Fundamentals Lesson 8 Skin integrity and wound care/ specimen/diagnostic

Question 1

The patient has just returned from the post anesthesia care unit (PAC). during report, the nurse is told that the patient has a Penrose drain in the left lower quadrant. The patient asks why the drain us being used. What response by the nurse is most accurate?

1. “the drain allows for the postoperative instillation of wound irritation fluid”
2. The drain is used to reduce infection in the postoperative period
3. Penrose drains are used to drain body fluids from the area surrounding the wound by suction.
4. Gravity is used to drain fluid from the area around the wound with the Penrose drain.

Answer 1

Gravity is used to drain fluid from the area around the wound with the Penrose drain.

Question 2

The nurse finds that the patient’s incision has eviscerated . Which action should the nurse take? SATA

1. Place the patient in high fowlers
2. Give patient fluids to prevent shock
3. Do not allow the patient to get out of bed
4. replace dressings with sterile fluffy pads
5. apply warm, moist sterile dressings

Answer 2

apply warm, moist sterile dressings

(find out which else based on text, wasn’t in the answer choices)

Question 3

hcp has ordered the patient’s wound be irrigated . Primary rationale for this procedure?

1. To remove debris from the wound
2. to decrease scar formation’
3. to improve circulation from the wound
4. to decrease irritation from wound drainage

Answer 3

to remove debris from the wound

Question 4

Best indicator that a wound had become infected?

Answer 4

Purulent drainage is coming from the wound area

Question 5

Which nursing entry is the most complete in its description of a wound?

1. wound appears to be healing well, dressing dry and intact.
2. Wound well approximated with min drainage
3. Drainage size of quarter; wound pink; 4x4 applied
4. Incisional edges approximated without erythema or exudate; two 4x4s applied

Answer 5

Incisional edges approximated without erythema or exudate; two 4x4s applied.

Question 6

Which statement is correct in regard to the use of an abdominal binder?

1. It replaces the need for underlying dressings
2. It should be kept loose for patient comfort
3. The patient has to be sitting or standing when it is applied
4. The patient must have adequate ventilatory capacity

Answer 6

The patient must have adequate ventilatory capacity

Question 7

What is the first step when packing a wound?

1. Assess its size, shape and depth
2. prepare a sterile field
3. select gauze packing material
4. Irrigate the wound

Answer 7

select gauze packing material

Question 8

What is the correct procedure for the wet to dry dressing method?

1. Place dry gauze into the wound and remove it when it is wet
2. Medicate the patient for pain after you change the dressing
3. Complete this type of dressing change just once a day
4. Place moist gauze into the wound and remove it when its dry

Answer 8

Place moist gauze in the wound and remove it when its dry

Question 9

which phrase best describes serous drainage?

1. fresh bleeding
2. thick and yellow
3. clear, watery plasma
4. beige to brown and foul smelling

Answer 9

clear, watery plasma

Question 10

The hcp has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention?

1. collection of wound drainage
2. Reduction of abdominal swelling
3. reduction of stress on the abdominal incision
4. stimulation of peristalsis from direct pressure

Answer 10

reduction of street on the abdominal incision

Question 11

What are the traditional purposes of a wet to dry dressing? SATA

1. Debridement
2. Cooling
3. Comfort
4. Prevent infection’
5. Maintenance of moisture at the wound bed

Answer 11

debridement
maintenance of moisture at the wound bed

Question 12

What action should the nurse implement to reduce surgical wound infection? SATA

1. Hand hygiene
2. cleansing the incision from the least contaminated to the most contaminated
3. leaving the incision open to air
4. changing the dressing using sterile technique
5. ensuring the patient is consuming an adequate diet

Answer 12

changing the dressing using sterile technique
Hand hygiene
cleansing the incision from the least contaminated to the most contaminated

Question 13

The student nurse is changing a patient’s dressing. What action indicates the need for further action?

1. Enclose the soiled dressing with a latex gloves
2. clean the wound in circles toward the incision
3. Free the tape by pulling it away from the incision
4. remove the soiled dressing with sterile gloves
5. apply the clean dressing with clean gloves

Answer 13

2. clean the wound in circles toward the incision
3. Free the tape by pulling it away from the incision
4. remove the soiled dressing with sterile gloves
5. apply the clean dressing with clean gloves