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The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
- A. Weigh the patient to estimate the weight of the saturated dressing.
- B. Reinforce the dressing.
- C. Circle and date the outline of the exudate on the dressing.
- D. Count each dressing as 1 mL of drainage.
Correct Answer: C
Rationale: Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.
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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.
What marked advantage does primary intention have over other phases of wound healing?
- A. Healing is rapid.
- B. Healing rarely becomes infected.
- C. Minimal scarring results.
- D. Healing is painless.
Correct Answer: C
Rationale: Wounds that heal by primary intention have minimal scarring.
What technique will the nurse implement to assist the postoperative patient to cough?
- A. Support the patient's back.
- B. Offer an antitussive.
- C. Splint the abdomen with a pillow.
- D. Lean patient against the bedside table.
Correct Answer: C
Rationale: To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.
The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?
- A. Offer fluids every 4 hours.
- B. Encourage the consumption of large meals.
- C. Encourage up to 1000 mL of daily fluid intake.
- D. Encourage the consumption of small frequent meals.
Correct Answer: D
Rationale: To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours.