1) Which of the following actions does

1) Which of the following actions does NOT demonstrate Aseptic Non-Touch Technique? non-touch technique of key parts and key sites Using aseptic field and forceps to do wound care. Wound cleaning with a circular motion from outer clean to inner unclean area. Hand washing with 5 moments Proper use of gloves Using single swabs per stroke. 2) Identify the types of medications that can inhibit the wound healing process. NSAIDs, glucocorticoids and vasodilators. Glucocorticoids, nicotine and NSAIDs Haemostatic agents, vasodilators and glucocorticoids. Vasoconstrictors, vasodilators and haemostatic agents. 3) TIME is a framework used to assist in preparing a wound bed for healing. When assessing the M in TIME, what are you assessing? The circulation to the wound bed. The presence or balance of moisture. Haemostasis and wound edge approximation. Increased wound size and exudate. 4) Which of the following are resources that you could utilise for wound management information? Wounds Australia Organisation policies Wound Care specialist/ clinical nurse consultant Community social work network Internet 5) Pain management is essential to good wound care. Background pain is best described as_______________ pain associated with procedures. pain associated with the underlying cause. pain associated with everyday activities. pain associated with psychological stress. 6) The wound of a postoperative patient is being cleaned by the nurse. Which nursing action demonstrates the right wound-care procedure? The nurse swabs the wound from the bottom to the top The nurse uses friction when cleaning the wound to loosen dead cells. The nurse swabs the wound with povidone—iodine to fight infection in the wound. The nurse works outward from the wound in lines parallel to it. 7) For a person with a Braden scale score of 14, the recommended nursing action is to: implement a pressure injury bundle. apply a transparent wound dressing to the coccyx, request a physical therapy order, assess the individual according to agency policy, implement a repositioning schedule 8) Which mechanisms allow epithelial cells to travel over granulation tissue during moist wound healing? Effective thermoregulation and pain relief. Increased warmth and sloughing of cells. Cell sloughing and thermoregulation Reduced pain and reduced fever. 9) The nurse examines the wounds of the patients. Which patients do you think the nurse would put at risk for slow wound healing? (Choose all of the options that apply.) A patient who consumes a high-vitamin A and C-rich diet A person suffering from a peripheral vascular disease An elderly person who is confined to a bed. A 10-year-old girl with a surgical scar A patient on corticosteroid medication A morbidly obese patient 10) Carlos presented to emergency with a three-week-old shoulder wound. It seems to be black in colour, with a lot of thick yellow discharge and bright red edges. Determine how medical terminology might be used to document this. The wound has a serous oozing, a huge black region, and some slight irritation around the edges The wound appears necrotic, with pus and inflammation around the edges. The wound seems moist, with a crimson border and haemoserous oozing. Wound has good epithelialization, purulent pus, and inflammation around the borders. 11) Timothy has a huge wound on his finger that needs suturing after he sliced it with a knife. Choose the type of wound you’re dealing with. abrasion. laceration. puncture. bite. 12) Which of the following does not contribute to formation of a wound? Unrelieved pressure Human papilloma virus Necrotising Fasciitis Influenza Ring worm infection 13) A pressure ulcer that presents as a deep crater with or without undermining adjacent tissue is stage I stage II stage IV stage III 14) Which of the following interventions should be used to avoid pressure ulcers? If patient is unable to change position independently, implement a repositioning schedule. If the patient’s condition worsens, the frequency of skin evaluations may need to be increased. For bed bound clients, implement preventative dressings and pressure relieving mattresses. Maintain a 30 degree tilt in the head of the bed at all times to reduce pressure and shearing stress on the sacral area. To avoid skin injury caused by friction and shearing, health care personnel should drag skin across sheets when putting or pulling up the patient in bed. The patient should be provided with more fluids. SCIENCE HEALTH SCIENCE NURSING HLT 54121

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