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The nurse assures a patient that the purple raised immature scar of a surgical wound is normal and caused by ___ formation.
Correct Answer: collagen
Rationale: Collagen forms as an immature scar over a new surgical wound.
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Which are the phases of wound healing?
- A. Reconstruction
- B. Hemostasis
- C. Inflammation
- D. Granulation
- E. Maturation
Correct Answer: A,B,C,E
Rationale: The steps in wound healing are hemostasis, inflammation, reconstruction, and maturation.
The nurse encourages a patient recovering from a hysterectomy to drink at least ___ mL of fluid a day.
Correct Answer: 2000
Rationale: A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.
The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?
- A. Remove 7 more alternate staples and securely tape with Steri-Strips.
- B. Cover with moist dressing and apply a binder.
- C. Continue to remove staples as ordered because this is an expected outcome.
- D. Leave the 12 staples in place and record the separation.
Correct Answer: D
Rationale: If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation.
The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
- A. Dirty wound
- B. Clean-contaminated wound
- C. Contaminated wound
- D. Clean wound
Correct Answer: D
Rationale: A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively.
What is the advantage of an occlusive dressing?
- A. Allows air to the incision.
- B. Keeps the incision moist.
- C. Delays epithelialization.
- D. Does not have to be changed.
Correct Answer: B
Rationale: Occlusive dressings keep the incision moist and increase epithelialization.