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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.
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Which are the phases of wound healing?
- A. Reconstruction
- B. Hemostasis
- C. Inflammation
- D. Granulation
- E. Maturation
Correct Answer: A,B,C,E
Rationale: The steps in wound healing are hemostasis, inflammation, reconstruction, and maturation.
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 nurse assessing a patient's wound notes pale red watery drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: D
Rationale: Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding.
The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
- A. Dirty wound
- B. Clean-contaminated wound
- C. Contaminated wound
- D. Clean wound
Correct Answer: D
Rationale: A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively.
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.