Nokea
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.
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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.
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.
The nurse assessing a patient's wound notes thick yellow drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: B
Rationale: Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. 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 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.
When preparing to remove a dressing the nurse should don ___ gloves.
Correct Answer: clean
Rationale: To remove a dressing, clean gloves are appropriate.