Question 1

The day following surgery,the nurse notes bloody drainage on the dressing.How will the nurse describe this drainage when documenting?

Accepted Answer

A)   Serosanguineous
B)   Sanguineous
C)   Serous
D)   PurulentE) B) and D)
F) A) and B)

Question 2

The nurse is removing every other staple from a surgical wound,which has been closed with 15 staples.The wound begins to separate after removal of 3 of the 15.What nursing action should be implemented?

Accepted Answer

A)   Remove 7 more alternate staples and securely tape with Steri-Strips.
B)   Cover with moist dressing and apply a binder.
C)   Continue to remove staples as ordered because this is an expected outcome.
D)   Leave the 12 staples in place and record the separation.E) A) and B)
F) A) and C)

Question 3

The nurse is preparing to perform a dressing change on a patient following a total hip replacement.When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?

Accepted Answer

A)   After the dressing change
B)   At least 15 minutes before the dressing change
C)   At least 30 minutes before the dressing change
D)   At least 1 hour before the dressing changeE) B) and D)
F) A) and D)

Question 4

What are the advantages of a transparent dressing? (Select all that apply. )

Accepted Answer

A)   Adheres to undamaged skin.
B)   Contains the exudate.
C)   Reduces wound contamination.
D)   Serves as a barrier to external bacteria.
E)   Slows epithelial growth.F) B) and E)
G) A) and B)

Question 5

The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain.What is the maximum amount of drainage considered normal?

Accepted Answer

A)   50 mL
B)   100 mL
C)   200 mL
D)   300 mLE) None of the above
F) All of the above

Question 6

The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting.How should the nurse assess the amount of drainage?

Accepted Answer

A)   Weigh the patient to estimate the weight of the saturated dressing.
B)   Reinforce the dressing.
C)   Circle and date the outline of the exudate on the dressing.
D)   Count each dressing as 1 mL of drainage.E) A) and B)
F) All of the above

Question 7

The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the health care provider.What is an advantage of gauze bandages?

Accepted Answer

A)   Provision of warmth.
B)   Applies strong pressure.
C)   Antibacterial effects.
D)   Prevents skin maceration.E) A) and B)
F) A) and C)

Question 8

The nurse is preparing a presentation regarding the effects of diabetes mellitus.What will the nurse include regarding the effects of diabetes mellitus?

Accepted Answer

A)   Improves overall tissue perfusion.
B)   Promotes release of oxygen to tissues.
C)   Causes hemoglobin to have a greater affinity for oxygen.
D)   Causes hemoglobin to have a decreased affinity for oxygen.E) A) and C)
F) All of the above

Question 9

The nurse assessing a patient's wound notes pale red watery drainage.How will the nurse most accurately document this finding?

Accepted Answer

A)   Serous drainage
B)   Purulent drainage
C)   Sanguineous drainage
D)   Serosanguineous drainageE) B) and C)
F) All of the above

Question 10

What technique will the nurse implement to assist the postoperative patient to cough?

Accepted Answer

A)   Support the patient's back.
B)   Offer an antitussive.
C)   Splint the abdomen with a pillow.
D)   Lean patient against the bedside table.E) B) and C)
F) None of the above

Question 11

What is the advantage of an occlusive dressing?

Accepted Answer

A)   Allows air to the incision.
B)   Keeps the incision moist.
C)   Delays epithelialization.
D)   Does not have to be changed.E) A) and C)
F) All of the above

Question 12

What marked advantage does primary intention have over other phases of wound healing?

Accepted Answer

A)   Healing is rapid.
B)   Healing rarely becomes infected.
C)   Minimal scarring results.
D)   Healing is painless.E) None of the above
F) A) and C)

Question 13

The nurse assessing a postoperative patient discovers that the pulse is rapid,blood pressure has decreased,urinary output has decreased,and the dressing is dry.What can the nurse determine is indicated by these findings?

Accepted Answer

A)   Pain shock
B)   Dehydration
C)   Internal hemorrhage
D)   Acute infectionE) C) and D)
F) B) and C)

Question 14

Which are the phases of wound healing? (Select all that apply. )

Accepted Answer

A)   Reconstruction
B)   Hemostasis
C)   Inflammation
D)   Granulation
E)   MaturationF) B) and C)
G) None of the above

Question 15

Which solutions can be used on a wet-to-dry dressing? (Select all that apply. )

Accepted Answer

A)   Normal saline
B)   Lactated Ringer
C)   Acetic acid
D)   Dakin
E)   LysolF) B) and E)
G) All of the above

Question 16

What phase is a wound in when blood and fluid flow into the vascular space and produce edema,erythema,heat,and pain?

Accepted Answer

A)   Healing
B)   Inflammatory
C)   Reconstruction
D)   MaturationE) None of the above
F) All of the above

Question 17

A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for a stage 2 foot injury.The patient refuses to follow an ADA diet as ordered by a health care provider and is morbidly obese.The nurse assesses the injury to be healing,free from signs and symptoms of infection,with a positive pedal pulse and warm to touch.What patient problem will be identified as a priority?

Accepted Answer

A)   Infection
B)   Altered nutrition: more than body requirements
C)   Impaired skin integrity
D)   Altered peripheral tissue perfusionE) A) and B)
F) B) and D)

Question 18

The nurse assessing a patient's wound notes a clear watery drainage.How will the nurse most accurately document this finding?

Accepted Answer

A)   Serous drainage
B)   Purulent drainage
C)   Sanguineous drainage
D)   Serosanguineous drainageE) A) and B)
F) None of the above

Exam 22: Surgical Wound Care

Which are the phases of wound healing? (Select all that apply. )

Correct Answer
verified

Correct Answer
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The nurse is removing every other staple from a surgical wound,which has been closed with 15 staples.The wound begins to separate after removal of 3 of the 15.What nursing action should be implemented?

Correct Answer
verified

What are the advantages of a transparent dressing? (Select all that apply. )

Correct Answer
verified

The nurse is preparing a presentation regarding the effects of diabetes mellitus.What will the nurse include regarding the effects of diabetes mellitus?

Correct Answer
verified

What marked advantage does primary intention have over other phases of wound healing?

Correct Answer
verified

What is the advantage of an occlusive dressing?

Correct Answer
verified

What phase is a wound in when blood and fluid flow into the vascular space and produce edema,erythema,heat,and pain?

Correct Answer
verified

The nurse assessing a postoperative patient discovers that the pulse is rapid,blood pressure has decreased,urinary output has decreased,and the dressing is dry.What can the nurse determine is indicated by these findings?

Correct Answer
verified

The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the health care provider.What is an advantage of gauze bandages?

Correct Answer
verified

Which solutions can be used on a wet-to-dry dressing? (Select all that apply. )

Correct Answer
verified

The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain.What is the maximum amount of drainage considered normal?

Correct Answer
verified

The nurse is preparing to perform a dressing change on a patient following a total hip replacement.When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?

Correct Answer
verified

The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting.How should the nurse assess the amount of drainage?

Correct Answer
verified

The nurse assessing a patient's wound notes a clear watery drainage.How will the nurse most accurately document this finding?

Correct Answer
verified

The day following surgery,the nurse notes bloody drainage on the dressing.How will the nurse describe this drainage when documenting?

Correct Answer
verified

The nurse assessing a patient's wound notes pale red watery drainage.How will the nurse most accurately document this finding?

Correct Answer
verified

What technique will the nurse implement to assist the postoperative patient to cough?

Correct Answer
verified

Exam 22: Surgical Wound Care

Which are the phases of wound healing? (Select all that apply. )

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

The nurse is removing every other staple from a surgical wound,which has been closed with 15 staples.The wound begins to separate after removal of 3 of the 15.What nursing action should be implemented?

Correct AnswerverifiedShow Answer

What are the advantages of a transparent dressing? (Select all that apply. )

Correct AnswerverifiedShow Answer

The nurse is preparing a presentation regarding the effects of diabetes mellitus.What will the nurse include regarding the effects of diabetes mellitus?

Correct AnswerverifiedShow Answer

What marked advantage does primary intention have over other phases of wound healing?

Correct AnswerverifiedShow Answer

What is the advantage of an occlusive dressing?

Correct AnswerverifiedShow Answer

What phase is a wound in when blood and fluid flow into the vascular space and produce edema,erythema,heat,and pain?

Correct AnswerverifiedShow Answer

The nurse assessing a postoperative patient discovers that the pulse is rapid,blood pressure has decreased,urinary output has decreased,and the dressing is dry.What can the nurse determine is indicated by these findings?

Correct AnswerverifiedShow Answer

The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the health care provider.What is an advantage of gauze bandages?

Correct AnswerverifiedShow Answer

Which solutions can be used on a wet-to-dry dressing? (Select all that apply. )

Correct AnswerverifiedShow Answer

The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain.What is the maximum amount of drainage considered normal?

Correct AnswerverifiedShow Answer

The nurse is preparing to perform a dressing change on a patient following a total hip replacement.When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?

Correct AnswerverifiedShow Answer

The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting.How should the nurse assess the amount of drainage?

Correct AnswerverifiedShow Answer

The nurse assessing a patient's wound notes a clear watery drainage.How will the nurse most accurately document this finding?

Correct AnswerverifiedShow Answer

The day following surgery,the nurse notes bloody drainage on the dressing.How will the nurse describe this drainage when documenting?

Correct AnswerverifiedShow Answer

The nurse assessing a patient's wound notes pale red watery drainage.How will the nurse most accurately document this finding?

Correct AnswerverifiedShow Answer

What technique will the nurse implement to assist the postoperative patient to cough?

Correct AnswerverifiedShow Answer

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
verified

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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