Nokea
Which solutions can be used on a wet-to-dry dressing?
- A. Normal saline
- B. Lactated Ringer
- C. Acetic acid
- D. Dakin
- E. Lysol
Correct Answer: A,B,C,D
Rationale: Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings.
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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 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.
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.
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.
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.