Question 1

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.

Question 2

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

The nurse inspects the dressing every 2 to 4 hours for the first 24 hours.

Question 3

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 4

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

Accepted Answer

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

Question 5

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

The primary purpose of a wet-to-dry dressing is to debride a wound mechanically.

Question 6

The physician 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

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 7

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

Accepted Answer

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

Question 8

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

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

Question 9

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

Accepted Answer

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

Question 10

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

Accepted Answer

The term sanguineous means bloody. It is indicative of active bleeding.

Question 11

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 irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.

Question 12

What is the usual length of time before suture removal?

Accepted Answer

Sutures are generally removed within 7 to 10 days.

Question 13

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

If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation.

Question 14

The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the hand-held showerhead from the wound when irrigating the wound?

Accepted Answer

When wound irrigation is done at home with a hand-held showerhead, the showerhead should be held approximately 12 inches from the wound.

Question 15

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

Accepted Answer

Wounds that heal by primary intention have minimal scarring.

Question 16

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 17

What is the advantage of an occlusive dressing?

Accepted Answer

Occlusive dressings keep the incision moist and increase epithelialization.

Question 18

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 in the clot begins to hold the wound together.

Question 19

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

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 20

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

When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.

Quiz 14: Surgical Wound Care