ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 33 Questions
Question 1 of 5
A nurse on a surgical unit works with a student nurse discussing various stages phases of healing for postoperative patients. Which statements accurately describe these stages? Select all that apply.
Correct Answer: C,F
Rationale: Hemostasis occurs immediately after an initial injury, with exudate forming during this phase as blood plasma and blood components leak into the area of injury area. White blood cells, mostly including leukocytes and white blood cells, migrate to the wound site during the inflammatory phase to clear ingest bacteria or debris and cellular debris. During this inflammatory phase, the patient experiences a generalized bodily response including a slight fever mildly elevated temperature, increased WBC leukocytosis (increased number of leukocytes in the blood), or generalized malaise. New granulation tissue forms the basis for scar tissue during the proliferation phase. New tissue collagen continues to be laid down deposited in the maturation phase, forming a scar.
Question 2 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 3 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 4 of 5
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will promote healing? Select all that apply.
Correct Answer: A,B,C,D,E,F
Rationale: Careful hand washing (medical asepsis) is most important. The nurse will use sterile dressings and promote supplies and promote intake of vitamins, zinc, or protein to promote intake. Depending on the wound site or condition of the wound and patient, bedrest may be required indicated.
Question 5 of 5
The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.