Chapter 13 - Surgical Wound care

98 Questions | Total Attempts: 1866

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Chapter 13 - Surgical Wound care

From Foundations of Nursing by Christensen and Kockrow, pages 310-342. For any questions, email [email protected] Com


Questions and Answers
  • 1. 
    After an abdominal surgery, abdominal muscles contract and cause intraabdominal pressure. If the incisional area is weak, what is possible to happen?
    • A. 

      Dehiscence

    • B. 

      Evisceration

    • C. 

      Decubitus

    • D. 

      Shearing

  • 2. 
    How are wounds classified? Select all the apply:
    • A. 

      Cause

    • B. 

      Severity of injury

    • C. 

      Amount of contamination

    • D. 

      Skin's integrity

    • E. 

      Color and shape

  • 3. 
    A cut produced surgically by a sharp instrument creating an opening into an organ or space in the body
    • A. 

      Puncture

    • B. 

      Incision

    • C. 

      Stoma

    • D. 

      Abrasion

  • 4. 
    Stab wound for a drainage system 
    • A. 

      Puncture

    • B. 

      Incision

    • C. 

      Stoma

    • D. 

      Abrasion

  • 5. 
    Classification of wound according to the CDC. Select all that apply:
    • A. 

      Clean

    • B. 

      Clean-contaminated

    • C. 

      Contaminated

    • D. 

      Dirty or infected

    • E. 

      Aseptic or sterile

  • 6. 
    Which of the following four phases of wound healing are arranged accordingly
    • A. 

      Hemostasis, inflammatory phase, maturation, reconstruction

    • B. 

      Hemostasis, inflammatory phase, reconstruction, maturation

    • C. 

      Hemostasis, reconstruction, maturation, inflammatory phase

    • D. 

      Inflammatory phase, hemostasis, maturation, reconstruction

  • 7. 
    During hemostasis, termination of bleeding begins and blood clots are formed.  What is in the blood clot that helps hold the wound together?
    • A. 

      Granulation

    • B. 

      Hemes

    • C. 

      Fibrin

    • D. 

      Leucocytes

  • 8. 
    When does wound dehiscence primarily take place?
    • A. 

      Maturation phase

    • B. 

      Reconstruction phase

    • C. 

      Inflammatory phase

    • D. 

      Mitotic phase

  • 9. 
    Definition of a Keloid
    • A. 

      A painful disease involving tissue damage

    • B. 

      This is another phase of wound healing

    • C. 

      Same as an eschar only with a lighter color

    • D. 

      Overgrowth of a collagenous scar tissue at the site of the wound

  • 10. 
    Best Definition of EXUDATE
    • A. 

      Exactly the same as Drainage

    • B. 

      It is a noun derived from the verb "to exude"

    • C. 

      Fluid, cells, or other substances that have been slowly exuded or discharged, from cells or blood through small pores or breaks in cell membranes.

    • D. 

      That which emerges from an injured tissue

  • 11. 
    What is granulation tissue?
    • A. 

      Composed of small microscopic grains of epithelial cells

    • B. 

      A group of cells that form a grain

    • C. 

      The tissue that remains after a scar is healed

    • D. 

      Soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen.

  • 12. 
    • A. 

      The stages for wound healing provide a model for acute wound healing and not necessarily chronic.

    • B. 

      The stages of wound healing are not necessarily linear

    • C. 

      The least amount of scar after healing would be in the primary intention wound

    • D. 

      Tertiary intention healing produces the smallest scar

  • 13. 
    A patient who had an appendicitis removed early in the morning is having a hard time going to sleep because of coughing. What is the best non-pharmacological intervention that a nurse could provide him?
    • A. 

      Apply a pillow, rolled blanket, or the palms of the hands to the incisional area to lessen intraabdominal pressure

    • B. 

      Administer a PRN pain medication

    • C. 

      Call the surgeon and tell him to intervene

    • D. 

      Bind the wound with a Montgomery wrap

  • 14. 
    The process of applying a pillow, rolling a bath blanket, or the palms of the hands to an incisional area to decrease intraabdominal pressure is called what?. 
    • A. 

      Binding

    • B. 

      Wrapping

    • C. 

      Splinting

    • D. 

      Dressing

  • 15. 
    It is a factor that impairs wound healing by interfering with normal cellular mechanisms that promote release of oxygen to tissues. It reduces the amount of functional hemoglobin in blood. 
    • A. 

      Obesity

    • B. 

      Radiation

    • C. 

      Smoking

    • D. 

      Malnutrition

  • 16. 
    A chronic disease that impairs wound healing because it causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. An effect of this disease alters ability of leukocytes to perform phagocytosis needed for wound healing. This same effect will also support overgrowth of fungal and yeasts infection which are both contraindicated for wound healing
    • A. 

      Multiple sclerosis

    • B. 

      Diabetes insipidus

    • C. 

      Diabetes mellitus

    • D. 

      Myocardial infection

  • 17. 
    Which of the following groups are not a factor that could impair wound healing?
    • A. 

      Obesity, malnutrition and age

    • B. 

      Impaired oxygenation, radiation and smoking

    • C. 

      Height, weight and body mass

    • D. 

      Drugs, diabetes mellitus and wound stress

  • 18. 
    During the first day after surgery, how often would you inspect the dressings? 
    • A. 

      Every 2 to 4 hours for the first 24 hours

    • B. 

      Every 8 to 10 hours for the first 42 hours

    • C. 

      Every 6 to 8 hours for the first 30 hours

    • D. 

      Every 2 to 4 hours for the first 12 hours

  • 19. 
    Which of the following is not an evidence of infection?
    • A. 

      Elevated WBC

    • B. 

      Purulent drainage

    • C. 

      Primary intention

    • D. 

      Increased leukocytes

  • 20. 
    When doing wound care, which of the following should be the first thing to do?
    • A. 

      Introduce yourself

    • B. 

      Explain the procedure

    • C. 

      Refer to medical record, care plan or kardex

    • D. 

      Identify patient

  • 21. 
    When are dressings over closed wound usually removed?
    • A. 

      The day after surgery

    • B. 

      On the third day

    • C. 

      A week after surgery

    • D. 

      When the physician gives the order

  • 22. 
    What kind of dressings promote healing by keeping wounds moist yet sterile? 
    • A. 

      Binders and steri-strips

    • B. 

      Transparent and permeable dressings

    • C. 

      Occlusive and semi-occlusive dressings

    • D. 

      Wet and dry dressings

  • 23. 
    When using an occlusive dressing, where will the tape strips be attached?  
    • A. 

      Several inches apart

    • B. 

      On all sides of the dressing

    • C. 

      One on top of the other

    • D. 

      On the four corners

  • 24. 
    When Montgomery straps are soiled, when do they get replaced? 
    • A. 

      Every 2 hours

    • B. 

      Once every shift

    • C. 

      At least once a week

    • D. 

      Every 2 to 3 days

  • 25. 
    A method and a trend that allows atmospheric oxygen to circulate above the wound, aiding in the healing process
    • A. 

      Use Montgomery straps without binders

    • B. 

      Protect sutured, clean wounds with occlusive dressing after surgery.

    • C. 

      Leave sutured, clean wounds undressed after surgery or use loose dressings

    • D. 

      Allow dry to dry dressings using occlusive gauze

  • 26. 
    Often the choice for management of wound with little exudate or drainage such as abrasions and non-draining postoperative incisions. 
    • A. 

      Semi-occlusive

    • B. 

      Wet-to-dry dressing

    • C. 

      Dry dressing

    • D. 

      Occlusive

  • 27. 
    Which of the following statements about dry dressing are true? Select all that apply 
    • A. 

      Keeps initial bleeding to a minimum, protects wound from injury and prevents introduction of bacteria

    • B. 

      If dry dressing adheres to a wound, moisten dressing with distilled water before removing the gauze

    • C. 

      Prevents deeper tissue from drying out by keeping wound surface moist

    • D. 

      Does not debride wounds

  • 28. 
    A one day postoperative patient is scheduled to have an initial wound dressing. What would be an appropriate thing to do before doing the intervention? 
    • A. 

      Provide an analgesic while doing wound care

    • B. 

      Give an analgesic 30 minutes before exposing the wound

    • C. 

      Offer an analgesic after changing the dressing

    • D. 

      Do not offer any analgesic because it is contraindicated

  • 29. 
    When doing wound care, which of the following should not be done? 
    • A. 

      Wash hands before donning sterile gloves

    • B. 

      Use sterile gloves while removing wound dressing

    • C. 

      If drains are present, remove dressings one layer at a time

    • D. 

      Cover wound with appropriately sized dry sterile dressing and use drain dressing, if applicable

  • 30. 
    When changing a sterile dry dressing, which of the following is a proper way of cleaning a wound?
    • A. 

      Cleanse wound and surrounding area with regular swab, starting from incision and moving outward, using one stroke per swab

    • B. 

      Cleanse wound and surrounding area with antiseptic swab, starting from incision and moving outward, using one stroke per swab.

    • C. 

      Cleanse wound and surrounding area with alcohol, starting from incision and moving outward

    • D. 

      Cleanse wound and surrounding area with antiseptic swab, starting from the edges of the wound towards the incision

  • 31. 
    Which of the following are commonly used wetting agents? Select all that apply:
    • A. 

      Normal Saline

    • B. 

      Distilled Water

    • C. 

      Sodium Hypochlorite Solution

    • D. 

      Isotonic Solutions and Lactated Ringer

    • E. 

      Dakin

  • 32. 
    What is the primary purpose of wet-to-dry dressing?
    • A. 

      To mechanically debride a wound

    • B. 

      To perform aseptic cleansing

    • C. 

      To protect the wound from further injury

    • D. 

      To provide an aesthetic appearance to wound dressing

  • 33. 
    Which of the following are effective antimicrobial agents either for Psuedomonas Aeruginosa or other pathogens but  are toxic to fibroblasts in standard solutions?
    • A. 

      Povidone-iodine

    • B. 

      Lactated Ringer

    • C. 

      Hypertonic Solutions

    • D. 

      Acetic Acid

  • 34. 
    In changing a wet-to-dry dressing, what happens when you apply dry dressing over wet gauze? 
    • A. 

      Pulls microbes from the wounds and allows termination of pathogens

    • B. 

      Pulls moisture from the wound and allows for absorption of excess moisture

    • C. 

      Pulls ischemic tissue and removes excess drainage

    • D. 

      Pulls necrotic tissue from the wound and accelerates healing

  • 35. 
    After opening and partially using a 10 ml bottle of a normal saline wetting agent for wound care, what should be done next?
    • A. 

      Wetting solutions should always be refrigerated 24 hours after opening and to prevent harboring microorganism growth.

    • B. 

      Wetting solutions should be discarded 24 hours after opening and replaced with fresh solution because they can harbor microorganism growth.

    • C. 

      Wetting solutions should be discarded an hours after opening and replaced with fresh solution because they can harbor microorganism growth.

    • D. 

      Wetting solutions should be sealed after after opening and used as often as needed

  • 36. 
    What are the advantages of a transparent dressing? Select all that apply: 
    • A. 

      Adheres to undamaged skin to contain exudate and minimize wound contamination

    • B. 

      Promotes a moist environment that speeds epithelial cell growth

    • C. 

      Accelerates wound healing by providing fibroblast stimulators

    • D. 

      Serves as a barrier to external fluids and bacteria yet still allows the wound to breathe

    • E. 

      Allows wound assessment without removing the film, as well as remove the film without damaging underlying tissue

  • 37. 
    For best results, when or how should transparent dressings be used? Select all that apply; 
    • A. 

      On clean debrided wounds that are not actively bleeding

    • B. 

      Apply it so not wrinkles form, but do not stretch it over the skin

    • C. 

      On eschar or over non-stagale decubitus

    • D. 

      Ideal for small superficial wounds and as a dressing over an IV catheter site

  • 38. 
    Gentle washing of an area with a stream of solution delivered through a syringe. 
    • A. 

      Sterilization

    • B. 

      Irrigation

    • C. 

      Innundation

    • D. 

      Effleurage

  • 39. 
    After applying a transparent dressing, it is labeled with which information? Select all that apply:
    • A. 

      Date

    • B. 

      Initials

    • C. 

      Location

    • D. 

      Time

  • 40. 
    The principles of basic wound irrigation include the following. Select all that apply
    • A. 

      After irrigation, dry the wound with a clean gauze

    • B. 

      Cleanse in a direction from the least contaminated to the most contaminated

    • C. 

      During irrigation, apply cold compress

    • D. 

      When irrigating, make sure all the solution flows from the least contaminated to the most contaminated

  • 41. 
    Wound irrigation promotes wound healing through the following reasons. Select all that apply:
    • A. 

      By removing debris from wound surface

    • B. 

      By loosening and removing eschar

    • C. 

      By moistening the wound

    • D. 

      By decreasing bacterial counts

  • 42. 
    Common solutions used for irrigation. Select all that apply
    • A. 

      Warm water

    • B. 

      Hydrogen peroxide

    • C. 

      Mild detergent

    • D. 

      Saline

  • 43. 
    When doing wound irrigation for a deep wound with small opening (deep ulcers), which of the following devices should you use?
    • A. 

      13-gauge needle with a 25 mL syringe

    • B. 

      Tuberculin needle

    • C. 

      19-gauge needle (or angiocath) with a 35 mL syringe

    • D. 

      Same needle as insulin

  • 44. 
    When doing a wound irrigation, how should the syringe be positioned? 
    • A. 

      1 finger-length above the wound

    • B. 

      1 cm above the wound

    • C. 

      1 inch above the wound

    • D. 

      1 mm above the wound

  • 45. 
    When doing wound care, in order to prevent fluid from being retained in the wound, how should a patient be positioned?
    • A. 

      The patient should stand while receiving wound care

    • B. 

      The patient should be an a dorsal recumbent position

    • C. 

      The patient should be supine for comfort

    • D. 

      Position the patient to his/her side to encourage the irrigant to flow away from the wound

  • 46. 
    Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection 
    • A. 

      Adhesion

    • B. 

      Abscess

    • C. 

      Cellulitis

    • D. 

      Dehiscence

  • 47. 
    Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery or injury
    • A. 

      Cellulitis

    • B. 

      Evisceration

    • C. 

      Extravasation

    • D. 

      Hematoma

  • 48. 
    Passage or escape into the tissues, usually of blood, serum or lymph 
    • A. 

      Adhesion

    • B. 

      Evisceration

    • C. 

      Extravasation

    • D. 

      Hematoma

  • 49. 
    In order to determine whether a patient is hemorrhaging, what do you need to observe? Select all that apply:
    • A. 

      Increased thirst and restlessness

    • B. 

      Cool, clammy skin

    • C. 

      Rapid thready pulse

    • D. 

      Decreased blood pressure and urinary output

    • E. 

      Paresthesia on lower extremities

  • 50. 
    • A. 

      Hypervolemic shock leading to an excessive dehydration

    • B. 

      Hypovolemic shock leading to a cardiac infection

    • C. 

      Hypovolemic shock leading to a collapsed circulatory system

    • D. 

      Hypervolemic shock leading to water retention

  • 51. 
    Which of the following is not an appropriate response to wound evisceration?
    • A. 

      Cover the protruding organ with a sterile dressing moistened with sterile normal saline solution to prevent wound contamination and keep abdominal contents moist.

    • B. 

      Raise the gatch near the foot of the bed and keep the patient into a sitting position with knees straight.

    • C. 

      Stay calm and monitor patient closely.

    • D. 

      Use clean towels or dressings if there are no sterile dressings available

  • 52. 
    When a post-operative patient states that something has given way and the feeling is brought on by periods of sneezing, coughing or vomiting, what could have possibly happened? 
    • A. 

      Early symptoms of flu

    • B. 

      Patient is having a running nose

    • C. 

      A wound dehiscence occurred

    • D. 

      The patient is just hungry

  • 53. 
    When does wound dehiscence most frequently take place? 
    • A. 

      Between the second and third week after surgery.

    • B. 

      Between the 5th and 12th postoperative days.

    • C. 

      Between 24 to 48 hours after surgery

    • D. 

      Between the 3rd and 10th postoperative days

  • 54. 
    When evisceration follows dehiscence, what interventions are needed? Select all that apply:
    • A. 

      The patient is to remain bed bound in a low Fowler's position with knees flexed to reduce pressure on wound.

    • B. 

      Keep patient on NPO status, and cover wound and contents with warm, sterile saline dressing

    • C. 

      Change patient position every 2 hours to avoid decubitus

    • D. 

      Notify surgeon immediately

  • 55. 
    When are sutures and staples generally removed?
    • A. 

      In 1 to 2 weeks after surgery or sooner if healing is adequate

    • B. 

      In 48 to 60 hours after surgery or sooner if healing is adequate

    • C. 

      In 7 to 10 days after surgery or sooner if healing is adequate

    • D. 

      In 5 to 8 days after surgery or sooner if healing is adequate

  • 56. 
    What is the appropriate way of removing sutures or staples?
    • A. 

      First, every suture or staple is removed in an orderly sequence, and replaced with a steri-strip, and the same sequence occurs with the remainder in the second phase.

    • B. 

      First, place a steri-strip, and then every other suture or staple is removed. The same sequence occurs with the remaining staples.

    • C. 

      First, all sutures or staple are removed and then replaced with a steri-strip.

    • D. 

      First, every other suture or staple is removed and replaced with a steri-strip, and the same sequence occurs with the remainder in the second phase.

  • 57. 
    How long do retention sutures remain in place?
    • A. 

      Less than 14 days

    • B. 

      14 days or more

    • C. 

      Between 10 and 14 days

    • D. 

      Not more than 2 weeks

  • 58. 
    Fluid that have slowly discharged from cells or blood vessels through small pores or breaks in cell membrane. 
    • A. 

      Drainage

    • B. 

      Exudate

    • C. 

      Edema

    • D. 

      Interstitial fluid

  • 59. 
    Removal of fluids from a body cavity, wound or other source of discharge by one or more methods. 
    • A. 

      Exudate

    • B. 

      Extravasation

    • C. 

      Drainage

    • D. 

      Cellular suction

  • 60. 
    Before applying a steri-srip, what is applied to make the skin tacky and cause the steri-strip to adhere more securely?
    • A. 

      Vaseline

    • B. 

      Iodine

    • C. 

      Tincture of benzoin

    • D. 

      Cold cream

  • 61. 
    When a patient has steri-strips, what would be the recommended form of body hygiene?
    • A. 

      Instruct a patient to take a shower

    • B. 

      Instruct patient to soak in bath tub

    • C. 

      Instruct patient not to take a bath

    • D. 

      Instruct patient just to wash face for a while

  • 62. 
    Steri-strips are not removed and are allowed to loosen and peel off gradually
    • A. 

      True

    • B. 

      False

  • 63. 
    Also known as separate sutures characterized with knots that are lined up on the same side of incision. 
    • A. 

      Interrupted sutures

    • B. 

      Continuous Sutures

    • C. 

      Blanket sutures

    • D. 

      Retention sutures

  • 64. 
    Wire sutures are removed by physician
    • A. 

      True

    • B. 

      False

  • 65. 
    A nurse is removing a suture. Which of the following would be a sign that this nurse needs further training?  
    • A. 

      Grasps and elevates knotted end of suture with hemostat or forceps.

    • B. 

      Grasps continuous suture and removes loop of suture, pulling contaminated stitch through tissue

    • C. 

      Documents the number of staples or sutures removed

    • D. 

      Removes one to three sutures at a time

  • 66. 
    • A. 

      Assess the patient for complication

    • B. 

      Empty the Hemovac and clean appropriately

    • C. 

      Report the findings to the physician immediately

    • D. 

      Change the patient dressing

  • 67. 
    A nurse was asked to document the amount of exudate from a post-op patient who does not have a wound vacuum bag. She observes that the dressing was soaked in blood. After weighing the dressing, she noted that it weighed 2 oz. What is the proper amount of exudate that should be documented?       
    • A. 

      60 g

    • B. 

      2 oz.

    • C. 

      60 ml

    • D. 

      2 g.

  • 68. 
    A system of tubing and other apparatus attached to the body to remove fluid in an airtight circuit that prevents environmental contaminants from entering the wound.   
    • A. 

      Open drainage system

    • B. 

      Closed drainage system

    • C. 

      Suction drainage

    • D. 

      Vacuum drainage

  • 69. 
    How often should a Davol or Hemovac systems  be observed?
    • A. 

      Every hour

    • B. 

      Every 2 to 4 hours

    • C. 

      Once every shift

    • D. 

      At least once a day

  • 70. 
    When assessing the drainage of a T-Tube Drainage System, which of the following should be expected? Select all that apply:  
    • A. 

      Amount varies from 250 to 500 mL / 24 hours

    • B. 

      Slightly blood tinged in the first 24 hours

    • C. 

      Yellowish and dark brown after a day

    • D. 

      Color is normally greenish brown and thick

  • 71. 
    A device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. It accelerates wound healing by promoting the formation of granulation tissue, collagen, fibroblasts, and inflammatory cells in order to close or improve the condition of a wound in preparation for a skin graft.  
    • A. 

      Hemivac

    • B. 

      Wound Vacuum-assisted closure (Wound VAC)

    • C. 

      Jackson Pratt

    • D. 

      Davol

  • 72. 
    A patient who recently suffered a vehicular accident is using a Wound Vac device. Due to the severity of the accident, the patient has purulent drainage. How often should his dressing be changed?   
    • A. 

      Every hour

    • B. 

      Every 42 hours

    • C. 

      Every 24 hours

    • D. 

      Once a shift

  • 73. 
    How often should a Wound Vac dressing be changed for a patient with a clean wound?
    • A. 

      Once a week

    • B. 

      Every other day

    • C. 

      Three times a week

    • D. 

      Every other week

  • 74. 
    Since it is not an invasive procedure, a  Wound Vacuum Assisted Closure (Wound VAC)  device does not require a Physician's order.   
    • A. 

      True

    • B. 

      False

  • 75. 
    In a Wound VAC system, what is the negative pressure required for it to work?  
    • A. 

      Between 10 - 100 mm Hg, average of 100 mm Hg

    • B. 

      Between 5 - 200 mm Hg, average of 125 mm Hg

    • C. 

      Between 25 - 75 mm Hg, average 50 mm Hg

    • D. 

      Between 40 - 60 mm Hg, average 50 mm Hg

  • 76. 
    What should be the position of a Wound VAC system for it to work?
    • A. 

      Place VAC on a level surface or hang from the foot of the bed

    • B. 

      Place VAC parallel to the patient while sleeping

    • C. 

      Place VAC on the ground to avoid contamination

    • D. 

      Place VAC wherever the patient finds it convenient to reach

  • 77. 
    A moist environment may damage the wound edges (peri-wound skin). It is classified as moisture-associated skin damage (MASD). What do you call this damage?
    • A. 

      Laceration

    • B. 

      Maceration

    • C. 

      Incision

    • D. 

      Evisceration

  • 78. 
    A strip or roll of cloth or other material can be wound around a part of the body in a variety of ways for multiple purposes.
    • A. 

      Scarf

    • B. 

      Bandage

    • C. 

      Gauze

    • D. 

      Bandana

  • 79. 
    A type of bandage that is made of large pieces of material to fit a specific body part mostly made of elastic, cotton, muslin or flannel 
    • A. 

      Tie

    • B. 

      Gauze

    • C. 

      Binder

    • D. 

      Bandana

  • 80. 
    Which of the following wound care tasks could be delegated to an AP? 
    • A. 

      Applying a transparent dressing

    • B. 

      Removing a suture

    • C. 

      Applying an abdominal binder

    • D. 

      Assessment of patient before and after applying a binder

    • E. 

      Applying a Wound VAC

  • 81. 
    When bandaging extremities, how do you apply them?
    • A. 

      When bandaging extremities, it is important to measure the distance between turns.

    • B. 

      When bandaging extremities, begin with the part that is proximal to the heart and then go distal.

    • C. 

      When bandaging extremities, apply bandage first at the distal end and progress toward the trunk (heart)

    • D. 

      When bandaging extremities, it does not matter which end to start

  • 82. 
    Use  _____  _______ rather than _____   ______ to fasten bandages on small children or infants. 
    • A. 

      Loose clips, adhesive tapes

    • B. 

      Permanent glue, steel staples

    • C. 

      Rubber band, iron wire

    • D. 

      Adhesive tapes, loose clips

  • 83. 
    Unless otherwise directed by physician, how often do you remove and reapply elastic bandage?
    • A. 

      Once every 8 hours

    • B. 

      Three times a day

    • C. 

      Every two hours

    • D. 

      Before and after meals

  • 84. 
    How long does the outer edge of a wound appear inflamed?
    • A. 

      First 2 to 3 weeks

    • B. 

      First 2 to 3 hours

    • C. 

      First 2 to 3 days

    • D. 

      First 20 to 30 minutes

  • 85. 
    Without a physician's order, what do you do with a dressing that is saturated with exudate?
    • A. 

      Wait for an order before doing anything

    • B. 

      Go ahead and replace it. Then inform the physician later

    • C. 

      Reinforce the dressing over the incisional area by placing sterile gauze on top of the original dressing and anchor it securely

    • D. 

      Do nothing until the order has arrived

  • 86. 
    Existence of a wound indicates what kind of nursing diagnosis?
    • A. 

      Risk for infection

    • B. 

      Impaired skin integrity

    • C. 

      Loss of self image

    • D. 

      Powerlessness

  • 87. 
    How long would a normally healing wound fill withe epithelial cells and edge closely
    • A. 

      Around 5 days

    • B. 

      Within a week or less

    • C. 

      Within 7 to 10 days

    • D. 

      Almost a month

  • 88. 
    When applying a triangular blinder (Sling), where do you tie the square knot?
    • A. 

      At the lateral area of neck on the affected side

    • B. 

      Right where the elbow is

    • C. 

      At the lateral area of neck on uninjured side

    • D. 

      At the dorsal area of neck close to the occiput

  • 89. 
    Dressing selection will be done according to agency policy and traditional universal care plans. 
    • A. 

      True

    • B. 

      False