Nokea
Your patient has a large abdominal wound with copious drainage and many layers of gauze 4x4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient?
- A. Change to surgical adhesive instead of tape to hold dressings in place
- B. Call the doctor and ask for an order to decrease dressing change frequency
- C. Ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape
- D. Wrap gauze around the patient's trunk to hold the dressings in place
Correct Answer: C
Rationale: Montgomery straps or an abdominal binder reduce skin irritation by minimizing tape use while securing dressings.
You may also like to solve these questions
Which one of the following interventions would you rateas the most important for care of his pressure injury?
- A. Change the wet-to-damp dressing on his right hipwound gid using sterile technique.
- B. Tell dietary service about his food likes and dislikes.
- C. Reposition the patient every 2 hours around the clock,avoiding the right lateral position.
- D. Assess the condition of the pressure injury once daily.
- E. Provide Foley care every shift.
- F. Work to increase the length of time the patient can tolerate sitting in a chair.
Correct Answer: C
Rationale: Frequent repositioning is the most critical intervention in preventing further skin breakdown and promoting healing of pressure injuries. Since the wound is on his right hip, avoiding the right lateral position helps reduce pressure on the affected area, improving circulation and tissue recovery. This intervention directly addresses pressure relief, which is the primary cause of pressure injuries.
A patient has signs of infection in his left shoulder incision-erythema, warmth, and a small amount of purulent drainage. You prepare to report this to the health-care provider. Which information will you have ready when you call?
- A. Vital signs
- B. Name and dosage of pain medication currently ordered
- C. Appropriate laboratory results
- D. Patient's rating of incisional pain
- E. Description of the wound and drainage
- F. Names of all staff who have changed his dressing since surgery
- G. Signs of infection you observe
Correct Answer: A,C,E,G
Rationale: Vital signs, lab results, wound description, and infection signs are critical for the provider to assess and plan treatment.
Which one of the following assessment findings makes it impossible to stage a pressure injury?
- A. Purulent drainage
- B. Eschar
- C. Sloughing tissue
- D. Erythema
- E. Drainage
- F. Signs of infection
- G. Undermining
Correct Answer: B
Rationale: Eschar obscures the wound bed, making it impossible to assess the depth and stage of a pressure injury.
A patient's J-P drain should be emptied:
- A. every 2 hours
- B. every 8 hours
- C. when one-half to two-thirds full
- D. only when it needs to be reactivated
- E. when the container is full
Correct Answer: C
Rationale: A J-P drain should be emptied when one-half to two-thirds full to maintain proper suction and prevent complications.
The phase of healing during which granulation tissue forms in a wound is the:
- A. inflammatory phase
- B. reconstruction phase
- C. maturation phase
- D. remodeling phase
Correct Answer: B
Rationale: Granulation tissue forms during the reconstruction (proliferative) phase, filling the wound with new tissue.