warts
* Plantar warts (verruca plantaris) are caused by a contagious viral infection w/human papillomavirus (HPV).
Plantar warts may appear
singly or in clusters and typically have a yellow, brown, gray, or black color. Thrombosed capillary loops within the lesion give rise to characteristic black or red pinpoint spots.
Which of the following is not a physiologic change to the skin that occurs naturally w/age?
Decreased sweat glands
Increased fatty layers
Decreased collagen & elastin fibers
Increased time for epidermal regeneration
Increased fatty layers
The following are physiologic changes to the skin that occurs naturally with age?
- Decreased sweat glands
- Decreased collagen & elastin fibers
- Increased time for epidermal regeneration
When educating a patient w/a neuropathic foot on the apppropriate socks to wear, a provider should make the following statements:
- Choose a cotton / acrylic blend to assist in wicking moisture away from the foot
- The sock should be fully cushioned with a nonrestrictive top
- For active patient, socks can be obtained w/silicone over high-stress areas to prevent shear
* The socks should not have mended areas and seams over bony prominces *
- _____ ______ was developed to monitor and track the effectiveness of physical therapy technologies used for pressure ulcer healing
- The SWHT is a qualitative tool
- The documentation is simple, and the outcomes are visual
The Sussman Wound Healing Tool (SWHT)
A wound care nurse is assessing a pt. who pesent to the ED w/a clean, full thickness wound. Which of the following solutions would be best for cleansing this wound?
Sodium hypochlorite solution
Hydrogen peroxide
Normal saline
Povidone-iodine
Normal saline
What is a postive Buerger's sign?
When the lower extremity is dependent, the ishemic lime exhibits a red or ruddy color (dependent rubor)
Upon elevating the lower extremity for 60 seconds, skin pallor is noted in patients with ischemic skin
Exercise induces cramping or tiredness of the calf, thigh, buttock (claudication)
A thickkened fold of skin at the base of the second toe, or second finger can be gently pinched and lifted (Stemmer's sign)
Upon elevating the lower extremity for 60 seconds, skin pallor is noted in patients with ischemic skin
_______, or dependent rubor, is positive when the ischemic limb becomes red or ruddy in the dependent position, reflecting reactive hyperemia.
Glodflam's sign
A positive _____ sign is the development of pallor when the lower extremity is elevated for 60 seconds, indicating poor arterial circulation & peripheral arterial disease (PAD).
Beurger's
Which of the following topical agents is most appropriate for superficial second-degree burns?
Mupirocin
Aloe vera
Bacitracin
Silver sulfadiazine cream
Silver sulfadiazine cream
What is the most commonly used compression product during the initial phase of treatment for lymphedema?
Compression wraps
A pressure ulcer is assessed on a patient's coccyx as full-thickness tissue loos w/visible subcutaenous fat. The woud has not reached bone, tendon, muscle, or cartilage, and there is undermining in the wound. What stage ulcer is this, based on the NPUAP classification system?
Stage II
Stage IV
Unstageable/unclassified
Stage III
Stage III
Narional Pressure Ulcer Advisory Panel
Stage I:
Intact skin w/onon blanchable erythema that is not blue or purple, usually over bony prominence.
Narional Pressure Ulcer Advisory Panel
Stage II:
Partial-thickness skin loss involving the epidermis and /or dermis. Presents as a shallow open ulcer with a red-pink wound bed, without shoulgh. * May also appear as an intact or ruptured serum-filled blister.
Narional Pressure Ulcer Advisory Panel
Stage IV:
Full-thickness skin & tissue loss w/exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. * Slough or eschar may be present in parts of the wound bed.
Narional Pressure Ulcer Advisory Panel
Stage: Unstageable:
Full thickness skin/tissue loss in which the true depth cannot be determined because it is obscured by slogh or eschar.