Question 1

When blood and fluid flow into the vascular space and produce edema,erythema,heat,and pain,the nurse knows that the wound is in which phase?

Accepted Answer

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

Question 2

The nurse observes a loop of bowel protruding from the surgical incision.The nurse's initial intervention should be to:

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.

Question 3

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

Accepted Answer

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

Question 4

The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain.It is considered abnormal if the drainage exceeds:

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 5

The usual length of time before suture removal is:

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 6

The nurse follows the basic concept of wound irrigation when directing 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 7

The nurse explains that the advantage of an occlusive dressing is that it:

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 8

The nurse recognizes that the Jackson-Pratt drainage removal system is classified as a(n):

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 9

Hemostasis begins as soon as the injury occurs and a clot begins to form.The substance in the clot that holds the wound together is:

Accepted Answer

A)  fibrin. 
B)  thrombin. 
C)  protime. 
D)  calcium. 
A)  fibrin. 
B)  thrombin. 
C)  protime. 
D)  calcium.

Question 10

To keep the patient comfortable during a dressing change,the nurse may administer an analgesic:

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

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

Accepted Answer

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

Question 12

The nurse instructing a patient about the effects of smoking informs the patient that smoking:

Accepted Answer

A)  increases the amount of tissue oxygenation. 
B)  increases the amount of functional hemoglobin in blood. 
C)  may decrease platelet aggregation and cause hypercoagulability. 
D)  interferes with normal cellular mechanisms that promote release of oxygen. 
A)  increases the amount of tissue oxygenation. 
B)  increases the amount of functional hemoglobin in blood. 
C)  may decrease platelet aggregation and cause hypercoagulability. 
D)  interferes with normal cellular mechanisms that promote release of oxygen.

Question 13

For the first 24 hours following surgery,the nurse assesses for bleeding by observing the dressing and the area under the patient every:

Accepted Answer

A)  30 minutes. 
B)  60 minutes. 
C)  2 to 4 hours. 
D)  5 to 8 hours. 
A)  30 minutes. 
B)  60 minutes. 
C)  2 to 4 hours. 
D)  5 to 8 hours.

Question 14

During assessment of a postoperative patient,the nurse discovers that the pulse is rapid,blood pressure has decreased,urinary output has decreased,and the dressing is dry.The nurse recognizes these findings as indicative of:

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 15

The nurse assessing a patient's wound notes bright red drainage.The nurse documents this finding as:

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.

Exam 13: Surgical Wound Care

When blood and fluid flow into the vascular space and produce edema,erythema,heat,and pain,the nurse knows that the wound is in which phase?

The nurse observes a loop of bowel protruding from the surgical incision.The nurse's initial intervention should be to:

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.It is considered abnormal if the drainage exceeds:

The usual length of time before suture removal is:

The nurse follows the basic concept of wound irrigation when directing the flow of the irrigant:

The nurse explains that the advantage of an occlusive dressing is that it:

The nurse recognizes that the Jackson-Pratt drainage removal system is classified as a(n):

Hemostasis begins as soon as the injury occurs and a clot begins to form.The substance in the clot that holds the wound together is:

To keep the patient comfortable during a dressing change,the nurse may administer an analgesic:

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

The nurse instructing a patient about the effects of smoking informs the patient that smoking:

For the first 24 hours following surgery,the nurse assesses for bleeding by observing the dressing and the area under the patient every:

During assessment of a postoperative patient,the nurse discovers that the pulse is rapid,blood pressure has decreased,urinary output has decreased,and the dressing is dry.The nurse recognizes these findings as indicative of:

The nurse assessing a patient's wound notes bright red drainage.The nurse documents this finding as:

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