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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.
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What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?
- A. Tegaderm or Opsite
- B. Abdominal pads held in place with paper tape
- C. Retention
- D. Montgomery straps
Correct Answer: D
Rationale: Montgomery straps secure dressings with ties, allowing changes without removing tape from the skin.
A nurse is assessing a surgical patient for internal hemorrhage. Which of the following would indicate internal hemorrhage?
- A. Headache.
- B. Rising pulse and falling blood pressure.
- C. Lethargy, falling pulse, and rising blood pressure.
- D. Restlessness, rising pulse, and falling blood pressure.
Correct Answer: D
Rationale: Restlessness, rising pulse, and falling blood pressure indicate hypovolemic shock from internal hemorrhage due to blood loss affecting circulation.
The nurse assesses the large raised scar on the African American patient. How should the nurse document the lesion?
- A. Contusion
- B. Keloid
- C. Laceration
- D. Hematoma
Correct Answer: B
Rationale: A keloid is a raised scar that grows beyond the original wound, common in African Americans due to increased collagen production. A contusion is a bruise, a laceration is a tear, and a hematoma is a blood collection under the skin.
Many factors aid in healing. You can assist the patient in improving their healing ability by encouraging the following (Select all that apply):
- A. Keeping skin and surrounding tissue clean and dry.
- B. Proper nutrition with adequate protein and vitamins.
- C. Resting as much as possible and keeping the incisional area still.
- D. Increasing fluid intake to at least 4000 mL per day.
- E. Exercise and deep breathing to increase oxygen.
Correct Answer: A,B,C,E
Rationale: A: Reduces infection risk. B: Supports tissue repair. C: Minimizes tension on the wound. E: Oxygen aids healing. 4000 mL (D) is excessive unless specified.
The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:
- A. Drawing the wound edges together using negative pressure.
- B. Strengthening the wall of the wound.
- C. Interrupting the proliferation of bacteria in the wound.
- D. Making and air occlusive cover for the wound
Correct Answer: A
Rationale: Vacuum-assisted closure uses negative pressure to draw wound edges together, promoting granulation and healing.