Nokea
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.
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What marked advantage does primary intention have over other phases of wound healing?
- A. Healing is rapid.
- B. Healing rarely becomes infected.
- C. Minimal scarring results.
- D. Healing is painless.
Correct Answer: C
Rationale: Wounds that heal by primary intention have minimal scarring.
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 nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service?
- A. Positive pressure is applied by this device.
- B. Healing is facilitated by decrease in drainage.
- C. Promotes formulation of granulation tissue.
- D. Reduces local and peripheral edema.
- E. Drops bacterial level in wound.
Correct Answer: C,D,E
Rationale: Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed.
The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
- A. Weigh the patient to estimate the weight of the saturated dressing.
- B. Reinforce the dressing.
- C. Circle and date the outline of the exudate on the dressing.
- D. Count each dressing as 1 mL of drainage.
Correct Answer: C
Rationale: Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.
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.