Nokea
The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
- A. 50 mL
- B. 100 mL
- C. 200 mL
- D. 300 mL
Correct Answer: D
Rationale: Drainage greater than 300 mL in 24 hours is considered abnormal.
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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.
The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service?
- A. Positive pressure is applied by this device.
- B. Healing is facilitated by decrease in drainage.
- C. Promotes formulation of granulation tissue.
- D. Reduces local and peripheral edema.
- E. Drops bacterial level in wound.
Correct Answer: C,D,E
Rationale: Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed.
What phase of wound healing is a wound in when blood and fluid flow into the vascular space and produce edema erythema heat and pain?
- A. Healing
- B. Inflammatory
- C. Reconstruction
- D. Maturation
Correct Answer: B
Rationale: During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space.
When removing the dressing on a patient the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
- A. Call the RN.
- B. Gently remove the gauze with sterile forceps.
- C. Cover with occlusive dressing.
- D. Moisten the dressing with sterile water.
Correct Answer: D
Rationale: When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.
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.