Nokea
A patient's J-P drain should be emptied:
- A. every 2 hours
- B. every 8 hours
- C. when one-half to two-thirds full
- D. only when it needs to be reactivated
- E. when the container is full
Correct Answer: C
Rationale: A J-P drain should be emptied when one-half to two-thirds full to maintain proper suction and prevent complications.
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A patient returns from surgery with a left shoulder dressing. A 3-inch diameter spot of red drainage is visible on the anterior portion of the dressing. The health-care provider does not want the dressing disturbed for 24 hours. What will you do?
- A. Call the health-care provider to report the drainage and request a change in orders
- B. Reinforce the dressing by adding several gauze 4x4s over the area
- C. Draw a line on the dressing outlining the drainage, with the date, time, and your initials
- D. Document the drainage in the chart and observe for further drainage over the next several hours
Correct Answer: C,D
Rationale: Outlining and documenting the drainage allows monitoring for expansion without disturbing the dressing, per provider orders.
Your patient has a large abdominal wound with copious drainage and many layers of gauze 4x4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient?
- A. Change to surgical adhesive instead of tape to hold dressings in place
- B. Call the doctor and ask for an order to decrease dressing change frequency
- C. Ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape
- D. Wrap gauze around the patient's trunk to hold the dressings in place
Correct Answer: C
Rationale: Montgomery straps or an abdominal binder reduce skin irritation by minimizing tape use while securing dressings.
The phase of healing during which granulation tissue forms in a wound is the:
- A. inflammatory phase
- B. reconstruction phase
- C. maturation phase
- D. remodeling phase
Correct Answer: B
Rationale: Granulation tissue forms during the reconstruction (proliferative) phase, filling the wound with new tissue.
Which one of the following interventions would you rateas the most important for care of his pressure injury?
- A. Change the wet-to-damp dressing on his right hipwound gid using sterile technique.
- B. Tell dietary service about his food likes and dislikes.
- C. Reposition the patient every 2 hours around the clock,avoiding the right lateral position.
- D. Assess the condition of the pressure injury once daily.
- E. Provide Foley care every shift.
- F. Work to increase the length of time the patient can tolerate sitting in a chair.
Correct Answer: C
Rationale: Frequent repositioning is the most critical intervention in preventing further skin breakdown and promoting healing of pressure injuries. Since the wound is on his right hip, avoiding the right lateral position helps reduce pressure on the affected area, improving circulation and tissue recovery. This intervention directly addresses pressure relief, which is the primary cause of pressure injuries.
Which one of the following assessment findings makes it impossible to stage a pressure injury?
- A. Purulent drainage
- B. Eschar
- C. Sloughing tissue
- D. Erythema
- E. Drainage
- F. Signs of infection
- G. Undermining
Correct Answer: B
Rationale: Eschar obscures the wound bed, making it impossible to assess the depth and stage of a pressure injury.