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What is the advantage of an occlusive dressing?
- A. Allows air to the incision.
- B. Keeps the incision moist.
- C. Delays epithelialization.
- D. Does not have to be changed.
Correct Answer: B
Rationale: Occlusive dressings keep the incision moist and increase epithelialization.
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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.
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 carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
- A. 50 mL
- B. 100 mL
- C. 200 mL
- D. 300 mL
Correct Answer: D
Rationale: Drainage greater than 300 mL in 24 hours is considered abnormal.
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.
The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: C
Rationale: Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.