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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.
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The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the health care provider. What is an advantage of gauze bandages?
- A. Provision of warmth.
- B. Applies strong pressure.
- C. Antibacterial effects.
- D. Prevents skin maceration.
Correct Answer: D
Rationale: Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation that helps prevent skin maceration (the softening and breaking down of skin from prolonged exposure to moisture). Flannel bandages provide warmth. Elastic bandages are effective for pressure application. Gauze bandages do not have antibacterial effects.
What are the advantages of a transparent dressing?
- A. Adheres to undamaged skin.
- B. Contains the exudate.
- C. Reduces wound contamination.
- D. Serves as a barrier to external bacteria.
- E. Slows epithelial growth.
Correct Answer: A,B,C,D
Rationale: Transparent dressings have the advantages of adhering to undamaged skin, containing the exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding epithelial growth.
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.
What is the classification for the Jackson-Pratt drainage removal system?
- A. Sterile drainage system
- B. Closed drainage system
- C. Open drainage system
- D. Self-measuring drainage system
Correct Answer: B
Rationale: The Jackson-Pratt removal system is a type of closed drainage system.
The nurse encourages a patient recovering from a hysterectomy to drink at least ___ mL of fluid a day.
Correct Answer: 2000
Rationale: A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.