Question 1

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. A,B,C,D

Question 2

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 B

Question 3

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 A,B,C,E

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 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 6

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 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

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 9

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 10

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 11

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.

Question 12

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

Question 13

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 14

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 15

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 16

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 17

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 18

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 19

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

Question 20

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

Exam 22: Surgical Wound Care

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

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?

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

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 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 handheld showerhead from the wound when irrigating the wound?

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

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?

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

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

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

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 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

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Health Promotion for the Infant, child, and Adolescent

Basic Pediatric Nursing Care

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Health Promotion and Care of the Older Adult

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Care of the Patient With a Psychiatric Disorder

Care of the Patient With an Addictive Personality

Home Health Nursing

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