Nokea
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.
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The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
- A. From the area of least contamination to the area of most contamination
- B. Forcefully into the wound
- C. Gently over the skin into the wound
- D. From a distance of about 12 in
Correct Answer: A
Rationale: The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.
When preparing to remove a dressing the nurse should don ___ gloves.
Correct Answer: clean
Rationale: To remove a dressing, clean gloves are appropriate.
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.
What is the usual length of time before suture removal?
- A. 2 to 3 days
- B. 4 to 5 days
- C. 5 to 6 days
- D. 7 to 10 days
Correct Answer: D
Rationale: Sutures are generally removed within 7 to 10 days.
What are the advantages of a transparent dressing?
- A. Adheres to undamaged skin.
- B. Contains the exudate.
- C. Reduces wound contamination.
- D. Serves as a barrier to external bacteria.
- E. Slows epithelial growth.
Correct Answer: A,B,C,D
Rationale: Transparent dressings have the advantages of adhering to undamaged skin, containing the exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding epithelial growth.