BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
ANSWER ALL QUESTIONS IN THIS SECTION
QUESTION 1
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:
opens the plug on the port for emptying the drainage reservoir and drains the
contents into the measuring container.
presses downward until the bottom and top of the Hemovac are in contact to
reestablish the vacuum.
holds the surfaces of the Hemovac together with one hand, cleans the opening and
plug with an alcohol swab with the other hand, and immediately replaces the plug.
empties the Hemovac drain, replaces the plug, and records the amount of drainage.
- ANSWERS-Empties the Hemovac drain, replaces the plug, records the amount of
drainage
QUESTION 2
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.
END OF
PAGE 1
, BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
Because a Penrose drain has to be frequently compressed to create a constant low-
pressure suction.
To prevent the tubing from migrating into the wound.
To advance the tube as the wound heals. - ANSWERS-Because drainage can be
irritating to the skin and may cause skin breakdown
QUESTION 3
Which of the following is inappropriate to delegate to nursing assistive personnel
(NAP)?
Emptying a closed drainage container.
Measuring the amount of drainage.
Assessment of wound drainage.
Reporting the amount on the patient's intake and output record. - ANSWERS-
Assessment of wound drainage
QUESTION 4
The patient complains "It feels like the drain is pulling on my surgical site." What
is the nurse's best action?
END OF
PAGE 2
, BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
Secure the drain above the incision to the dressing with tape and a safety pin and
instruct the patient to keep the drain above the insertion site when ambulating,
sitting, and lying.
Correct! 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.
Instruct the patient that this is the normal sensation of having a drain.
Have the patient lie down and advance the drain further into the patient until the
sensation is relieved and drainage is noted in tubing; secure a new dressing over
insertion site of drain. - ANSWERS-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
QUESTION 5
Which of the following are functions of dressings? (Select all that apply.)
To promote hemostasis.
To keep the wound bed dry.
Wound debridement.
To prevent contamination.
To increase circulation. - ANSWERS-To promote hemostasis
Wound debridement
To prevent contamination
END OF
PAGE 3
, BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
QUESTION 6
Which of the following patients would be expected to benefit from a damp-to-dry
dressing? (Select all that apply.)
A 24-year-old patient with an open and infected wound from a spider bite.
A 7-year-old with abrasions on the knees.
A 50-year-old with a postoperative knee-replacement incision.
A 30-year-old after large cyst removal with necrotic tissue present in crater-type
wound.
A 19-year-old with a superficial laceration on the arm. - ANSWERS-A 24-year-old
patient with an open and infected wound from a spider bite
A 30-year-old after large cyst removal with necrotic tissue present in crater-type
wound
QUESTION 7
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.)
Premedicates for pain.
END OF
PAGE 4
NURSING FUNDAMENTALS
EXAM
ANSWER ALL QUESTIONS IN THIS SECTION
QUESTION 1
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:
opens the plug on the port for emptying the drainage reservoir and drains the
contents into the measuring container.
presses downward until the bottom and top of the Hemovac are in contact to
reestablish the vacuum.
holds the surfaces of the Hemovac together with one hand, cleans the opening and
plug with an alcohol swab with the other hand, and immediately replaces the plug.
empties the Hemovac drain, replaces the plug, and records the amount of drainage.
- ANSWERS-Empties the Hemovac drain, replaces the plug, records the amount of
drainage
QUESTION 2
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.
END OF
PAGE 1
, BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
Because a Penrose drain has to be frequently compressed to create a constant low-
pressure suction.
To prevent the tubing from migrating into the wound.
To advance the tube as the wound heals. - ANSWERS-Because drainage can be
irritating to the skin and may cause skin breakdown
QUESTION 3
Which of the following is inappropriate to delegate to nursing assistive personnel
(NAP)?
Emptying a closed drainage container.
Measuring the amount of drainage.
Assessment of wound drainage.
Reporting the amount on the patient's intake and output record. - ANSWERS-
Assessment of wound drainage
QUESTION 4
The patient complains "It feels like the drain is pulling on my surgical site." What
is the nurse's best action?
END OF
PAGE 2
, BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
Secure the drain above the incision to the dressing with tape and a safety pin and
instruct the patient to keep the drain above the insertion site when ambulating,
sitting, and lying.
Correct! 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.
Instruct the patient that this is the normal sensation of having a drain.
Have the patient lie down and advance the drain further into the patient until the
sensation is relieved and drainage is noted in tubing; secure a new dressing over
insertion site of drain. - ANSWERS-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
QUESTION 5
Which of the following are functions of dressings? (Select all that apply.)
To promote hemostasis.
To keep the wound bed dry.
Wound debridement.
To prevent contamination.
To increase circulation. - ANSWERS-To promote hemostasis
Wound debridement
To prevent contamination
END OF
PAGE 3
, BSN 206 FOUNDATIONS OF 2025
NURSING FUNDAMENTALS
EXAM
QUESTION 6
Which of the following patients would be expected to benefit from a damp-to-dry
dressing? (Select all that apply.)
A 24-year-old patient with an open and infected wound from a spider bite.
A 7-year-old with abrasions on the knees.
A 50-year-old with a postoperative knee-replacement incision.
A 30-year-old after large cyst removal with necrotic tissue present in crater-type
wound.
A 19-year-old with a superficial laceration on the arm. - ANSWERS-A 24-year-old
patient with an open and infected wound from a spider bite
A 30-year-old after large cyst removal with necrotic tissue present in crater-type
wound
QUESTION 7
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.)
Premedicates for pain.
END OF
PAGE 4
