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The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing?
- A. Every 30 minutes
- B. Every 60 minutes
- C. Every 2 to 4 hours
- D. Every 5 to 8 hours
Correct Answer: C
Rationale: The nurse inspects the dressing every 2 to 4 hours for the first 24 hours.
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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.
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.
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 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.
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.