Question 1

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

Accepted Answer

A)  Serous drainage 
B)  Purulent drainage 
C)  Sanguineous drainage 
D)  Serosanguineous drainage 
A)  Serous drainage 
B)  Purulent drainage 
C)  Sanguineous drainage 
D)  Serosanguineous drainage C

Question 2

The nurse observes a loop of bowel protruding from the surgical incision.What is the first intervention the nurse should implement?

Accepted Answer

A)  Call the RN. 
B)  Cover the bowel with a sterile saline dressing. 
C)  Turn the patient to the side of the evisceration. 
D)  Raise the patient up to a high Fowler's position. 
A)  Call the RN. 
B)  Cover the bowel with a sterile saline dressing. 
C)  Turn the patient to the side of the evisceration. 
D)  Raise the patient up to a high Fowler's position. B

Question 3

The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC)device for hospital nurses.What accurate information will be included in this in-service? (Select all that apply. )

Accepted Answer

A)  Positive pressure is applied by this device. 
B)  Healing is facilitated by decrease in drainage. 
C)  Promotes formulation of granulation tissue. 
D)  Reduces local and peripheral edema. 
E)  Drops bacterial level in wound. 
A)  Positive pressure is applied by this device. 
B)  Healing is facilitated by decrease in drainage. 
C)  Promotes formulation of granulation tissue. 
D)  Reduces local and peripheral edema. 
E)  Drops bacterial level in wound. C,D,E

Question 4

The nurse is caring for a patient with a surgical wound.How can the nurse promote healing?

Accepted Answer

A)  Offer fluids every 4 hours. 
B)  Encourage the consumption of large meals. 
C)  Encourage up to 1000 mL of daily fluid intake. 
D)  Encourage the consumption of small frequent meals. 
A)  Offer fluids every 4 hours. 
B)  Encourage the consumption of large meals. 
C)  Encourage up to 1000 mL of daily fluid intake. 
D)  Encourage the consumption of small frequent meals.

Question 5

What is the classification for the Jackson-Pratt drainage removal system?

Accepted Answer

A)  Sterile drainage system 
B)  Closed drainage system 
C)  Open drainage system 
D)  Self-measuring drainage system 
A)  Sterile drainage system 
B)  Closed drainage system 
C)  Open drainage system 
D)  Self-measuring drainage system

Question 6

When preparing to remove a dressing,the nurse should don __________ gloves.

Accepted Answer

The answer of When preparing to remove a dressing,the nurse...

Question 7

When removing the dressing on a patient,the nurse discovers that the gauze dressing has adhered to the wound.What intervention should the nurse implement?

Accepted Answer

A)  Call the RN. 
B)  Gently remove the gauze with sterile forceps. 
C)  Cover with occlusive dressing. 
D)  Moisten the dressing with sterile water. 
A)  Call the RN. 
B)  Gently remove the gauze with sterile forceps. 
C)  Cover with occlusive dressing. 
D)  Moisten the dressing with sterile water.

Question 8

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

Accepted Answer

A)  Serous drainage 
B)  Purulent drainage 
C)  Sanguineous drainage 
D)  Serosanguineous drainage 
A)  Serous drainage 
B)  Purulent drainage 
C)  Sanguineous drainage 
D)  Serosanguineous drainage

Question 9

The nurse encourages a patient recovering from a hysterectomy to drink at least _______ mL of fluid a day.

Accepted Answer

The answer of The nurse encourages a patient recovering from...

Question 10

The nurse is irrigating a leg wound of a patient on the trauma unit.Where should the nurse direct the flow of the irrigant?

Accepted Answer

A)  From the area of least contamination to the area of most contamination 
B)  Forcefully into the wound 
C)  Gently over the skin into the wound 
D)  From a distance of about 12 in 
A)  From the area of least contamination to the area of most contamination 
B)  Forcefully into the wound 
C)  Gently over the skin into the wound 
D)  From a distance of about 12 in

Question 11

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry.This drying process causes it to adhere to the wound.What is the result of this intervention when the dressing is removed?

Accepted Answer

A)  Destruction of tissue 
B)  Bleeding 
C)  Mechanical débridement 
D)  Prevention of infection 
A)  Destruction of tissue 
B)  Bleeding 
C)  Mechanical débridement 
D)  Prevention of infection

Question 12

The Centers for Disease Control and Prevention (CDC)classifies wounds according to the amount of contamination.What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?

Accepted Answer

A)  Dirty wound 
B)  Clean-contaminated wound 
C)  Contaminated wound 
D)  Clean wound 
A)  Dirty wound 
B)  Clean-contaminated wound 
C)  Contaminated wound 
D)  Clean wound

Question 13

Hemostasis begins as soon as the injury occurs and a clot begins to form.What is the substance in the clot that holds the wound together?

Accepted Answer

A)  Fibrin 
B)  Thrombin 
C)  Protime 
D)  Calcium 
A)  Fibrin 
B)  Thrombin 
C)  Protime 
D)  Calcium

Question 14

The nurse is providing instruction to a patient regarding home wound irrigation.How far should the patient hold the handheld showerhead from the wound when irrigating the wound?

Accepted Answer

A)  2.5 in 
B)  6 in 
C)  12 in 
D)  18 in 
A)  2.5 in 
B)  6 in 
C)  12 in 
D)  18 in

Question 15

What is the usual length of time before suture removal?

Accepted Answer

A)  2 to 3 days 
B)  4 to 5 days 
C)  5 to 6 days 
D)  7 to 10 days 
A)  2 to 3 days 
B)  4 to 5 days 
C)  5 to 6 days 
D)  7 to 10 days

Question 16

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated.What does the nurse recognize that this indicates?

Accepted Answer

A)  Cellulitis 
B)  Dehiscence 
C)  Evisceration 
D)  Extravasation 
A)  Cellulitis 
B)  Dehiscence 
C)  Evisceration 
D)  Extravasation

Question 17

The nurse is instructing a patient who has a drain in a surgical wound.How will the nurse indicate that the wound will heal?

Accepted Answer

A)  Primary intention 
B)  Secondary intention 
C)  Tertiary intention 
D)  Deliberate intention 
A)  Primary intention 
B)  Secondary intention 
C)  Tertiary intention 
D)  Deliberate intention

Question 18

The nurse is instructing a patient about the effects of smoking.What accurate information does the nurse provide?

Accepted Answer

A)  Smoking increases the amount of tissue oxygenation. 
B)  Smoking increases the amount of functional hemoglobin in blood. 
C)  Smoking may decrease platelet aggregation and cause hypercoagulability. 
D)  Smoking interferes with normal cellular mechanisms that promote release of oxygen. 
A)  Smoking increases the amount of tissue oxygenation. 
B)  Smoking increases the amount of functional hemoglobin in blood. 
C)  Smoking may decrease platelet aggregation and cause hypercoagulability. 
D)  Smoking interferes with normal cellular mechanisms that promote release of oxygen.

Question 19

The nurse assures a patient that the purple,raised,immature scar of a surgical wound is normal and caused by _______ formation.

Accepted Answer

The answer of The nurse assures a patient that the...

Question 20

The nurse is caring for a patient during the first 24 hours following surgery.How often will the nurse assess for bleeding under the dressing?

Accepted Answer

A)  Every 30 minutes 
B)  Every 60 minutes 
C)  Every 2 to 4 hours 
D)  Every 5 to 8 hours 
A)  Every 30 minutes 
B)  Every 60 minutes 
C)  Every 2 to 4 hours 
D)  Every 5 to 8 hours

Exam 22: Surgical Wound Care

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

The nurse observes a loop of bowel protruding from the surgical incision.What is the first intervention the nurse should implement?

The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC)device for hospital nurses.What accurate information will be included in this in-service? (Select all that apply. )

The nurse is caring for a patient with a surgical wound.How can the nurse promote healing?

What is the classification for the Jackson-Pratt drainage removal system?

When preparing to remove a dressing,the nurse should don __________ gloves.

When removing the dressing on a patient,the nurse discovers that the gauze dressing has adhered to the wound.What intervention should the nurse implement?

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

The nurse encourages a patient recovering from a hysterectomy to drink at least _______ mL of fluid a day.

The nurse is irrigating a leg wound of a patient on the trauma unit.Where should the nurse direct the flow of the irrigant?

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry.This drying process causes it to adhere to the wound.What is the result of this intervention when the dressing is removed?

The Centers for Disease Control and Prevention (CDC)classifies wounds according to the amount of contamination.What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?

Hemostasis begins as soon as the injury occurs and a clot begins to form.What is the substance in the clot that holds the wound together?

The nurse is providing instruction to a patient regarding home wound irrigation.How far should the patient hold the handheld showerhead from the wound when irrigating the wound?

What is the usual length of time before suture removal?

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated.What does the nurse recognize that this indicates?

The nurse is instructing a patient who has a drain in a surgical wound.How will the nurse indicate that the wound will heal?

The nurse is instructing a patient about the effects of smoking.What accurate information does the nurse provide?

The nurse assures a patient that the purple,raised,immature scar of a surgical wound is normal and caused by _______ formation.

The nurse is caring for a patient during the first 24 hours following surgery.How often will the nurse assess for bleeding under the dressing?

The Evolution of Nursing

Legal and Ethical Aspects of Nursing

Documentation

Communication

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patients Environment

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Admission, transfer, and Discharge

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Physical Assessment

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Elimination and Gastric Intubation

Care of Patients Experiencing Urgent Alterations in Health

Dosage Calculation and Medication Administration

Fluids and Electrolytes

Nutritional Concepts and Related Therapies

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Specimen Collection and Diagnostic Testing

Lifespan Development

Loss, grief, dying, and Death

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Introduction to Anatomy and Physiology

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Care of the Patient With a Respiratory Disorder

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Care of the Patient With an Endocrine Disorder

Care of the Patient With a Reproductive Disorder

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