Question 1

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 2

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 3

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 4

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 5

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 6

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 7

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 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 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 10

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 11

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 12

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 13

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

Accepted Answer

2000
A recovering su

Question 14

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 15

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 16

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 17

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

Accepted Answer

clean
To remove a dr

Question 18

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.

Exam 22: Surgical Wound Care

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

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

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

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

What is the usual length of time before suture removal?

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

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?

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

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

What is the advantage of an occlusive dressing?

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?

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

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

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