ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 33 : Skin Integrity and Wound Care Questions
Question 1 of 5
How will the nurse and Sam know that the treatment plan has been effective? Select all that apply.
Correct Answer: A,C,D
Rationale: Effective treatment is indicated by wound healing (
A), patient satisfaction and adherence (
C), and partner's ability to recognize infection signs (
D). Occasional fever (
B) suggests persistent infection, and walking a mile (E) is unrelated to wound healing outcomes.
Question 2 of 5
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
Question 3 of 5
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
Question 4 of 5
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, 'Something is falling out of my incision!' The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
Correct Answer: C,B,A,E,D
Rationale: The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the wound), and notify the surgical site of the situation (to address the problem issue, likely requiring with surgery). The patient must be kept NPO for prompt surgical repair will be needed. After the patient has received attention, the nurse should document all assessments and interventions performed in a timely manner.
Question 5 of 5
A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.