WorksheetsChapter 22 and 42: Surgical Wound Care
Total questions: 133
Worksheet time: 1hrs 13mins
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
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.
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
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.
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.
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
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
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.
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.
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.
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?
Dirty wound
Clean-contaminated wound
Contaminated wound
Clean wound
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?
Fibrin
Thrombin
Protime
Calcium
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?
Healing
Inflammatory
Reconstruction
Maturation
What marked advantage does primary intention have over other phases of wound healing?
Healing is rapid.
Healing rarely becomes infected.
Minimal scarring results.
Healing is painless.
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?
Every 30 minutes
Every 60 minutes
Every 2 to 4 hours
Every 5 to 8 hours
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?
After the dressing change
At least 15 minutes before the dressing change
At least 30 minutes before the dressing change
At least 1 hour before the dressing change
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?
Destruction of tissue
Bleeding
Mechanical débridement
Prevention of infection
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?
Pain shock
Dehydration
Internal hemorrhage
Acute infection
What is the usual length of time before suture removal?
2 to 3 days
4 to 5 days
5 to 6 days
7 to 10 days
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?
50 mL
100 mL
200 mL
300 mL
What is the classification for the Jackson-Pratt drainage removal system?
Sterile drainage system
Closed drainage system
Open drainage system
Self-measuring drainage system
The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?
Offer fluids every 4 hours.
Encourage the consumption of large meals.
Encourage up to 1000 mL of daily fluid intake.
Encourage the consumption of small frequent meals.
The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?
Smoking increases the amount of tissue oxygenation.
Smoking increases the amount of functional hemoglobin in blood.
Smoking may decrease platelet aggregation and cause hypercoagulability.
Smoking interferes with normal cellular mechanisms that promote release of oxygen.
The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
Improves overall tissue perfusion.
Promotes release of oxygen to tissues.
Causes hemoglobin to have a greater affinity for oxygen.
Causes hemoglobin to have a decreased affinity for oxygen.
The nurse assessing a patient’s wound notes a clear watery drainage. How will the nurse most accurately document this finding?
Serous drainage
Purulent drainage
Sanguineous drainage
Serosanguineous drainage
The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse most accurately document this finding?
Serous drainage
Purulent drainage
Sanguineous drainage
Serosanguineous drainage
The nurse assessing a patient’s wound notes pale red watery drainage. How will the nurse most accurately document this finding?
Serous drainage
Purulent drainage
Sanguineous drainage
Serosanguineous drainage
The nurse assessing a patient’s wound notes bright red drainage. How will the nurse most accurately document this finding?
Serous drainage
Purulent drainage
Sanguineous drainage
Serosanguineous drainage
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?
Cellulitis
Dehiscence
Evisceration
Extravasation
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?
Provision of warmth.
Applies strong pressure.
Antibacterial effects.
Prevents skin maceration.
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?
Infection
Altered nutrition: more than body requirements
Impaired skin integrity
Altered peripheral tissue perfusion
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?
Positive pressure is applied by this device.
Healing is facilitated by decrease in drainage.
Promotes formulation of granulation tissue.
Reduces local and peripheral edema.
Drops bacterial level in wound.
Which are the phases of wound healing? (Select all that apply.)
Reconstruction
Hemostasis
Inflammation
Granulation
Maturation
Which solutions can be used on a wet-to-dry dressing?
Normal saline
Lactated Ringer
Acetic acid
Dakin
Lysol
What are the advantages of a transparent dressing?
Adheres to undamaged skin.
Contains the exudate.
Reduces wound contamination.
Serves as a barrier to external bacteria.
Slows epithelial growth.
The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by (a) formation.
The nurse encourages a patient recovering from a hysterectomy to drink at least (a) mL of fluid a day.
When preparing to remove a dressing, the nurse should don (a) gloves.
The patient is 38 years old and is in her second postoperative day after placement of an intramedullary rod in her left femur. She is receiving analgesia via a patient- controlled analgesia (PCA) device. The inappropriate intervention related to caring for a patient with a PCA is:
Maintaining the system
Recording activations of the system
Administering the analgesia to the patient
Monitoring the patient's pain
A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?
Palliative
Diagnostic
Reconstructive
Ablative
The Patient's Bill of Rights states that a patient must give his or her permission for any specific test or procedure to be performed. What is the legal term for this permission?
Verbal consent
Medical documentation
Informed consent
Informed decision
An informed consent was to be obtained from the patient for his scheduled open cholecystectomy. Which circumstance could prevent the patient from signing his informed consent?
Pain radiating to the scapula
An injection of Demerol, 75 mg IM, 1 hour ago
The presence of jaundice and scleral icterus
His concern over his insurance company not covering the procedure
The anesthesiologist provides anesthesia by inhalation and IV administration routes.
general
regional
specific
preoperative
A type of anesthesia that requires a depressed level of consciousness is
regional anesthesia.
specific anesthesia.
optional sedation.
conscious sedation.
The older adult patient may not respond to surgical treatment as well as a younger adult because of
poor skin turgor resulting in dehydration.
disturbed body image related to surgical incision.
his or her body's response to physiological changes.
decreased peristalsis related to general anesthesia.
A 45-year-old patient has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP). Which postoperative nursing interventions would be contraindicated?
Coughing every 2 hours
Leg exercises every 2 hours
Monitoring intravenous therapy at 50 ml/hr
Assessing vital signs every 2 hours
A male patient, age 80, has had a total hip replacement. Anxiety, hypotension, and jarring during transfer from the recovery room to his room can cause a postoperative increase in which of his vital signs?
Pulse rate
Temperature
Blood pressure
Pain
A patient, age 65, underwent a right hemicolectomy. On postoperative day 4, her surgical wound dehisced. This means that
there is partial or complete wound separation.
there has been inadequate wound closure.
abdominal viscera protrude through the walls.
the wound will not heal well when it is resutured.
A patient is on postoperative day 2 after a nephrectomy. The nurse is aware that the most effective way to increase her peristalsis is
ambulation
an enema
encouraging hot liquids
administering a laxative
A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?
Check ankle dressings.
Check airway for patency.
Check intravenous site.
Check vital signs.
Frequent assessment of a postoperative patient is essential. One of the first signs and symptoms of hemorrhage may be
increasing blood pressure.
decreasing pulse.
restlessness.
weakness, apathy.
Frequent monitoring of the postoperative patient's vital signs assesses which body system?
Gastrointestinal
Endocrine
Neurological
Cardiovascular
Decreased activity in an obese surgical patient predisposes the patient to which complication?
Cardiac arrest
Pneumonia
Incisional hernias
Hypoventilation
The nurse acknowledges that all preoperative nursing interventions have been performed by signing which document?
Nurse's notes
Anesthesia record
Preoperative checklist
Physician's order sheet
Which nursing interventions would be appropriate after a wound evisceration?
Place the patient in high Fowler's position.
Give the patient fluids to prevent shock.
Replace the dressing with sterile fluffy pads.
Apply a warm, moist normal saline sterile dressing.
When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative?
Only when the patient asks.
Regularly every three to four hours before pain gets severe.
Only when the physician orders.
Only when the patient is in severe pain.
What nursing interventions will minimize the effects of venous stasis?
Pillows under the knee in a position of comfort
Sitting with the feet flat on the floor
Early ambulation
Gentle leg massage
Serum potassium levels are usually determined before surgery to
assess kidney function.
determine respiratory insufficiency.
prevent dysrhythmias related to anesthesia.
measure functional liver capability.
The nurse is assisting with the sponge and instrument count in the operating room.
The operative phase in which the nurse is assisting is called the
perioperative phase.
preoperative phase.
intraoperative phase.
postoperative phase.
Which early postoperative observation is abnormal and should be reported immediately?
Emesis that is red
Complaint of feeling cold
Nausea
Complaint of pain
Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication of
hypovolemic shock.
dehiscence.
atelectasis.
pulmonary embolus.
An appendectomy during a hysterectomy would be classified as
major, emergency, diagnostic.
major, urgent, palliative.
minor, elective, ablative.
minor, urgent, reconstructive.
Which patients would be at greatest risk during surgery?
78-year-old taking an analgesic agent
43-year-old taking an antihypertensive agent
27-year-old taking an anticoagulant agent
10-year-old taking an antibiotic agent
A patient will have an incision in the lower left abdomen. Which intervention by the nurse will help decrease discomfort in the incisional area when she coughs postoperatively?
Apply a splint directly over the lower abdomen.
Keep the patient flat with feet flexed.
Turn her on her right side.
Apply a splint above and below the incision.
Although informed about the proposed surgical procedure, the patient has only vague responses about the postoperative period. A nursing diagnosis at this time would be
Impaired verbal communication.
Impaired gas exchange.
Deficient knowledge, postoperative.
Acute pain.
A patient and a nurse develop a preoperative teaching plan. In teaching the patient to cough effectively after surgery, the nurse should tell her to practice
breathing through her nose, holding her breath, and exhaling slowly.
taking three deep breaths and coughing from the chest.
inhaling while contracting the abdominal muscles and exhaling while contracting the diaphragm.
taking short, frequent panting breaths and coughing from the throat to clear accumulated mucus.
What is the responsibility of the nurse regarding informed consent?
Explain the surgical options.
Explain the operative risks.
Obtain the patient's signature.
Check form for appropriate signatures.
On the patient's return to the medical-surgical unit, the nurse performs an abdominal assessment. To assess bowel sounds, the nurse auscultates the lower abdomen for
1 minute.
5 to 20 seconds.
as long as it takes to hear a bowel sound.
one full inspiration and expiration.
Which preoperative fear is linked to postoperative behavior?
Fear of anesthesia and death
Fear of death and malnutrition
Fear of unknown and lack of respect
Fear of malnutrition and addiction to new medications
Ideally, preop teaching should be done
immediately before surgery to eliminate fear.
2 months in advance so the patient can prepare.
1 to 2 days before the surgery when anxiety is not as high.
in the surgical holding area.
In preparation for the return of the surgical patient, the patient's bed and equipment should be in what position?
Lowest position with side rails elevated with oxygen and suction equipment available
Highest position with side rails elevated with IV pole and pump at bedside
Lowest position with side rails down on the receiving side
Highest position with the side rails down on receiving side and up on opposite side
Southeast Asian and Native American patients often do not make eye contact when preoperative teaching is being performed because
they aren't educated.
they aren't paying attention.
they believe eye contact is disrespectful.
they believe they are superior to the nurse.
What are the high-risk conditions that may affect perioperative procedures?
Age, health, occupation, mental status
Financial income, health, nutritional status
Age, mental state, nutritional status, health
Occupation, age, nutritional status, health
Financial Income, occupation, age, health
A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.)
Care of the wound site and any dressings
When he may operate a motor vehicle
Signs and symptoms to report to the physician
Call the physician's office once he arrives home
Actions and side effects of any medications
Two considerations for the older adult surgical patient include (Select the two that apply.)
pre- and postoperative teaching.
lower morbidity and mortality.
quick assessment skills.
surgery causes much physiological stress.
In preparing the patient for abdominal surgery, the Assistive Personnel (AP) can perform which interventions? (Select all that apply.)
Vital signs
Insertion of N/G tube
Enema
Height and weight
Obtain operative consent
(a) therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem.
Discharge planning for a surgical procedure begins in the period and continues through the period.
intraoperative
preoperative
recuperative
recovery
A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU.
a. System review
b. Breathing
c. Circulation
d. Airway
e. Level of consciousness
(a)
What is the nurse’s first step when caring for a patient needing wound care?
Washing hands
Explaining the procedure to the patient
Assembling all equipment and supplies
Checking the medical record for the health care provider’s orders
The nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. What would be the priority nursing assessment when inspecting the skin that is distal to the bandage?
Circulatory impairment
Inflammation
Bacteria
Impaired skin integrity
When classifying wounds, which classification results from the presence of gastrointestinal products?
Contaminated
Clean-contaminated
Dirty
Clean
If a patient with an abdominal incision begins to cough, which intervention is the most appropriate?
Sit the patient up in a semi-Fowler’s position.
Apply a pillow to the incision with slight pressure.
Roll the patient to the left side.
Offer the patient a drink of water.
When removing staples from a surgical incision, which intervention is most appropriate?
Remove every other staple; then wait several days to remove the rest.
Remove the middle staples first, then proceed to the outer edges, and apply the dressing.
Remove all the staples. If the edges pull apart, apply Steri-Strips.
Remove every other staple first, and replace with Steri-Strips while ensuring that the incision remains closed.
The health care provider has ordered a sterile dry dressing change. What is the most appropriate way to cleanse the wound and surrounding area?
Use a sterile swab to soak up any drainage; then apply a clean dressing.
Using an aseptic swab, start from the incision outward, one stroke per swab, then allow to air-dry.
Using an aseptic swab, start at the top of the incision, using the same swab until dirty; then get a clean swab.
Using an aseptic swab, start on the side of the wound closest to you, one stroke per swab.
The nurse health care provider has ordered for a patient’s leg wound to be irrigated using an antiseptic solution. What would the nurse do to reduce the chance of contamination?
Direct the solution toward unhealthy tissue to healthy tissue within the wound.
Place the tip of the syringe touching the area needing to being cleaned.
Have the solution flow from the least contaminated to the most contaminated area.
Instill the solution with force to remove any debris quickly from the wound.
A patient has come to the PACU after hip replacement surgery. Following the nursing assessment, the health care teams need to set up a plan of care. What would the nurse anticipate to be the highest priority patient problem?
Tissue perfusion, ineffective
Nutrition: less than body requirements, imbalanced
Nutrition: more than body requirements, imbalanced
Skin integrity, impaired
A patient is 3 days postoperation from abdominal surgery. Which conditions would the nurse assessing the abdominal incision consider normal? (Select all that apply.)
Clean, well-approximated edges
Staples or sutures intact
A foul-smelling odor
A small amount of serous drainage
Protrusion of tissue when patient coughs
Which is an accurate statement regarding the older adult facing surgery?
Older adults undergoing surgical procedures have lower mortality and morbidity rates than younger adults.
Older patients tend to recover more quickly from surgery than younger patients.
Disorientation or toxic reactions can occur in the older adult after the administration of anesthetics, sedatives, or analgesics.
Preoperative and postoperative teaching should require less time with the older adult than it does with young adults.
The nurse is caring for a patient prior to surgery who makes minimal eye contact during preoperative teaching. Which measure will the nurse take?
Stop the preoperative teaching.
Reduce the amount of eye contact used by the nurse.
Politely ask the patient to please listen to the instructions.
Ask another staff nurse to take over the care of this patient.
Which is true regarding preoperative teaching?
The best time for preoperative education is 1 to 2 hours before the surgery is scheduled.
In preoperative teaching, the nurse should primarily use questions that can be answered “yes” or “no” to verify patient understanding.
Preoperative information helps lessen anxiety, reduce the amount of anesthesia required, decrease postoperative pain, and reduce corticosteroid production.
Referring the patient to support groups is not an appropriate nursing intervention during the preoperative phase.
Which is the true statement regarding informed consent?
Informed consent occurs when the nurse discusses the surgical procedure, risks, and alternatives with the patient.
The best time to have the patient sign the consent form is after receiving the preoperative medication, because the patient will be more relaxed.
If the patient’s life is in danger and the family members cannot be located, the surgeon may not legally perform surgery.
The witness of a consent form is only verifying that this is the person who signed the consent and that it is a voluntary consent.
Which will the nurse do to help prevent respiratory complications in a patient postoperatively?
Assist the patient to deep breathe and cough after all types of surgeries.
Encourage the patient to use the incentive spirometer device 10 breaths every 4 hours.
Teach the patient how to use the incentive spirometer within the first 4 hours after surgery.
Assist the patient to ambulate within a few hours of surgery, unless contraindicated.
Which is true regarding preoperative medication?
After receiving preoperative medication, the patient is generally encouraged to ambulate on the nursing unit to encourage deep breathing.
The patient who has received an opioid analgesic usually requires a larger amount of anesthetic once in surgery.
The preoperative medication reduces respiratory tract secretions.
After surgery, all preoperative medications are automatically resumed for the patient.
Which stage of general anesthesia includes the administration of anesthetic agents and endotracheal intubation?
Induction
Maintenance
Emergence
Stage IV
What is a routine type of sedation that might be used for a surgical procedure that does not require complete anesthesia but rather a depressed level of consciousness?
Local anesthesia
Bier block
Regional anesthesia
Conscious sedation (Moderate sedation)
Which is the usual interval at which nursing assessments, including vital signs, are monitored in the postoperative phase?
Fifteen minutes times 4; every 30 minutes times 4; every hour times 4; then every 4 hours
Five minutes times 4; every 10 minutes times 4; every 30 minutes times 4; then every hour
Thirty minutes times 4; every hour times 4; then every 4 hours
Four hours followed by once a shift
Which is a true statements regarding medications and surgery? (Select all that apply.)
Review of the patient’s current medication regimen is essential to promote a safe surgical outcome.
An acutely ill patient may receive several medications in a perioperative setting at one time.
The patient’s chart should be flagged to alert all health care providers to the patient’s allergy status.
Herbal remedies and dietary supplements need not be included in the patient’s medication review, because these are natural products.
Asking a patient about drug and alcohol use is intrusive and is a violation of patient confidentiality protocols.
Review Questions for the NCLEX® Examination: The patient has just returned from the postanesthesia care unit (PACU). During report, the nurse is told that the patient has a Jackson-Pratt drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate?
“The drain allows for the postoperative instillation of wound irrigation fluid in order to keep the wound clean.”
“The drain is used to reduce infection in the postoperative period.”
“Drains are used to contain and remove body fluids from the wound by mild suction.”
“Drains are used to minimize postoperative discomfort after a surgical procedure.”
Review Questions for the NCLEX® Examination: The nurse finds that the patient’s incision has eviscerated. What action should the nurse take? (Select all that apply.) .
Place the patient in high-Fowler’s position.
Give the patient fluids to prevent shock.
Do not allow the patient to get out of bed.
Replace dressings with sterile fluffy pads.
Apply warm, moist sterile dressings.
Review Questions for the NCLEX® Examination: The health care provider has ordered that the patient’s wound be irrigated. What is the primary rationale for this procedure?
To remove debris from the wound
To decrease scar formation
To improve circulation from the wound
To decrease irritation from wound drainage
Review Questions for the NCLEX® Examination: What statements indicate that a wound has become infected? (Select all that apply.)
Palpation of the wound reveals serosanguinous fluid under its edges.
Wound cultures are positive.
Purulent drainage is coming from the wound area.
Upon removal, the nurse notes that the dressing is dry.
The wound has a foul odor.
Review Questions for the NCLEX® Examination: Which nursing entry is the most complete in its description of a wound?
Wound appears to be healing well, dressing dry and intact
Wound well approximated, with minimal drainage
Drainage size of quarter; wound pink; 4 × 4 applied
Incisional edges approximated without erythema or exudate; two 4 × 4s applied
Review Questions for the NCLEX® Examination: Which statement is correct in regard to the use of an abdominal binder?
It replaces the need for underlying dressings.
It should be kept loose for patient comfort.
The patient has to be sitting or standing when it is applied.
The patient must have adequate ventilatory capacity.
Review Questions for the NCLEX® Examination: What is the first step when packing a wound?
Assess its size, shape, and depth.
Prepare a sterile field.
Select gauze packing material.
Irrigate the wound.
Review Questions for the NCLEX® Examination: What is the correct procedure for the wet-to-dry dressing method?
Place dry gauze into the wound and remove it when it is wet.
Medicate the patient for pain after you change the dressing.
Complete this type of dressing change just once a day.
Place moist gauze into the wound and remove it at prescribed intervals.
Review Questions for the NCLEX® Examination: Which phrase best describes serous drainage?
Fresh bleeding
Thick and yellow
Clear, watery plasma
Beige to brown and foul smelling
Review Questions for the NCLEX® Examination: The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention?
Collection of wound drainage
Reduction of abdominal swelling
Reduction of stress on the abdominal incision
Stimulation of peristalsis from direct pressure
Review Questions for the NCLEX® Examination: What are the traditional purposes of a wet-to-dry dressing? (Select all that apply.)
Debridement
Cooling
Comfort
Prevention of infection
Maintenance of moisture at the wound bed
Review Questions for the NCLEX® Examination: What action should the nurse implement to reduce surgical wound infection?
Adhering to the principles of hand hygiene
Cleansing the incision from the least contaminated to the most contaminated area
Leaving the incision open to the air
Changing the dressing using sterile technique
Ensuring that the patient is consuming an adequate diet
Review Questions for the NCLEX® Examination: The student nurse is changing a patient’s dressing. What action indicates the need for further education? (Select all that apply.)
Enclose the soiled dressing within a latex glove.
Clean the wound in circles toward the incision.
Free the tape by pulling it away from the incision.
Remove the soiled dressing with sterile gloves.
Apply the clean dressing with clean gloves.
Review Questions for the NCLEX® Examination: When the drainage in a Hemovac reservoir is emptied, which nursing action is essential for reestablishing the negative pressure within this drainage device?
Fill the reservoir with sterile normal saline solution.
Secure the reservoir to the skin near the wound.
Compress the reservoir and close the vent.
Open the vent, allowing the reservoir to fill with air.
Review Questions for the NCLEX® Examination: Which patient is more at risk for wound dehiscence?
The patient who smokes
The patient who is obese
The patient with a history of peripheral vascular disease
The patient who is immunocompromised
Review Questions for the NCLEX® Examination: The student nurse is correct when indicating which drain is providing suction-assisted drainage?
Jackson-Pratt
Hemovac
Penrose
Wound VAC system
T-tube system
Review Questions for the NCLEX® Examination: The health care provider has ordered that all sutures on a patient with an abdominal hysterectomy be removed on the fifth postoperative day and that Steri-Strips be applied. During suture removal, the nurse notices the incision edges are slightly separating. What is the best action by the nurse?
Continue removing the sutures and apply the Steri-Strips.
Stop the suture removal and contact the health care provider immediately.
Continue removing the sutures and applying the Steri-Strips, then cover the incision with a dry sterile dressing.
Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.
Review Questions for the NCLEX® Examination: When providing care to a patient with a Hemovac drain, what actions are included in the plan of care?
Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations.
Clamp the tubing during patient ambulation and activity to prevent excess drainage during these times.
Empty the bulb drainage receptacle when it is one-fourth full.
Pin the bulb above the insertion site to assist in proper drainage of exudate.
Review Questions for the NCLEX® Examination: During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding?
The dressing is saturated with bright red sanguineous drainage, and the patient has an increased urinary output.
The dressing is dry and intact, the patient’s blood pressure has decreased, and pulse and respirations have increased.
The dressing is saturated with serosanguineous drainage, and the patient is diaphoretic, with a decrease in pulse and respirations.
The dressing is dry and intact, and the patient reports shortness of breath and has an elevated temperature.
Review Questions for the NCLEX® Examination: A patient is being discharged, and the nurse is teaching the patient how to do daily dressing changes at home. What is the most important point to include in the teaching plan?
Discussion of surgical asepsis
Discussion of hand hygiene
Instruction in sterilization
Demonstration of gloving
Review Questions for the NCLEX® Examination: The nurse is caring for a patient following a colon resection with a transverse colostomy. The patient is experiencing pain at the operative site and surrounding tissues. To assist this patient in the prevention of postoperative pulmonary complications, what interventions will be most helpful preoperatively? (Select all that apply.)
Ask the surgeon to prescribe IPPB treatment.
Teach and observe the patient perform leg exercises.
Teach and observe the patient use an incentive spirometer correctly.
Tell the patient that lack of an effective cough may result in pulmonary complications.
Ask the patient to perform a return demonstration of controlled coughing.
Review Questions for the NCLEX® Examination: A patient underwent surgery for lysis of adhesions. He is transferred from the PACU to his room on the surgical floor. During the immediate postoperative period on the surgical floor, how often should the nurse measure blood pressure, pulse, and respirations?
Every 15 minutes
Every 5 minutes
Every 20 minutes
Every 30 minutes
Review Questions for the NCLEX® Examination: The nurse is assessing the bowel sounds of a patient who had a suprapubic prostatectomy 2 days ago. To confirm that no bowel sounds are present, the nurse would need to auscultate each quadrant for how long?
1 minute
3 minutes
10 minutes
15 minutes
Review Questions for the NCLEX® Examination: A patient is recovering from a right lobectomy. The nurse is going to assist in splinting the patient’s incision so that the patient can cough and breathe deeply. When should an intramuscular analgesic be administered to achieve the most therapeutic effect?
After the procedure so the patient can rest
15 minutes before the procedure
1 hour before the procedure
30 minutes before the procedure
Review Questions for the NCLEX® Examination: A patient reports being allergic to penicillin. Which question would elicit the most useful information?
“When did the reaction occur?”
“What infection did you have that required penicillin?”
“What type of allergic reaction did you have?”
“Did you notify your physician of the allergy?”
Review Questions for the NCLEX® Examination: Which patient is at greatest risk for surgical and anesthetic complications?
A 3-year-old patient scheduled for hernia repair
An 80-year-old patient scheduled for exploratory laparotomy
An 18-year-old patient scheduled for an appendectomy
A 42-year-old patient scheduled for breast biopsy
Review Questions for the NCLEX® Examination: An alert 75-year-old patient is to undergo elective surgery. Who must sign the operative permit?
The patient
The patient and the patient’s spouse
Either the patient or the patient’s spouse
The patient and the surgeon
Review Questions for the NCLEX® Examination: What is the best nursing intervention to help a patient cope with fear of pain associated with surgery?
Describe the degree of pain expected.
Explain the availability of pain medication.
Inform the patient of the frequency of pain medication.
Divert the patient when talking about pain.
Review Questions for the NCLEX® Examination: A patient tells the nurse that “using this tube thing [incentive spirometer] is a waste of time.” Which statement by the nurse best explains the purpose of the incentive spirometer?
“It helps by directly removing excess secretions from the lungs.”
“It increases pulmonary circulation.”
“It helps promote lung expansion and prevent pulmonary complications.”
“It helps stimulate the cough reflex and keeps your lungs working.”
Review Questions for the NCLEX® Examination: When a patient is prepared for surgery, which interventions are appropriate during the preoperative period? (Select all that apply.)
Provide sips of water for a dry mouth.
Remove the patient’s makeup and nail polish.
Remove the patient’s gown before transport to the OR.
Leave on all of the patient’s jewelry.
Teach the patient postoperative breathing and coughing exercises.
Review Questions for the NCLEX® Examination: Which statement is accurate regarding a patient who receives general or regional anesthesia in an ambulatory surgery center?
The patient will remain in the unit longer than a hospitalized patient.
The patient is allowed to ambulate as soon as he or she is admitted to the recovery area.
The patient’s level of consciousness must be near the level of preoperative functioning before dismissal.
The patient is immediately given liberal amounts of fluid to promote excretion of the anesthesia.
Review Questions for the NCLEX® Examination: After abdominal surgery, a patient is suspected of having internal bleeding. Which finding is most indicative of this complication? (Select all that apply.)
Increased blood pressure
Incisional pain
Increased abdominal distention
Increased urinary output
Increased respirations
Review Questions for the NCLEX® Examination: An obese patient is at risk for poor wound healing postoperatively for what reasons? (Select all that apply.)
Ventilation capacity is reduced.
Fatty tissue has a poor blood supply.
The risk for dehiscence is increased.
Clotting factors are delayed.
Thrombophlebitis risk is increased.
Review Questions for the NCLEX® Examination: A patient asks the nurse why the nurse asked for the name and dosage of all prescription and over-the-counter medications (including herbal remedies) taken before surgery. Which response by the nurse is most accurate?
“These medications may cause allergies to develop.”
“These medications are automatically ordered postoperatively.”
“These medications should be taken the morning of surgery with sips of water.”
“These medications may create a greater risk for complications or interact with anesthetic agents.”
Review Questions for the NCLEX® Examination: The nurse is correct when identifying a patient who smokes two packs of cigarettes per day as being at most risk for which postoperative complication?
Infection
Pneumonia
Hypotension
Cardiac dysrhythmias
