Practice Question ch 22

Question 1

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

1. “The drain allows for the postoperative instillation of wound irrigation 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

4

Question 2

The nurse finds that the patient’s incision has eviscerated. What action should the nurse take? ( Select all that apply .)

1. Place the patient in high Fowler’s position.
2. Give the 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

4

Question 3

. The health care provider has ordered the patient’s wound be irrigated . What is the 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

1

Question 4

What is the best indicator that a wound has become infected?

1. Palpation of the wound reveals excess fluid under its edges .
2. Wound cultures are positive .
3. Purulent drainage is coming from the wound area .
4. The wound has a distinct odor .

Answer 4

3

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 minimal drainage
3. Drainage size of quarter ; wound pink ; 4 * 4 applied
4. Incisional edges approximated without erythema or exudate ; two 4 * 4s applied

Answer 5

4

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

4

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

3

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 it is dry.

Answer 8

4

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

3

Question 10

The health care provider 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

3

Question 11

What are the traditional purposes of a wet - to - dry dressing ? (Select all that apply . )

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

Answer 11

1,5

Question 12

What action should the nurse implement to reduce surgical wound infection ? ( Select all that apply.)

1. Adhering to the principles of hand hygiene
2. Cleansing the incision from the least contaminated to the most contaminated area
3. Leaving the incision open to the air
4. Changing the dressing using sterile technique
5. Ensuring the patient is consuming an adequate diet

Answer 12

4

Question 13

The student nurse is changing a patient’s dressing. What action indicates the need for further education? ( Select all that apply.)

1. Enclose the soiled dressing within a latex glove.
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

2,3,4,5

Question 14

When the drainage in a Hemovac reservoir is emptied , which nursing action is essential for reestablishing the negative pressure within this drainage device ?

1. Fill the reservoir with sterile normal saline solution .
2. Secure the reservoir to the skin near the wound .
3. Compress the reservoir and close the vent . 4. Open the vent , allowing the reservoir to fill with air .

Answer 14

3

Question 15

Which patient is more at risk for wound dehiscence ?

1. The patient who smokes
2. The patient who is obese
3. The patient with a history of peripheral vascular disease
4. The patient who is immunocompromised

Answer 15

2

Question 16

The student nurse is correct when indicating which drain as providing suction - assisted drainage ?

1. Jackson - Pratt
2. Hemovac
3. Penrose
4. Wound VAC system
5. T -tube system

Answer 16

3

Question 17

The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri -Strips applied . During suture removal , the nurse notices the incision edges are slightly separating. What is the best action by the nurse ?

1. Continue removing the sutures and apply the Steri -Strips .
2. Stop the suture removal and contact the health care provider immediately .
3. Continue removing the sutures and applying the Steri-Strips, then cover the incision with a dry sterile dressing .
4. Stop the suture removal, apply Steri-Strips where sutures already have been removed , and notify the health care provider .

Answer 17

4

Question 18

When providing care to a patient with a Hemovac drain , what actions are included in the plan of care?

1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations .
2. Clamp the tubing during patient ambulation and activity to prevent excess drainage during these times .
3. Empty the bulb drainage receptacle when it is one - fourth full .
4. Pin the bulb above the insertion site to assist in proper drainage of exudate .

Answer 18

1

Question 19

During assessment of a patient after abdominal surgery , the nurse suspects internal hemorrhaging based on which finding ?

1. The dressing is saturated with bright red sanguineous drainage , and the patient has an increased urinary output .
2. The dressing is dry and intact , the patient’s blood pressure has decreased , and pulse and respirations have increased .
3. The dressing is saturated with serosanguineous drainage , and the patient is diaphoretic with a decrease in pulse and respirations .
4. The dressing is dry and intact , and the patient reports shortness of breath and has an elevated temperature .

Answer 19

2

Question 20

practice question 1-10

Answer 20

ch 22