Nokea
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.
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The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?
- A. Cellulitis
- B. Dehiscence
- C. Evisceration
- D. Extravasation
Correct Answer: B
Rationale: Dehiscence is separation of a surgical incision or rupture of a wound closure.
The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: C
Rationale: Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.
Which solutions can be used on a wet-to-dry dressing?
- A. Normal saline
- B. Lactated Ringer
- C. Acetic acid
- D. Dakin
- E. Lysol
Correct Answer: A,B,C,D
Rationale: Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings.
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 is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the handheld showerhead from the wound when irrigating the wound?
- A. 2.5 in
- B. 6 in
- C. 12 in
- D. 18 in
Correct Answer: C
Rationale: When wound irrigation is done at home with a handheld showerhead, the showerhead should be held approximately 12 in from the wound.