Nokea
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.
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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.
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 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.
The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
- A. From the area of least contamination to the area of most contamination
- B. Forcefully into the wound
- C. Gently over the skin into the wound
- D. From a distance of about 12 in
Correct Answer: A
Rationale: The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.
The nurse assessing a patient's wound notes a clear watery drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: A
Rationale: Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. 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.