Surgical wound Care (Foundations)

Question 1

The nurse instructs a patient who has a drain in a surgical wound that the wound will heal by:

a. primary intention.
b. secondary intention.
c. tertiary intention.
d. deliberate intention.

Answer 1

c. tertiary intention.

When wounds are kept open by a drain, they heal by tertiary intention.

Question 2

To assist the postoperative patient to cough, the nurse:

a. supports the patient’s back.
b. offers an antitussive.
c. splints the abdomen with a pillow.
d. leans patient against the bedside table.

Answer 2

c. splints the abdomen with a pillow

splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.

Question 3

The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as:

a. serosanguineous.
b. sanguineous.
c. serous.
d. purulent.

Answer 3

b. sanguineous.

means bloody. It is indicative of active bleeding.

Question 4

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

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.

and increase epithelialization.

Question 5

When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should:

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 instructs the patient in home wound irrigation to hold the hand-held showerhead approximately ______ inches from the wound .

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

Answer 6

c. 12

Question 7

The nurse follows the basic concept of wound irrigation when directing 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 inches.

Answer 7

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

to prevent microorganisms from entering the wound.

Question 8

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

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.

Although the RN must be notified, covering the loop of bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line.

Question 9

The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. If the wound begins to separate after removal of 3 of the 15 staples, the nurse should:

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

Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by:

a. weighing the patient to estimate the weight of the saturated dressing.
b. reinforcing the dressing.
c. circling and dating the outline of the exudate on the dressing.
d. counting each dressing as 1 mL of drainage.

Answer 10

c. circling and dating the outline of the exudate on the dressing.

Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.

Question 11

The Centers for Disease Control (CDC) classifies wounds according to the amount of contamination. An uninfected surgical wound with less than a 5% chance of becoming infected postoperatively is classified as a:

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. The substance in the clot that holds the wound together is:

a. fibrin.
b. thrombin.
c. protime.
d. calcium.

Answer 12

a. fibrin.

Question 13

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?

a. Healing
b. Inflammatory
c. Reconstruction
d. Maturation

Answer 13

b. Inflammatory

During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space.

Question 14

Primary intention has a marked advantage over other phases of wound healing because:

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

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

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

Answer 15

c. 2 to 4 hours.

Question 16

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

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.

It may help to give an analgesic at least 30 minutes before exposing the wound.

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, which when removed results in:

a. destruction of tissue.
b. bleeding.
c. mechanical debridement.
d. prevention of infection.

Answer 17

c. mechanical debridement.

Question 18

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:

a. pain shock.
b. dehydration.
c. internal hemorrhage.
d. acute infection.

Answer 18

c. internal hemorrhage.

If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.

Question 19

The usual length of time before suture removal is:

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. It is considered abnormal if the drainage exceeds:

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

Answer 20

d. 300 mL.

Drainage greater than 300 mL in 24 hours is considered abnormal.

Question 21

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

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 caring for a patient with a surgical wound promotes healing by:

a. offering fluids every 4 hours.
b. encouraging the consumption of large meals.
c. encouraging up to 1000 mL of daily fluid intake.
d. encouraging the consumption of small frequent meals.

Answer 22

d. encouraging the consumption of small frequent meals

To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours.

Question 23

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

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.

Answer 23

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

Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.

Question 24

The nurse instructing a patient about the effects of diabetes mellitus informs the patient that 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.

Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.

Question 25

The nurse assessing a patient’s wound notes a clear watery drainage. The nurse documents this finding as:

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. The nurse documents this finding as:

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. The nurse documents this finding as:

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. The nurse documents this finding as:

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. The nurse recognizes this as an indication of:

a. cellulitis.
b. dehiscence.
c. evisceration.
d. extravasation.

Answer 29

b. dehiscence.

Question 30

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

a. Reconstruction
b. Hemostasis
c. Inflammatory
d. Granulation
e. Maturation

Answer 30

a. Reconstruction
b. Hemostasis
c. Inflammatory
e. Maturation

Question 31

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

a. Normal saline
b. Lactated Ringer’s
c. Acetic acid
d. Dakin’s
e. Lysol

Answer 31

a. Normal saline
b. Lactated Ringer’s
c. Acetic acid
d. Dakin’s

Question 32

The nurse assures a patient that the purple, raised, immature scar of his surgical wound is normal and caused by _______ formation.

Answer 32

collagen

forms as an immature scar over a new surgical wound.

Question 33

The nurse encourages a patient recovering from a hysterectomy to drink at least _______ mL of fluid a day.

Answer 33

2000

A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.

Question 34

When preparing to remove a dressing, the nurse should don __________ gloves.

Answer 34

clean

Question 35

A transparent dressing has which advantages? (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. Speeds epithelial growth

Answer 35

a. Adheres to undamaged skin
b. Contains the exudate
c. Reduces wound contamination
d. Serves as a barrier to external bacteria
e. Speeds epithelial growth

Question 36

When the nurse arrives on the scene of a fire, the first thing to do for a burn victim is to:

a. apply dressings.
b. cover with a blanket.
c. cool the burn immediately.
d. apply topical ointment.

Answer 36

c. cool the burn immediately.

The burn should be cooled immediately to stop the burning process.