Nokea
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.
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The day following surgery the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: B
Rationale: The term sanguineous means bloody. It is indicative of active bleeding.
The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
- A. From the area of least contamination to the area of most contamination
- B. Forcefully into the wound
- C. Gently over the skin into the wound
- D. From a distance of about 12 in
Correct Answer: A
Rationale: The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.
Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?
- A. Fibrin
- B. Thrombin
- C. Protime
- D. Calcium
Correct Answer: A
Rationale: Fibrin in the clot begins to hold the wound together.
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 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.