SOLUTIONS SCORED A+
✔✔The nurse is caring for a patient who had knee replacement surgery 5 days ago.
The patient's knee appears red and is very warm to the touch. The patient requests pain
medication. Which of the following would be a correct explanation of what the nurse has
assessed? - ✔✔The patient is showing signs of postopperative infection
✔✔The nurse is caring for a patient after major abdominal surgery. Which of the
following demonstrates correct understanding of wound dehiscence? - ✔✔The nurse
should be alert for an increase in serosanguineous drainage from the wound.
✔✔The nurse reports that a patient has a wound on his abdomen that is healing by
secondary intention. The nurse understands this means the patient: - ✔✔Is at greater
risk for infection.
✔✔A postoperative diabetic patient had an exploratory laparotomy (incision in the
abdomen) 5 days ago. The patient's history indicates obesity with a body mass index
(BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands
the patient should be observed for: - ✔✔Wound dehiscence.
✔✔The patient asks the nurse what the purpose is for his Hemovac drain. What is the
nurse's best response? - ✔✔To provide suction to remove and collect drainage from
your wound to help it heal."
✔✔When should wound drainage be cultured? - ✔✔When there is a change in color,
amount, or odor of drainage.
✔✔The nurse is teaching a patient how to empty his Hemovac drain. Which action of
the patient indicates that further instruction is needed? The patient: - ✔✔empties the
Hemovac drain, replaces the plug, and records the amount of drainage.
✔✔Because a patient has a Penrose drain, the nurse inspects the patient's skin and
changes the dressing by placing a drainage sponge around the drain. What is the
rationale for doing this? - ✔✔Because drainage can be irritating to the skin and may
cause skin breakdown.
✔✔Which of the following is inappropriate to delegate to nursing assistive personnel
(NAP)? - ✔✔Assessment of wound drainage.
✔✔The patient complains "It feels like the drain is pulling on my surgical site." What is
the nurse's best action? - ✔✔Make sure there is slack in the tubing from the reservoir to
the wound, allowing the patient movement and avoiding pulling at the insertion site.
, ✔✔A patient is to go home with a Jackson-Pratt drain. Which of the following
statements, if made by the patient, indicates further teaching is required? - ✔✔"If
drainage suddenly stops, it means the drain is ready to be removed."
✔✔Which of the following are functions of dressings? (Select all that apply.) - ✔✔To
prevent contamination
To promote hemostasis.
Wound debridement.
✔✔Which of the following patients would be expected to benefit from a damp-to-dry
dressing? (Select all that apply.) - ✔✔A 30-year-old after large cyst removal with
necrotic tissue present in crater-type wound.
A 24-year-old patient with an open and infected wound from a spider bite
✔✔The nurse is observing the patient's wife perform the damp-to-dry dressing change.
Which actions, if made by the patient's wife, indicate that further instruction is needed?
(Select all that apply.) - ✔✔Packs wound tightly.
Leaves contact or primary dressing dripping moist.
✔✔A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to
complain of pain. What measures may be taken? (Select all that apply.) - ✔✔Switch to
the white polyvinyl alcohol (PVA) soft foam.
Decrease the pressure setting.
Administer pain medication.
✔✔During a sterile dressing change, when are the gloves changed? - ✔✔After the old
dressing is removed and before cleansing the wound.
✔✔A patient states that she is unable to get her transparent dressing to stay in place.
What instruction should the nurse provide the patient? - ✔✔"Make sure that you have a
margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is
thoroughly dry before applying the dressing."
✔✔A patient asks the nurse why the Montgomery ties are being used instead of regular
tape. What is the nurse's best response? - ✔✔"Montgomery ties avoid frequent removal
of tape, which is irritating to the skin during dressing changes."
✔✔How can the nurse determine that negative pressure is being achieved with a wound
V.A.C.? - ✔✔The nurse can check for air leaks by listening with a stethoscope or by
moving the hand around the edges of the wound while applying light pressure..