Question 1

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 2

A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer.The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese.The nurse assesses the ulcer to be healing,free from signs and symptoms of infection,with a positive pedal pulse and warm to touch.What nursing diagnosis 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 3

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 4

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

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 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 7

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 8

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

Accepted Answer

collagen
Collagen fo

Question 9

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 10

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 11

The physician 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 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

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

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 15

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 16

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 17

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 18

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

Exam 14: Surgical Wound Care

What is the advantage of an occlusive dressing?

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

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

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

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?

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 physician 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 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?

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?

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

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

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

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 usual length of time before suture removal?

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

Professional Roles and Leadership

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