chapter 22

Question 1

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse
indicate that the wound will heal?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. Deliberate intention

Answer 1

c. Tertiary intention

Question 2

What technique will the nurse implement to assist the postoperative patient to cough?
a. Support the patient’s back.
b. Offer an antitussive.
c. Splint the abdomen with a pillow.
d. Lean patient against the bedside table.

Answer 2

c. Splint the abdomen with a pillow.

Question 3

The day following surgery, the nurse notes bloody drainage on the dressing. How will the
nurse describe this drainage when documenting?
a. Serosanguineous
b. Sanguineous
c. Serous
d. Purulent

Answer 3

b. Sanguineous

Question 4

What is the advantage of an occlusive dressing?
a. Allows air to the incision.
b. Keeps the incision moist.
c. Delays epithelialization.
d. Does not have to be changed.

Answer 4

b. Keeps the incision moist.

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?
a. Call the RN.
b. Gently remove the gauze with sterile forceps.
c. Cover with occlusive dressing.
d. Moisten the dressing with sterile water.

Answer 5

d. Moisten the dressing with sterile water.

Question 6

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?
a. 2.5 in
b. 6 in
c. 12 in
d. 18 in

Answer 6

c. 12 in

Question 7

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

Answer 7

a. From the area of least contamination to the area of most contamination

Question 8

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

Answer 8

b. Cover the bowel with a sterile saline dressing.

Question 9

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?
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.

Answer 9

d. Leave the 12 staples in place and record the separation.

Question 10

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?
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.

Answer 10

c. Circle and date the outline of the exudate on the dressing.

Question 11

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?
a. Dirty wound
b. Clean-contaminated wound
c. Contaminated wound
d. Clean wound

Answer 11

d. Clean wound

Question 12

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?
a. Fibrin
b. Thrombin
c. Protime
d. Calcium

Answer 12

a. Fibrin

Question 13

What phase of wound healing is a wound in when blood and fluid flow into the vascular
space and produce edema, erythema, heat, and pain?
a. Healing
b. Inflammatory
c. Reconstruction
d. Maturation

Answer 13

b. Inflammatory

Question 14

What marked advantage does primary intention have over other phases of wound healing?
a. Healing is rapid.
b. Healing rarely becomes infected.
c. Minimal scarring results.
d. Healing is painless.

Answer 14

c. Minimal scarring results.

Question 15

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?
a. Every 30 minutes
b. Every 60 minutes
c. Every 2 to 4 hours
d. Every 5 to 8 hours

Answer 15

c. Every 2 to 4 hours

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?
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

Answer 16

c. At least 30 minutes before the dressing change

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?
a. Destruction of tissue
b. Bleeding
c. Mechanical débridement
d. Prevention of infection

Answer 17

c. Mechanical débridement

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?
a. Pain shock
b. Dehydration
c. Internal hemorrhage
d. Acute infection

Answer 18

c. Internal hemorrhage

Question 19

What is the usual length of time before suture removal?
a. 2 to 3 days
b. 4 to 5 days
c. 5 to 6 days
d. 7 to 10 days

Answer 19

d. 7 to 10 days

Question 20

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 considerednormal?
a. 50 mL
b. 100 mL
c. 200 mL
d. 300 mL

Answer 20

d. 300 mL

Question 21

What is the classification for the Jackson-Pratt drainage removal system?
a. Sterile drainage system
b. Closed drainage system
c. Open drainage system
d. Self-measuring drainage system

Answer 21

b. Closed drainage system

Question 22

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

Answer 22

d. Encourage the consumption of small frequent meals.

Question 23

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

Answer 23

d. Smoking interferes with normal cellular mechanisms that promote release of
oxygen.

Question 24

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

Answer 24

c. Causes hemoglobin to have a greater affinity for oxygen.

Question 25

The nurse assessing a patient’s wound notes a clear watery drainage. How will the nurse
most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

Answer 25

a. Serous drainage

Question 26

The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse
most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

Answer 26

b. Purulent drainage

Question 27

The nurse assessing a patient’s wound notes pale red watery drainage. How will the nurse
most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

Answer 27

d. Serosanguineous drainage

Question 28

The nurse assessing a patient’s wound notes bright red drainage. How will the nurse most
accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

Answer 28

c. Sanguineous drainage

Question 29

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?
a. Cellulitis
b. Dehiscence
c. Evisceration
d. Extravasation

Answer 29

Dehiscence

Question 30

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 gauzebandages?
a. Provision of warmth.
b. Applies strong pressure.
c. Antibacterial effects.
d. Prevents skin maceration.

Answer 30

d. Prevents skin maceration.

Question 31

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?
a. Infection
b. Altered nutrition: more than body requirements
c. Impaired skin integrity
d. Altered peripheral tissue perfusion

Answer 31

b. Altered nutrition: more than body requirements