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What is the usual length of time before suture removal?
- A. 2 to 3 days
- B. 4 to 5 days
- C. 5 to 6 days
- D. 7 to 10 days
Correct Answer: D
Rationale: Sutures are generally removed within 7 to 10 days.
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What phase of wound healing is a wound in when blood and fluid flow into the vascular space and produce edema erythema heat and pain?
- A. Healing
- B. Inflammatory
- C. Reconstruction
- D. Maturation
Correct Answer: B
Rationale: During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space.
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.
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.
When removing the dressing on a patient the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
- A. Call the RN.
- B. Gently remove the gauze with sterile forceps.
- C. Cover with occlusive dressing.
- D. Moisten the dressing with sterile water.
Correct Answer: D
Rationale: When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.
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.