Nokea
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?
- A. Fibrin
- B. Thrombin
- C. Protime
- D. Calcium
Correct Answer: A
Rationale: Fibrin in the clot begins to hold the wound together.
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The nurse assessing a patient's wound notes thick yellow drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: B
Rationale: Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage.
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?
- A. Destruction of tissue
- B. Bleeding
- C. Mechanical débridement
- D. Prevention of infection
Correct Answer: C
Rationale: The primary purpose of a wet-to-dry dressing is to débride a wound mechanically.
What is the classification for the Jackson-Pratt drainage removal system?
- A. Sterile drainage system
- B. Closed drainage system
- C. Open drainage system
- D. Self-measuring drainage system
Correct Answer: B
Rationale: The Jackson-Pratt removal system is a type of closed drainage system.
When preparing to remove a dressing the nurse should don ___ gloves.
Correct Answer: clean
Rationale: To remove a dressing, clean gloves are appropriate.
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?
- A. 2.5 in
- B. 6 in
- C. 12 in
- D. 18 in
Correct Answer: C
Rationale: When wound irrigation is done at home with a handheld showerhead, the showerhead should be held approximately 12 in from the wound.