Question 1

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 inches 
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 inches

Question 2

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 3

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 4

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 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 position

Question 5

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 6

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 7

The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the physician. 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

Question 8

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 9

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 10

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 11

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 12

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 13

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 14

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

Accepted Answer

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

Question 15

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 16

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 17

Which solution(s) 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 18

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

Exam 14: Surgical Wound Care

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

The nurse assessing a patient's wound notes a clear watery 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?

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?

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

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

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?

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

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

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?

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

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

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

What is the usual length of time before suture removal?

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

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?

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 Patient’s Environment

Safety

Vital Signs

Physical Assessment

Admission, Transfer, and Discharge

Specimen Collection and Diagnostic Testing

Care of Patients Experiencing Urgent Alterations in Health

Complementary and Alternative Therapies

Pain Management, Comfort, Rest, and Sleep

Nutritional Concepts and Related Therapies

Fluids and Electrolytes

Mathematics and Medication Administration

Care of Patients with Alterations in Health

Life Span 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 a Urinary Disorder

Care of the Patient with an Endocrine Disorder

Care of the Patient with a Reproductive Disorder

Care of the Patient with a Sensory Disorder

Care of the Patient with a Neurologic Disorder

Care of the Patient with an Immune Disorder

Care of the Patient with HIV/AIDS

Care of the Patient with Cancer

Professional Roles and Leadership

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