Question 1

What phase is a wound in when blood and fluid flow into the vascular space and produce edema,erythema,heat,and pain?

Accepted Answer

The described phase is the inflammatory phase, which is characterized by increased blood and fluid flow to the area, resulting in edema (swelling), erythema (redness), heat, and pain. This phase occurs immediately after the injury and lasts for several days.

Question 2

The day following surgery,the nurse notes bloody drainage on the dressing.How will the nurse describe this drainage when documenting?

Accepted Answer

Sanguineous drainage is bloody drainage, indicating a fresh bleeding possibly caused by surgical incision. Serosanguineous drainage is a mixture of blood and serum and is expected to be seen in the initial postoperative period. Serous drainage is clear or slightly yellow fluid that seeps from the wound, while purulent drainage is thick, cloudy, or opaque and indicates an infection.

Question 3

What is the advantage of an occlusive dressing?

Accepted Answer

An occlusive dressing keeps the incision moist, which promotes faster healing and reduces scarring. It also protects the wound from outside contaminants and prevents the wound from drying out, reducing the risk of infection.

Question 4

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?

Accepted Answer

When wound irrigation is done at home with a handheld showerhead,the showerhead should be held approximately 12 in from the wound.

Question 5

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

Accepted Answer

The first intervention the nurse should implement is to cover the bowel with a sterile saline dressing to prevent dehydration, protect from further injury, and reduce the risk of infection. This is important because the exposed bowel can easily become contaminated and dry out, which can lead to serious complications. Once the bowel is covered, the nurse should call the RN to report the evisceration and obtain further instructions on how to proceed. Turning the patient to the side of the evisceration or raising the patient up to a high Fowler's position may be appropriate interventions depending on the patient's overall condition, but covering the bowel with a sterile saline dressing should be the initial priority.

Question 6

What is the usual length of time before suture removal?

Accepted Answer

Sutures are usually removed after 7 to 10 days unless otherwise specified by the healthcare provider. This allows for adequate wound healing and closure before the sutures are removed.

Question 7

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?

Accepted Answer

Administering an analgesic at least 30 minutes before the dressing change allows sufficient time for the medication to take effect, thereby promoting patient comfort during the procedure.

Question 8

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?

Accepted Answer

Circling and dating the outline of the exudate on the dressing is the best option because it provides a visual record of the amount and pattern of drainage without disturbing the wound or dressing. Weighing the patient to estimate the weight of the saturated dressing may be inaccurate and time-consuming. Reinforcing the dressing does not provide an accurate assessment of the amount of drainage, and counting each dressing as 1 mL of drainage does not account for variations in the amount and consistency of the exudate.

Question 9

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?

Accepted Answer

A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively.

Question 10

What marked advantage does primary intention have over other phases of wound healing?

Accepted Answer

Primary intention healing involves the edges of a wound being brought together and closed with sutures, staples or adhesive strips, resulting in minimal scarring. This is in contrast to secondary intention healing where the wound is left to heal on its own or tertiary intention healing where the wound is initially left open before being closed later, both of which can result in more noticeable scarring.

Question 11

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?

Accepted Answer

Fibrin is the substance in the clot that holds the wound together. Thrombin is an enzyme that plays a role in the formation of fibrin. Protime and calcium are factors involved in the coagulation cascade, but they do not directly hold the wound together.

Question 12

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?

Accepted Answer

The combination of a rapid pulse, decreased blood pressure, decreased urinary output, and dry dressing could indicate internal hemorrhage. This is a serious complication that requires immediate medical attention. Pain shock, dehydration, and acute infection may cause some of these symptoms, but not all of them combined.

Question 13

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

Accepted Answer

The nurse should direct the flow of the irrigant from the area of least contamination to the area of most contamination to prevent further contamination of the wound.

Question 14

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 considered normal?

Accepted Answer

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

Question 15

What technique will the nurse implement to assist the postoperative patient to cough?

Accepted Answer

Splinting the abdomen with a pillow can help to reduce pain and support the incision while the patient coughs. This can be especially helpful for postoperative patients who may be hesitant to cough due to pain or fear of incisional injury. Supporting the patient's back and leaning them against the bedside table are not effective coughing techniques, and offering an antitussive would actually suppress the coughing reflex and hinder recovery.

Question 16

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?

Accepted Answer

Wet-to-dry dressings are used for mechanical débridement, meaning the dried dressing adheres to the wound and removes any dead tissue or debris when removed. This can help promote wound healing by preparing the wound bed for new tissue growth.

Question 17

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?

Accepted Answer

Moisten the dressing with sterile water before attempting to remove it. This will help to loosen the dressing and prevent further injury to the wound or surrounding tissue.

Question 18

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?

Accepted Answer

During the first 24 hours following surgery, it is standard practice to assess for bleeding under the dressing every 2 to 4 hours to promptly identify and manage any postoperative hemorrhage.

Question 19

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?

Accepted Answer

Leaving the remaining staples in place is crucial to prevent further separation of the wound. Removing more staples or continuing as planned could exacerbate the wound separation. The nurse should document the incident to ensure proper follow-up and care adjustments.

Question 20

The nurse is instructing a patient who has a drain in a surgical wound.How will the nurse indicate that the wound will heal?

Accepted Answer

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

Quiz 22: Surgical Wound Care