QUESTIONS
A nurse is caring for a postoperative patient with a Jackson-Pratt (JP) drain. The nurse notes that the bulb is half bull of serosanguineous fluid and no
longer appears compressed. Which statement best explains how the JP drain functions?
A. It removes fluid by continuous suction from wall suction equipment attached to the drainage tubing.
B. It uses low intermittent negative pressure created when the bulb is compressed to draw fluid from the surgical site into the reservoir
C. It relies on gravity drainage, allowing fluid to collect passively in the bulb from the wound site.
1 D. It creates positive pressure that forces fluid out of the wound and into the bulb.
Scenario:
A nurse is caring for a postoperative patient with a surgical incision that shows minimal serosanguinous drainage. The provider has ordered a
dressing change.
Question:
Which action by the nurse demonstrates the most appropriate evidence‑based practice for managing a dressing with minimal drainage?
A. Reinforce the dressing with additional gauze to avoid disturbing the wound.
B. Remove the old dressing, cleanse the wound with sterile technique, and apply a dry sterile dressing.
C. Apply a hydrocolloid dressing to absorb excess drainage and promote autolytic debridement.
2 D. Leave the incision open to air since drainage is minimal.
A nurse is caring for a postoperative patient with a surgical abdominal incision secured with staples. During the
morning assessment, the nurse notes serosanguinous drainage saturating 50% of the dressing, slight wound
separation at the lower edge, and the patient reports a sudden pulling sensation at the incision site after
coughing. Which action should the nurse perform FIRST? (Created by: Ambrosia V.)
A. Apply firm pressure over the incision and secure the area with Montgomery straps.
B. Cover the wound with a sterile saline–moistened dressing and notify the provider.
C.Remove the soiled dressing to fully inspect the incision and measure wound depth.
D.Document the findings and reassess the incision in 1 hour.
3
, The nurse is caring for four adult clients on a long-term care unit. Which client requires the most immediate intervention to prevent
further impairment of skin integrity?
A. An 88-year-old client who is on a pressure-reducing mattress, incontinent of stool, and has a red, blanchable area on the coccyx after
being repositioned 2 hours ago.
B. A 79-year-old client with moist, warm skin folds under the breasts, complaining of mild burning and itching, who has limited mobility
due to fatigue.
C. A 90-year-old client who refuses to be repositioned and is found sitting in the same chair for 6 hours, with a red, non-blanchable area
on the left buttock.
D. A 65-year-old client who ambulates with a walker and reports dryness and cracking on both heels after walking several laps in the
hallway.
4
A nurse is caring for a patient with a surgical incision that’s healing slowly. Which nutrients should nurse encourage to promote wound healing?
(Select all that apply.)
A. Vitamin C
B. Vitamin A
C. Zinc
D. Protein
E. Sodium
5 F. Vitamin K
What food would help with the healing of pressure injuries? select all that apply.
a. Bananas
b. Lean meats
c. Carrots
d. Bell peppers
6 e. Grapes
A nurse is caring for a postoperative patient who had open abdominal surgery. The provider prescribes an abdominal binder to be worn while the
patient is out of bed. Which statement by the nurse best explains the primary purpose of the abdominal binder in promoting wound healing?
A. “The binder helps prevent blood clots by improving circulation to the surgical area.”
B. “The binder provides support to the incision, reducing stress on the wound and promoting proper healing.”
C. “The binder keeps the surgical site sterile and prevents infection from developing.”
7 D. “The binder decreases postoperative pain by immobilizing the abdominal muscles completely.”
, A postoperative patient suddenly reports a “pulling” pain at their abdominal incision. The nurse sees that the wound edges have separated with pink
drainage. What should the nurse do first?
A. Cover the wound with sterile saline-soaked gauze
B. Apply adhesive strips over the incision
C. Document the findings
8 D. Encourage the patient to ambulate
The nurse is preparing to obtain a wound culture from a patient with a draining surgical wound.
Place the following steps in the correct order to ensure accurate collection of the specimen.
1. Apply sterile gloves.
2. Cleanse the wound with sterile normal saline.
3. Label the specimen and send it to the lab.
4. Remove the old dressing and dispose of it.
5. Obtain the culture sample from viable tissue using a sterile swab.
6. Perform hand hygiene and set up sterile supplies.
9
A nurse is caring for a client who reports severe abdominal pain of unknown origin. The client asks the nurse for a heating pad to help relieve
discomfort. Which nursing action is most appropriate?
A. Apply a heating pad to the clients abdomen for 20 minutes to promote muscle relaxation
B. Encourage the client to assume a comfortable position and notify the healthcare provider
C. Provide the heating pad as requested while monitoring the client’s skin for burns
10 D. Place an ice pack on the abdomen to decrease inflammation and pain
You are asked to perform a skin assessment on a male patient who just arrived back from total left hip replacement. What risk factors could a client
with a BMI of 37 face? Select all that apply.
A. Fistula forming in the new hip bone
B. Friction burns on the epidermal layers of skin surrounding the right hip.
C. Evisceration
11 D. Dehiscence
When beginning to walk with a single cane, which leg should step first, and how should the cane be used in relation to that leg?
A: Step first with your strong (unaffected) leg and move the cane simultaneously with your strong leg.
B: Step first with your strong (unaffected) leg and move the cane simultaneously with your weak (affected) leg.
12 C: Step first with your weak (affected) leg and move the cane simultaneously with your strong leg.
A nurse is caring for a postoperative patient with a Jackson-Pratt (JP) drain. The nurse notes that the bulb is half bull of serosanguineous fluid and no
longer appears compressed. Which statement best explains how the JP drain functions?
A. It removes fluid by continuous suction from wall suction equipment attached to the drainage tubing.
B. It uses low intermittent negative pressure created when the bulb is compressed to draw fluid from the surgical site into the reservoir
C. It relies on gravity drainage, allowing fluid to collect passively in the bulb from the wound site.
1 D. It creates positive pressure that forces fluid out of the wound and into the bulb.
Scenario:
A nurse is caring for a postoperative patient with a surgical incision that shows minimal serosanguinous drainage. The provider has ordered a
dressing change.
Question:
Which action by the nurse demonstrates the most appropriate evidence‑based practice for managing a dressing with minimal drainage?
A. Reinforce the dressing with additional gauze to avoid disturbing the wound.
B. Remove the old dressing, cleanse the wound with sterile technique, and apply a dry sterile dressing.
C. Apply a hydrocolloid dressing to absorb excess drainage and promote autolytic debridement.
2 D. Leave the incision open to air since drainage is minimal.
A nurse is caring for a postoperative patient with a surgical abdominal incision secured with staples. During the
morning assessment, the nurse notes serosanguinous drainage saturating 50% of the dressing, slight wound
separation at the lower edge, and the patient reports a sudden pulling sensation at the incision site after
coughing. Which action should the nurse perform FIRST? (Created by: Ambrosia V.)
A. Apply firm pressure over the incision and secure the area with Montgomery straps.
B. Cover the wound with a sterile saline–moistened dressing and notify the provider.
C.Remove the soiled dressing to fully inspect the incision and measure wound depth.
D.Document the findings and reassess the incision in 1 hour.
3
, The nurse is caring for four adult clients on a long-term care unit. Which client requires the most immediate intervention to prevent
further impairment of skin integrity?
A. An 88-year-old client who is on a pressure-reducing mattress, incontinent of stool, and has a red, blanchable area on the coccyx after
being repositioned 2 hours ago.
B. A 79-year-old client with moist, warm skin folds under the breasts, complaining of mild burning and itching, who has limited mobility
due to fatigue.
C. A 90-year-old client who refuses to be repositioned and is found sitting in the same chair for 6 hours, with a red, non-blanchable area
on the left buttock.
D. A 65-year-old client who ambulates with a walker and reports dryness and cracking on both heels after walking several laps in the
hallway.
4
A nurse is caring for a patient with a surgical incision that’s healing slowly. Which nutrients should nurse encourage to promote wound healing?
(Select all that apply.)
A. Vitamin C
B. Vitamin A
C. Zinc
D. Protein
E. Sodium
5 F. Vitamin K
What food would help with the healing of pressure injuries? select all that apply.
a. Bananas
b. Lean meats
c. Carrots
d. Bell peppers
6 e. Grapes
A nurse is caring for a postoperative patient who had open abdominal surgery. The provider prescribes an abdominal binder to be worn while the
patient is out of bed. Which statement by the nurse best explains the primary purpose of the abdominal binder in promoting wound healing?
A. “The binder helps prevent blood clots by improving circulation to the surgical area.”
B. “The binder provides support to the incision, reducing stress on the wound and promoting proper healing.”
C. “The binder keeps the surgical site sterile and prevents infection from developing.”
7 D. “The binder decreases postoperative pain by immobilizing the abdominal muscles completely.”
, A postoperative patient suddenly reports a “pulling” pain at their abdominal incision. The nurse sees that the wound edges have separated with pink
drainage. What should the nurse do first?
A. Cover the wound with sterile saline-soaked gauze
B. Apply adhesive strips over the incision
C. Document the findings
8 D. Encourage the patient to ambulate
The nurse is preparing to obtain a wound culture from a patient with a draining surgical wound.
Place the following steps in the correct order to ensure accurate collection of the specimen.
1. Apply sterile gloves.
2. Cleanse the wound with sterile normal saline.
3. Label the specimen and send it to the lab.
4. Remove the old dressing and dispose of it.
5. Obtain the culture sample from viable tissue using a sterile swab.
6. Perform hand hygiene and set up sterile supplies.
9
A nurse is caring for a client who reports severe abdominal pain of unknown origin. The client asks the nurse for a heating pad to help relieve
discomfort. Which nursing action is most appropriate?
A. Apply a heating pad to the clients abdomen for 20 minutes to promote muscle relaxation
B. Encourage the client to assume a comfortable position and notify the healthcare provider
C. Provide the heating pad as requested while monitoring the client’s skin for burns
10 D. Place an ice pack on the abdomen to decrease inflammation and pain
You are asked to perform a skin assessment on a male patient who just arrived back from total left hip replacement. What risk factors could a client
with a BMI of 37 face? Select all that apply.
A. Fistula forming in the new hip bone
B. Friction burns on the epidermal layers of skin surrounding the right hip.
C. Evisceration
11 D. Dehiscence
When beginning to walk with a single cane, which leg should step first, and how should the cane be used in relation to that leg?
A: Step first with your strong (unaffected) leg and move the cane simultaneously with your strong leg.
B: Step first with your strong (unaffected) leg and move the cane simultaneously with your weak (affected) leg.
12 C: Step first with your weak (affected) leg and move the cane simultaneously with your strong leg.
