NUR 311 Midterm Review Questions With Complete
Solutions
Review this slide for Incentive Spirometry
The nurse has finished cleaning a client's surgical wound. What
is the nurse's next action in this procedure?
-Pat the wound dry with a sterile gauze sponge.
-Allow the wound to air dry for 2 minutes.
-Measure the length, depth, and width of the wound.
-Position the client to promote drainage of the solution.
-Pat the wound dry with a sterile gauze sponge.
The nurse assesses the surgical dressing of a client who has just
arrived from the postanesthesia care unit (PACU) and observes
the dressing has a moderate area of serous drainage on it. What
is the best action by the nurse?
,-Reinforce the dressing and assess site frequently.
-Change the dressing using sterile technique.
-Notify the health care provider of the bleeding.
-Call a rapid response and stay with the client.
-Reinforce the dressing and assess site frequently.
The nurse is planning to replace a client's wound dressing. The
deep wound bed is to remain moist and requires packing. Which
action is appropriate?
-Loosely pack the dampened dressing material to prevent too
much pressure on the wound bed.
-Instill 50 ml of normal saline into the wound and loosely cover
with packing material.
-Insert rolled gauze into the wound; saturate it with povidone-
iodine solution and cover with a moisture-impervious dressing.
-Fill the wound with sterile saline gel and cover with a large
transparent dressing.
-Loosely pack the dampened dressing material to prevent too
much pressure on the wound bed.
After setting up a sterile field and putting on sterile gloves, the
nurse prepares to clean a client's surgical wound. Which
cleaning technique does the nurse use to prevent contamination
of the wound? The nurse cleans the wound from the:
-top to the bottom using a new gauze for each wipe.
-outside to center using a new gauze for each wipe.
-side to side using a new gauze for each wipe.
-distal to proximal using a new gauze for each wipe.
,-top to the bottom using a new gauze for each wipe.
The nurse is caring for a client who has a deep wound and
whose saline-moistened wound dressing has been changed every
12 hours. While removing the old dressing, the nurse notes that
the packing material is dry and adheres to the wound bed. Which
modification is most appropriate?
-Reduce the time interval between dressing changes.
-Assure that the packing material is completely saturated when
placed in the wound.
-Use less packing material.
-Discontinue application of saline-moistened packing and apply
a hydrocolloid dressing instead.
-Reduce the time interval between dressing changes.
The nurse is preparing to clean a client's surgical wound. What
will the nurse assess before beginning the procedure?
-client's comfort and effectiveness of pain medication
-color of drainage on the wound dressings
-any physical limitations the client may have
-client's temperature and pulses
-client's comfort and effectiveness of pain medication
The nurse is changing the dressing on a client's surgical wound
and notices that part of the dressing is sticking to the underlying
skin. Which action does the nurse prioritize in this situation?
-Wipe the area with an alcohol wipe and pull the dressing from
the skin.
-Wipe the area with an antimicrobial swab and pull the dressing
from the skin.
, -Use small amounts of sterile saline to help loosen and remove
the dressing.
-Soak the area with sterile water using gauze pads.
-Use small amounts of sterile saline to help loosen and remove
the dressing.
The nurse is removing the dressing from an abdominal surgical
wound during wound care and notices that the wound edges are
not intact, there are multiple staples on the dressing, and the
surrounding tissue is red with purulent drainage. The chart
reports that the incision was clean and dry with the
approximated edges and staples intact upon the last assessment.
What recommended nursing intervention will the nurse
take first in this situation?
-Assess for pain, shortness of breath, and abdominal pressure.
-Place the client in a sitting position to reduce pressure on the
abdomen.
-Leave the wound open and notify the health care provider.
-Tell the client that this is a life-threatening situation and that the
health care provider will be called.
-Assess for pain, shortness of breath, and abdominal pressure.
The nurse is preparing to perform wound care. Which
intervention will be prioritized to prevent injury to the nurse?
-Raise the bed to elbow height.
-Maintain a sterile field.
-Position the client.
-Gather all necessary equipment.
Solutions
Review this slide for Incentive Spirometry
The nurse has finished cleaning a client's surgical wound. What
is the nurse's next action in this procedure?
-Pat the wound dry with a sterile gauze sponge.
-Allow the wound to air dry for 2 minutes.
-Measure the length, depth, and width of the wound.
-Position the client to promote drainage of the solution.
-Pat the wound dry with a sterile gauze sponge.
The nurse assesses the surgical dressing of a client who has just
arrived from the postanesthesia care unit (PACU) and observes
the dressing has a moderate area of serous drainage on it. What
is the best action by the nurse?
,-Reinforce the dressing and assess site frequently.
-Change the dressing using sterile technique.
-Notify the health care provider of the bleeding.
-Call a rapid response and stay with the client.
-Reinforce the dressing and assess site frequently.
The nurse is planning to replace a client's wound dressing. The
deep wound bed is to remain moist and requires packing. Which
action is appropriate?
-Loosely pack the dampened dressing material to prevent too
much pressure on the wound bed.
-Instill 50 ml of normal saline into the wound and loosely cover
with packing material.
-Insert rolled gauze into the wound; saturate it with povidone-
iodine solution and cover with a moisture-impervious dressing.
-Fill the wound with sterile saline gel and cover with a large
transparent dressing.
-Loosely pack the dampened dressing material to prevent too
much pressure on the wound bed.
After setting up a sterile field and putting on sterile gloves, the
nurse prepares to clean a client's surgical wound. Which
cleaning technique does the nurse use to prevent contamination
of the wound? The nurse cleans the wound from the:
-top to the bottom using a new gauze for each wipe.
-outside to center using a new gauze for each wipe.
-side to side using a new gauze for each wipe.
-distal to proximal using a new gauze for each wipe.
,-top to the bottom using a new gauze for each wipe.
The nurse is caring for a client who has a deep wound and
whose saline-moistened wound dressing has been changed every
12 hours. While removing the old dressing, the nurse notes that
the packing material is dry and adheres to the wound bed. Which
modification is most appropriate?
-Reduce the time interval between dressing changes.
-Assure that the packing material is completely saturated when
placed in the wound.
-Use less packing material.
-Discontinue application of saline-moistened packing and apply
a hydrocolloid dressing instead.
-Reduce the time interval between dressing changes.
The nurse is preparing to clean a client's surgical wound. What
will the nurse assess before beginning the procedure?
-client's comfort and effectiveness of pain medication
-color of drainage on the wound dressings
-any physical limitations the client may have
-client's temperature and pulses
-client's comfort and effectiveness of pain medication
The nurse is changing the dressing on a client's surgical wound
and notices that part of the dressing is sticking to the underlying
skin. Which action does the nurse prioritize in this situation?
-Wipe the area with an alcohol wipe and pull the dressing from
the skin.
-Wipe the area with an antimicrobial swab and pull the dressing
from the skin.
, -Use small amounts of sterile saline to help loosen and remove
the dressing.
-Soak the area with sterile water using gauze pads.
-Use small amounts of sterile saline to help loosen and remove
the dressing.
The nurse is removing the dressing from an abdominal surgical
wound during wound care and notices that the wound edges are
not intact, there are multiple staples on the dressing, and the
surrounding tissue is red with purulent drainage. The chart
reports that the incision was clean and dry with the
approximated edges and staples intact upon the last assessment.
What recommended nursing intervention will the nurse
take first in this situation?
-Assess for pain, shortness of breath, and abdominal pressure.
-Place the client in a sitting position to reduce pressure on the
abdomen.
-Leave the wound open and notify the health care provider.
-Tell the client that this is a life-threatening situation and that the
health care provider will be called.
-Assess for pain, shortness of breath, and abdominal pressure.
The nurse is preparing to perform wound care. Which
intervention will be prioritized to prevent injury to the nurse?
-Raise the bed to elbow height.
-Maintain a sterile field.
-Position the client.
-Gather all necessary equipment.
