NUR 3028 Exam II
Study online at https://quizlet.com/_feenx4
1. You want to record the amount D. All of the above.
of drainage from a wound. What
would the appropriate documen-
tation include and how would you
accomplish this?
A. Compare the weight of the exact
same dry dressing to the saturated
dressing.
B. After weighing the dressings as-
sume 1g of weight in drainage
equals 1mL of volume in drainage.
C. Document the amount of
drainage in notes.
D. All of the above.
2. The nurse is performing routine Clean the wound first by irrigating with normal saline,
wound dressing care and no- then collect the specimen.
ticed purulent drainage. There is a
standing order to culture any puru-
lent wound drainage. What is the
best method to collect the wound
culture?
3. A physical finding that would indi- Answer: Serosanguineous drainage along the incision
cate the patient is at an increased line the sixth postoperative day.
risk for wound dehiscence is: Rationale: This indicates that the incision's edges may
not be intact and are vulnerable for dehiscence and
evisceration. By the sixth postoperative day the exudate
should be serous, not serosanguineous.
4. Dr. Pain is expected to be on the B. Give pain medication 30 minutes prior to dressing
post-surgical floor you are working change.
, NUR 3028 Exam II
Study online at https://quizlet.com/_feenx4
on. She plans to change the dress-
ing of an 18-year-old with a GSW Rationale: Always pre-medicate the client, especially for
(gun shot wound) post surgery. the first dressing change. Dressing changes can be
This first dressing change, com- painful. You will learn how long it takes a medication
pleted by the physician, will include to start working, and this may help you decide when
replacing the packing and cutting to give the medication so that the client remains pain
away some dead tissue. There is an free for the dressing change. You can also try to work
order for a PRN pain med. Which is with the physician to determine when the change will
the correct nursing intervention? be done so she does not have to wait.
A. Give pain medication only if the
client is currently having pain
B. Give pain medication 30 minutes
prior to dressing change.
C. Allow the physician to change
the dressing without pre-medicat-
ing the client with pain meds when
the doctor says she does not want
to wait.
D. Give pain medication only after
the physician changes the dress-
ing.
5. A client has a large abdominal inci- Throw the packing away, and prepare a new one.
sion that requires a dressing. The
incision is packed with half-inch
iodoform packing, soaked in Be-
tadine, and covered with a ster-
ile 4x4 inch gauze. When chang-
ing the dressing, the nurse acci-
dentally drops the packing onto
the clients abdomen. The nurse
should:
, NUR 3028 Exam II
Study online at https://quizlet.com/_feenx4
6. The client is scheduled for a dress- Parallel to the skin surface while pulling toward the
ing change. When removing the wound.
adhesive tape used to secure the (You can also push down on the adjacent skin or use
dressing, the nurse should lift the saline to loosen very adhesive tape.)
edge and hold the tape:
7. You are caring for an obese patient The reduction of stress on the incision line while deep
post operative day 3 with a mid- breathing and coughing.
line abdominal incision. You ob-
serve he is wearing an abdominal
binder. The nurse understands the
indication for this type of binder is
for:
8. You are admitting a patient to Unstageable
your acute care setting from a
long term care facility. You observe
a sacral pressure ulcer. You note
there is dark, hard tissue cover-
ing the wound bed adhering to the
edges of the wound. How would
you document the stage of this
pressure ulcer?
9. When cleaning a midline abdom- False
inal incision which has a JP drain
3 inches from the top of the in-
cision, the nurse is using prop-
er technique when cleaning the
entire length of the incision with
one moistened gauze pad. True or
False?
Study online at https://quizlet.com/_feenx4
1. You want to record the amount D. All of the above.
of drainage from a wound. What
would the appropriate documen-
tation include and how would you
accomplish this?
A. Compare the weight of the exact
same dry dressing to the saturated
dressing.
B. After weighing the dressings as-
sume 1g of weight in drainage
equals 1mL of volume in drainage.
C. Document the amount of
drainage in notes.
D. All of the above.
2. The nurse is performing routine Clean the wound first by irrigating with normal saline,
wound dressing care and no- then collect the specimen.
ticed purulent drainage. There is a
standing order to culture any puru-
lent wound drainage. What is the
best method to collect the wound
culture?
3. A physical finding that would indi- Answer: Serosanguineous drainage along the incision
cate the patient is at an increased line the sixth postoperative day.
risk for wound dehiscence is: Rationale: This indicates that the incision's edges may
not be intact and are vulnerable for dehiscence and
evisceration. By the sixth postoperative day the exudate
should be serous, not serosanguineous.
4. Dr. Pain is expected to be on the B. Give pain medication 30 minutes prior to dressing
post-surgical floor you are working change.
, NUR 3028 Exam II
Study online at https://quizlet.com/_feenx4
on. She plans to change the dress-
ing of an 18-year-old with a GSW Rationale: Always pre-medicate the client, especially for
(gun shot wound) post surgery. the first dressing change. Dressing changes can be
This first dressing change, com- painful. You will learn how long it takes a medication
pleted by the physician, will include to start working, and this may help you decide when
replacing the packing and cutting to give the medication so that the client remains pain
away some dead tissue. There is an free for the dressing change. You can also try to work
order for a PRN pain med. Which is with the physician to determine when the change will
the correct nursing intervention? be done so she does not have to wait.
A. Give pain medication only if the
client is currently having pain
B. Give pain medication 30 minutes
prior to dressing change.
C. Allow the physician to change
the dressing without pre-medicat-
ing the client with pain meds when
the doctor says she does not want
to wait.
D. Give pain medication only after
the physician changes the dress-
ing.
5. A client has a large abdominal inci- Throw the packing away, and prepare a new one.
sion that requires a dressing. The
incision is packed with half-inch
iodoform packing, soaked in Be-
tadine, and covered with a ster-
ile 4x4 inch gauze. When chang-
ing the dressing, the nurse acci-
dentally drops the packing onto
the clients abdomen. The nurse
should:
, NUR 3028 Exam II
Study online at https://quizlet.com/_feenx4
6. The client is scheduled for a dress- Parallel to the skin surface while pulling toward the
ing change. When removing the wound.
adhesive tape used to secure the (You can also push down on the adjacent skin or use
dressing, the nurse should lift the saline to loosen very adhesive tape.)
edge and hold the tape:
7. You are caring for an obese patient The reduction of stress on the incision line while deep
post operative day 3 with a mid- breathing and coughing.
line abdominal incision. You ob-
serve he is wearing an abdominal
binder. The nurse understands the
indication for this type of binder is
for:
8. You are admitting a patient to Unstageable
your acute care setting from a
long term care facility. You observe
a sacral pressure ulcer. You note
there is dark, hard tissue cover-
ing the wound bed adhering to the
edges of the wound. How would
you document the stage of this
pressure ulcer?
9. When cleaning a midline abdom- False
inal incision which has a JP drain
3 inches from the top of the in-
cision, the nurse is using prop-
er technique when cleaning the
entire length of the incision with
one moistened gauze pad. True or
False?
