Nokea
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.
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Which solutions can be used on a wet-to-dry dressing?
- A. Normal saline
- B. Lactated Ringer
- C. Acetic acid
- D. Dakin
- E. Lysol
Correct Answer: A,B,C,D
Rationale: Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings.
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.
A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for a stage 2 foot injury. The patient refuses to follow an ADA diet as ordered by a health care provider and is morbidly obese. The nurse assesses the injury to be healing free from signs and symptoms of infection with a positive pedal pulse and warm to touch. What patient problem will be identified as a priority?
- A. Infection
- B. Altered nutrition: more than body requirements
- C. Impaired skin integrity
- D. Altered peripheral tissue perfusion
Correct Answer: B
Rationale: The nurse's assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority patient problem for this patient is altered nutrition: more than body requirements related to diet noncompliance.
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 with a surgical wound. How can the nurse promote healing?
- A. Offer fluids every 4 hours.
- B. Encourage the consumption of large meals.
- C. Encourage up to 1000 mL of daily fluid intake.
- D. Encourage the consumption of small frequent meals.
Correct Answer: D
Rationale: To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours.