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The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?
- A. Offer fluids every 4 hours.
- B. Encourage the consumption of large meals.
- C. Encourage up to 1000 mL of daily fluid intake.
- D. Encourage the consumption of small frequent meals.
Correct Answer: D
Rationale: To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours.
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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 nurse assessing a postoperative patient discovers that the pulse is rapid blood pressure has decreased urinary output has decreased and the dressing is dry. What can the nurse determine is indicated by these findings?
- A. Pain shock
- B. Dehydration
- C. Internal hemorrhage
- D. Acute infection
Correct Answer: C
Rationale: If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.
The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
- A. Call the RN.
- B. Cover the bowel with a sterile saline dressing.
- C. Turn the patient to the side of the evisceration.
- D. Raise the patient up to a high Fowler's position.
Correct Answer: B
Rationale: Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler's position to relieve strain on the suture line.
The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
- A. Improves overall tissue perfusion.
- B. Promotes release of oxygen to tissues.
- C. Causes hemoglobin to have a greater affinity for oxygen.
- D. Causes hemoglobin to have a decreased affinity for oxygen.
Correct Answer: C
Rationale: Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.
The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?
- A. Primary intention
- B. Secondary intention
- C. Tertiary intention
- D. Deliberate intention
Correct Answer: C
Rationale: When wounds are kept open by a drain, they heal by tertiary intention.