Nokea
The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?
- A. After the dressing change
- B. At least 15 minutes before the dressing change
- C. At least 30 minutes before the dressing change
- D. At least 1 hour before the dressing change
Correct Answer: C
Rationale: It may help to give an analgesic at least 30 minutes before exposing the wound.
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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.
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 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.
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.
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.