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1. The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included? Allow the solution to flow from the most contaminated to the least a. contaminated. b. Scrub vigorously when applying noncytotoxic solut$17.99
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1. The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included? Allow the solution to flow from the most contaminated to the least a. contaminated. b. Scrub vigorously when applying noncytotoxic solut
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Course
Nursing
Institution
Nursing
1. The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?
Allow the solution to flow from the most contaminated to the least
a. contaminated.
b. Scrub vigorously when applying noncytotoxic solution to the skin.
c. Cleanse in a di...
HESI MED SURG QUESTIONS AND
ANSWERS GRADED A.Approved
1. The nurse is cleansing a wound site. As the nurse administers the
procedure, which intervention should be included?
Allow the solution to flow from the most contaminated to the least
a. contaminated.
b. Scrub vigorously when applying noncytotoxic solution to the skin.
c. Cleanse in a direction from the least contaminated area.
d. Utilize clean gauze and clean gloves to cleanse a site.
ANS: C
Cleanse in a direction from the least contaminated area, such as from the wound or
incision, to the surrounding skin. While cleansing surgical or traumatic wounds by
applying noncytotoxic solution with sterile gauze or by irrigations is correct, vigorous
scrubbing is inappropriate and can cause damage to the skin. Use gentle friction when
applying solutions to the skin, and allow irrigation to flow from the least to the most
contaminated area.
2. The nurse is caring for a patient after an open abdominal aortic aneurysm repair.
The nurse requests an abdominal binder and carefully
applies the binder. Which is the best explanation for the nurse to use when 1
teaching the patient the reason for the binder?
,HESI MED SURG QUESTIONS AND
ANSWERS GRADED A.Approved
a. It reduces edema at the surgical site.
b. It secures the dressing in place.
c. It immobilizes the abdomen.
d. It supports the abdomen.
ANS: D
The patient has a large abdominal incision. This incision will need support, and an
abdominal binder will support this wound, especially during movement, as well as during
deep breathing and coughing. A binder can be used to immobilize a body part (e.g., an
elastic bandage applied around a sprained ankle). A binder can be used to prevent edema,
for example, in an extremity but in this case is not used to reduce edema at a surgical site.
A binder can be used to secure dressings such as elastic webbing applied around a leg
after vein stripping.
3. The nurse is caring for a postoperative medial meniscus repair of the
right knee. Which action should the nurse take to assist with pain management?
a. Monitor vital signs every 15 minutes.
b. Check pulses in the right foot.
c. Keep the leg dependent.
d. Apply ice.
ANS: D
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the
body part. Elevation (not dependent) assists in preventing edema, which in turn can cause
pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a
pain assessment but in itself is not an intervention that decreases pain. Checking the pulses
is important to monitor the circulation of the extremity but in itself is not a pain
, HESI MED SURG QUESTIONS AND
ANSWERS GRADED A.Approved
management intervention.
4. The patient has a risk for skin impairment and has a 15 on the Braden Scale
upon admission. The nurse has implemented interventions. Upon
reassessment, which Braden score will be the best sign that the risk for skin breakdown
is removed?
a. 12
b. 13
2
c. 20
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