Chapter 22 Flashcards
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
c. Tertiary intention
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.
c. Splint the abdomen with a pillow.
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
b. Sanguineous
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.
b. Keeps the incision moist.
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.
d. Moisten the dressing with sterile water.
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
c. 12 in
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
a. From the area of least contamination to the area of most contamination
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.
b. Cover the bowel with a sterile saline dressing.
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.
d. Leave the 12 staples in place and record the separation.
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.
c. Circle and date the outline of the exudate on the dressing.
The Centers for Disease Control and Prevention (CDC) classifies wounds according to theamount 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
d. Clean wound
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
a. Fibrin
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
b. Inflammatory
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.
c. Minimal scarring results.
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
c. Every 2 to 4 hours
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
c. At least 30 minutes before the dressing change
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
c. Mechanical débridement
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
c. Internal hemorrhage
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
d. 7 to 10 days
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
d. 300 mL
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
b. Closed drainage system
The nurse is caring for a patient with a surgical wound. How can the nurse promotehealing?
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.
d. Encourage the consumption of small frequent meals.
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.
d. Smoking interferes with normal cellular mechanisms that promote release of
oxygen.
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.
c. Causes hemoglobin to have a greater affinity for oxygen.
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
a. Serous drainage
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
b. Purulent drainage
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
d. Serosanguineous drainage
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
c. Sanguineous drainage
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
b. Dehiscence
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.
d. Prevents skin maceration.
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
b. Altered nutrition: more than body requirements
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.)
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.
c. Promotes formulation of granulation tissue.
d. Reduces local and peripheral edema.
e. Drops bacterial level in wound.
Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction
b. Hemostasis
c. Inflammation
d. Granulation
e. Maturation
a. Positive pressure is applied by this device.
b. Healing is facilitated by decrease in drainage.
c. Promotes formulation of granulation tissue.
e. Drops bacterial level in wound.
Which solutions can be used on a wet-to-dry dressing? (Select all that apply.)
a. Normal saline
b. Lactated Ringer
c. Acetic acid
d. Dakin
e. Lysol
a. Normal saline
b. Lactated Ringer
c. Acetic acid
e. Lysol
What are the advantages of a transparent dressing? (Select all that apply.)
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.
The nurse assures a patient that the purple, raised, immature scar of a surgical wound is
normal and caused by formation.
collagen
The nurse encourages a patient recovering from a hysterectomy to drink at least
mL of fluid a day.
2000
When preparing to remove a dressing, the nurse should don gloves.
clean
