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A patient who underwent a mastectomy must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, which action should the nurse correct?
- A. Points the device away from herself while opening it.
- B. Refrains from touching the drainage spout with her hand.
- C. Compresses the device in her hand before closing it.
- D. Uses one alcohol wipe to clean both the spout and the plug.
Correct Answer: D
Rationale: Using one wipe for both spout and plug risks contamination; separate wipes maintain sterility.
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The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:
- A. Second intention.
- B. Fourth intention.
- C. Third intention.
- D. First intention.
Correct Answer: D
Rationale: First intention healing occurs with clean, sutured incisions, minimizing scarring.
What is the physiological effect of moist heat on the treated area?
- A. Numbing the area treated.
- B. Drawing fluid to the site of application.
- C. dilating the blood vessels
- D. Constricting the blood vessels.
Correct Answer: C
Rationale: Moist heat dilates blood vessels, increasing blood flow and promoting healing.
Because the patient with an abdominal dressing requires frequent dressing changes, and the abdomen is beginning to show skin irritation from repeated tape removal, the nurse would change the dressing procedure in order to use:
- A. Elastic adhesive tape.
- B. Karaya paste.
- C. Montgomery straps.
- D. Paper tape.
Correct Answer: C
Rationale: Montgomery straps allow frequent dressing changes without removing tape from the skin, reducing irritation.
The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: B
Rationale: Stage 2 involves partial-thickness loss with a pink, viable wound bed, unlike Stage 1 (intact skin) or Stage 3 (full-thickness).
A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:
- A. The moisture creates an environment suitable for the growth of microorganisms in a wound.
- B. Greater pressure is exerted by a wet bed.
- C. Shearing is more likely from wet sheets.
- D. The patient has to be repositioned for the bed to be changed.
Correct Answer: A
Rationale: Moisture from incontinence fosters microbial growth, increasing infection risk.