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After a Foley catheter has been removed, the nurse should assess the patient for:
a. hemorrhage.
b. constipation.
c. urinary retention.
d. bladder spasm.
C
What would be the correct explanation of catheter care?
a. Cleansing the first 2 in of the catheter with soap and water every shift
b. Disinfecting the entire catheter with alcohol every shift
c. Lubricating the catheter with antiseptic lotion every 24 hours
d. Cleansing the meatal-catheter junction every 24 hours
A
During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
a. Withdraw the catheter.
b. Ask the patient to bear down.
c. Continue to inflate the balloon.
d. Advance the catheter into the bladder.
D
When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy?
a. It is always permanent.
b. It drains semiliquid stool.
c. It has a much larger stoma.
d. It does not need a pouch.
B
Before inserting a nasogastric tube, what measurement should the nurse take?
a. Tip of the nose to the earlobe to the xiphoid process
b. Bridge of the nose to the xiphoid process
c. Nose to the top of the ear to the stomach
d. Clavicular notch to the stomach
A
Bladder training is initiated on a patient preparing for discharge to home from an acute care setting. When should voiding times be scheduled? (Select all that apply.)
a. At least every hour
b. At patients request
c. Before each meal
d. At bedtime
e. Upon waking up in morning
C, D, E
The nurse administers an enema to a patient as ordered. What should be documented?
(Select all that apply.)
a. Date
b. Time
c. Type and volume of enema
d. Type and volume of enema
e. Characteristics of results
f. How patient tolerates procedure
A, B, C, D, E, F
__________ is the inability to control urine or bowel elimination and can be a psychologically distressing and socially disruptive problem, especially among older adults.
Incontinence
A ____________ tube is a flexible, hollow tube that is passed into the stomach via the nasopharynx.
Nasogastric
A ____________ is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
Urostomy
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
C
What technique will the nurse implement to assist the postoperative patient to cough?
a. Support the patient's back.
b. Offer an antitussive.
c. Splint the abdomen with a pillow.
d. Lean patient against the bedside table.
C
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
B
What is the advantage of an occlusive dressing?
a. Allows air to the incision.
b. Keeps the incision moist.
c. Delays epithelialization.
d. Does not have to be changed.
B
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.
D
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. 6in
c. 12in
d. 18in
C
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
A
The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
a. Call the RN.
b. Cover the bowel with a sterile saline dressing.
c. Turn the patient to the side of the evisceration.
d. Raise the patient up to a high Fowler's position.
B
The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?
a. Remove 7 more alternate staples and securely tape with Steri-Strips.
b. Cover with moist dressing and apply a binder.
c. Continue to remove staples as ordered because this is an expected outcome.
d. Leave the 12 staples in place and record the separation.
D
The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
a. Weigh the patient to estimate the weight of the saturated dressing.
b. Reinforce the dressing.
c. Circle and date the outline of the exudate on the dressing.
d. Count each dressing as 1 mL of drainage.
C
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
D
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
A
What phase of wound healing is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?
a. Healing
b. Inflammatory
c. Reconstruction
d. Maturation
B
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.
C
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
C
The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?
a. After the dressing change
b. At least 15 minutes before the dressing change
c. At least 30 minutes before the dressing change
d. At least 1 hour before the dressing change
C
The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
a. Destruction of tissue
b. Bleeding
c. Mechanical debridement
d. Prevention of infection
C
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
C
What is the usual length of time before suture removal?
a. 2to3days
b. 4to5days
c. 5to6days
d. 7to10days
D
The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
a. 50mL
b. 100 mL
c. 200 mL
d. 300 mL
D
What is the classification for the Jackson-Pratt drainage removal system?
a. Sterile drainage system
b. Closed drainage system
c. Open drainage system
d. Self-measuring drainage system
B
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.
D
The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?
a. Smoking increases the amount of tissue oxygenation.
b. Smoking increases the amount of functional hemoglobin in blood.
c. Smoking may decrease platelet aggregation and cause hypercoagulability.
d. Smoking interferes with normal cellular mechanisms that promote release of
oxygen.
D
The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
a. Improves overall tissue perfusion.
b. Promotes release of oxygen to tissues.
c. Causes hemoglobin to have a greater affinity for oxygen.
d. Causes hemoglobin to have a decreased affinity for oxygen.
C
The nurse assessing a patient's wound notes a clear watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage
A
The nurse assessing a patient's wound notes thick, yellow drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage
B
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
D
The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage
C
The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?
a. Cellulitis
b. Dehiscence
c. Evisceration
d. Extravasation
B
The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the health care provider. What is an advantage of gauze bandages?
a. Provision of warmth.
b. Applies strong pressure.
c. Antibacterial effects.
d. Prevents skin maceration.
D
A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for a stage 2 foot injury. The patient refuses to follow an ADA diet as ordered by a health care provider and is morbidly obese. The nurse assesses the injury to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What patient problem will be identified as a priority?
a. Infection
b. Altered nutrition: more than body requirements
c. Impaired skin integrity
d. Altered peripheral tissue perfusion
B
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? (Select all that apply.)
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.
C, D, E
Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction
b. Hemostasis
c. Inflammation
d. Granulation
e. Maturation
A, B, C, E
Which solutions can be used on a wet-to-dry dressing? (Select all that apply.)
a. Normal saline
b. Lactated Ringer
c. Acetic acid
d. Dakin
e. Lysol
A, B, C, D
What are the advantages of a transparent dressing? (Select all that apply.)
a. Adheres to undamaged skin.
b. Contains the exudate.
c. Reduces wound contamination.
d. Serves as a barrier to external bacteria.
e. Slows epithelial growth.
A, B, C, D
The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by ___________ formation.
Collagen
The nurse encourages a patient recovering from a hysterectomy to drink at least ___________ mL of fluid a day.
2000
When preparing to remove a dressing, the nurse should don ___________ gloves.
Clean
Note
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