Nokea
When preparing to remove a dressing the nurse should don ___ gloves.
Correct Answer: clean
Rationale: To remove a dressing, clean gloves are appropriate.
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The nurse assessing a postoperative patient discovers that the pulse is rapid blood pressure has decreased urinary output has decreased and the dressing is dry. What can the nurse determine is indicated by these findings?
- A. Pain shock
- B. Dehydration
- C. Internal hemorrhage
- D. Acute infection
Correct Answer: C
Rationale: If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.
The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the handheld showerhead from the wound when irrigating the wound?
- A. 2.5 in
- B. 6 in
- C. 12 in
- D. 18 in
Correct Answer: C
Rationale: When wound irrigation is done at home with a handheld showerhead, the showerhead should be held approximately 12 in from the wound.
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 assures a patient that the purple raised immature scar of a surgical wound is normal and caused by ___ formation.
Correct Answer: collagen
Rationale: Collagen forms as an immature scar over a new surgical 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.