Question 1

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. 
A)  Healing is rapid. 
B)  Healing rarely becomes infected. 
C)  Minimal scarring results. 
D)  Healing is painless.

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. 
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.

Question 3

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)  Maturation 
A)  Healing 
B)  Inflammatory 
C)  Reconstruction 
D)  Maturation

Question 4

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. 
A)  Allows air to the incision. 
B)  Keeps the incision moist. 
C)  Delays epithelialization. 
D)  Does not have to be changed.

Question 5

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

Question 6

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 change 
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 change

Question 7

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. 
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.

Question 8

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 mL 
A)  50 mL 
B)  100 mL 
C)  200 mL 
D)  300 mL

Question 9

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. 
A)  Support the patient's back. 
B)  Offer an antitussive. 
C)  Splint the abdomen with a pillow. 
D)  Lean patient against the bedside table.

Question 10

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 infection 
A)  Pain shock 
B)  Dehydration 
C)  Internal hemorrhage 
D)  Acute infection

Question 11

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

Question 12

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

Question 13

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

Accepted Answer

A)  Reconstruction 
B)  Hemostasis 
C)  Inflammation 
D)  Granulation 
E)  Maturation 
A)  Reconstruction 
B)  Hemostasis 
C)  Inflammation 
D)  Granulation 
E)  Maturation

Question 14

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

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)  Lysol 
A)  Normal saline 
B)  Lactated Ringer 
C)  Acetic acid 
D)  Dakin 
E)  Lysol

Question 16

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. 
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.

Question 17

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. 
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.

Question 18

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

Exam 22: Surgical Wound Care

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

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?

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

What is the advantage of an occlusive dressing?

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

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?

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?

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?

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

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?

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

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

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

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

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

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

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?

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

Safety

Admission, transfer, and Discharge

Vital Signs

Physical Assessment

Oxygenation

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

Complementary and Alternative Therapies

Pain Management, comfort, rest, and Sleep

Specimen Collection and Diagnostic Testing

Lifespan Development

Loss, grief, dying, and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, newborn, and Family With Special Needs

Health Promotion for the Infant, child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child With a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient With a Psychiatric Disorder

Care of the Patient With an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Introduction to Anatomy and Physiology

Care of the Surgical Patient

Care of the Patient With an Integumentary Disorder

Care of the Patient With a Musculoskeletal Disorder

Care of the Patient With a Gastrointestinal Disorder

Care of the Patient With a Gallbladder, liver, biliary Tract, or Exocrine Pancreatic Disorder

Care of the Patient With a Blood or Lymphatic Disorder

Care of the Patient With a Cardiovascular or a Peripheral Vascular Disorder

Care of the Patient With a Respiratory Disorder

Care of the Patient With an Endocrine Disorder

Care of the Patient With an Endocrine Disorder

Care of the Patient With a Reproductive Disorder

Care of the Patient With a Visual or Auditory Disorder

Care of the Patient With a Neurologic Disorder

Care of the Patient With an Immune Disorder

Care of the Patient With Hivaids

Care of the Patient With Cancer

Professional Roles and Leadership

Filters