ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 26 Questions
Question 1 of 5
A patient's J-P drain should be emptied:
Correct Answer: C
Rationale: A J-P drain should be emptied when one-half to two-thirds full to maintain proper suction and prevent complications.
Question 2 of 5
Your patient has a large abdominal wound with copious drainage and many layers of gauze 4x4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient?
Correct Answer: C
Rationale: Montgomery straps or an abdominal binder reduce skin irritation by minimizing tape use while securing dressings.
Question 3 of 5
You are caring for a 67-year-old male who had a cerebrovascular accident 3 weeks ago. In addition, he has developed a pressure injury on his right hip. Which of the following data that you collected will be useful in developing a care plan that will address his pressure ulcer?
Correct Answer: A,B,D,E
Rationale: When developing a care plan for a 67-year-old male with a pressure injury, several pieces of collected data are particularly useful. His weight loss from 165.5 to 161.8 pounds over the past week suggests nutritional deficits, which can impair wound healing and should be addressed through dietary interventions. The identification of the pressure injury as stage 3 indicates full-thickness tissue damage and guides the level of wound care required, such as debridement and specialized dressings. His inability to sit in a chair for more than 15 minutes highlights limited mobility, a major risk factor for pressure ulcers, requiring repositioning schedules and pressure-relieving devices. Additionally, while he dislikes some high-protein foods like cheese, beans, chicken, and fish, his preference for steak, eggs, nuts, and peanut butter still offers adequate protein options, which are critical for tissue repair and wound healing. These preferences should be incorporated into his care plan to ensure compliance with nutritional recommendations.
Question 4 of 5
You observe pink drainage from a patient's wound. You would describe this as:
Correct Answer: E
Rationale: Serosanguineous drainage is pink, combining clear serous fluid and small amounts of blood.
Question 5 of 5
The phase of healing during which granulation tissue forms in a wound is the:
Correct Answer: B
Rationale: Granulation tissue forms during the reconstruction (proliferative) phase, filling the wound with new tissue.