Chapter 22 and 42: Surgical Wound Care

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?

• Primary intention

• Secondary intention

• Tertiary intention

• Deliberate intention

Answer explanation

When wounds are kept open by a drain, they heal by tertiary intention.

What technique will the nurse implement to assist the postoperative patient to cough?

• Support the patient’s back.

• Offer an antitussive.

• Splint the abdomen with a pillow.

• Lean patient against the bedside table.

Answer explanation

To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.

The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?

• Serosanguineous

• Sanguineous

• Serous

• Purulent

Answer explanation

The term sanguineous means bloody. It is indicative of active bleeding.

What is the advantage of an occlusive dressing?

• Allows air to the incision.

• Keeps the incision moist.

• Delays epithelialization.

• Does not have to be changed.

Answer explanation

Occlusive dressings keep the incision moist and increase epithelialization.

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?

• Call the RN.

• Gently remove the gauze with sterile forceps.

• Cover with occlusive dressing.

• Moisten the dressing with sterile water.

Answer explanation

When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.

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?

• 2.5 in

• 6 in

• 12 in

• 18 in

Answer explanation

When wound irrigation is done at home with a handheld showerhead, the showerhead should be held approximately 12 in from the wound.

The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?

• From the area of least contamination to the area of most contamination

• Forcefully into the wound

• Gently over the skin into the wound

• From a distance of about 12 in

Answer explanation

The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

• Call the RN.

• Cover the bowel with a sterile saline dressing.

• Turn the patient to the side of the evisceration.

• Raise the patient up to a high Fowler’s position.

Answer explanation

Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line.

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?

• Remove 7 more alternate staples and securely tape with Steri-Strips.

• Cover with moist dressing and apply a binder.

• Continue to remove staples as ordered because this is an expected outcome.

• Leave the 12 staples in place and record the separation.

Answer explanation

If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation.

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?

• Weigh the patient to estimate the weight of the saturated dressing.

• Reinforce the dressing.

• Circle and date the outline of the exudate on the dressing.

• Count each dressing as 1 mL of drainage.

Answer explanation

Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.