Nokea
The drainage on the dressing over a patient's old IV site is clear and slightly yellow. This drainage is described as
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: C
Rationale: Serous drainage is clear or slightly yellow fluid, often seen in healing wounds or minor injuries like an old IV site.
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A patient has had emergency surgery because of a bowel obstruction. The wound becomes infected with Escherichia coli. This likely occurred because
- A. These bacteria are always present on the skin and easily enter a wound if sterile technique is not used.
- B. These bacteria grow in the absence of oxygen, which is the case in the bowel.
- C. These bacteria are present in the bowel, and with emergency surgery there is no time to perform special bowel preparations.
- D. The patient had poor nutritional intake because these bacteria grow in dying tissue.
Correct Answer: C
Rationale: E. coli, common in the bowel, likely contaminated the wound during emergency surgery due to lack of bowel prep time.
You are a nurse, and you are running behind schedule on a very busy workday. The UAP offers to change a patient's abdominal dressing for you. She is a first-semester nursing student. Which is the most appropriate response?
- A. That would be great. Don't forget to measure the open area in the middle of her incision for me.'
- B. I know you have been taught to do this in school, so you are not the same as the other UAPs. Go ahead and change the dressing.'
- C. Thanks, but could you help Mr. Wu walk in the hall instead? That way I can get that dressing changed.'
- D. You know you can't do that as a UAP. I would be in big trouble if I let you change that dressing!'
Correct Answer: C
Rationale: UAPs, including nursing students, are not permitted to perform complex tasks like dressing changes, which require nursing judgment. Delegating a simpler task is appropriate.
A patient with an open leg wound has the following laboratory results on his chart: WBC 15,350 mm^3 with an elevated percentage of neutrophils. What does this tell you about the patient's wound?
- A. He most likely no longer has any wound infection.
- B. He most likely has an acute wound infection.
- C. He most likely has a chronic wound infection.
- D. He most likely has a widespread bacterial infection.
Correct Answer: B
Rationale: Elevated WBC and neutrophils indicate an active immune response, typically seen in acute infections, suggesting the wound is acutely infected.
The nurse realizes that the patient with a shoulder incision needs more teaching when the patient says
- A. I know the signs of infection and will report them to the physician if they occur.'
- B. If my fever goes above 100 degrees, I will notify my doctor.'
- C. I know how to change the dressing on my incision and have done it three times.'
- D. I will take these antibiotics until the doctor removes the staples.'
Correct Answer: D
Rationale: Antibiotics should be taken for the full prescribed course, not until staples are removed, indicating a need for further teaching.
Classify the following wounds as either open or closed: A. Contusion, B. Abrasion, C. Laceration, D. Pressure injury
- A. A: Closed, B: Open, C: Open, D: Open
- B. A: Open, B: Closed, C: Closed, D: Closed
- C. A: Closed, B: Closed, C: Open, D: Open
- D. A: Open, B: Open, C: Closed, D: Closed
Correct Answer: A
Rationale: Contusions are closed (bruising under intact skin), while abrasions, lacerations, and pressure injuries are open (skin is broken).