Chapter 22: Surgical Wound Care
ANS:
2000
two thousand
A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 335
OBJ: 2 TOP: Fluid intake KEY: Nursing Process Step: Implementation - ANS-37. The nurse
encourages a patient recovering from a hysterectomy to drink at least mL of fluid a day.
ANS:
clean
To remove a dressing, clean gloves are appropriate.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337 OBJ: 7 TOP: Removal of a
dressing
KEY: Nursing Process Step: Implementation - ANS-38. When preparing to remove a dressing,
the nurse should don gloves.
ANS:
collagen
Collagen forms as an immature scar over a new surgical wound.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334 OBJ: 1 TOP: Immature scarring
KEY: Nursing Process Step: Implementation - ANS-36. The nurse assures a patient that the
purple, raised, immature scar of a surgical wound is normal and caused by formation.
ANS: A
Fibrin in the clot begins to hold the wound together.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334
OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation - ANS-12. Hemostasis
begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot
that holds the wound together?
a. Fibrin
b. Thrombin
c. Protime
d. Calcium
, ANS: A
Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the
appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red
and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a
mixture of serous and sanguineous drainage.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage
KEY: Nursing Process Step: Assessment - ANS-25. The nurse assessing a patient's wound
notes a clear watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage
ANS: A
The irrigant should flow from the least contaminated area to the most contaminated area to
prevent microorganisms from entering the wound.
PTS: 1 DIF: Cognitive Level: Application REF: Page 343 OBJ: 11 TOP: Wound irrigation
KEY: Nursing Process Step: Implementation - ANS-7. The nurse is irrigating a leg wound of a
patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
a. From the area of least contamination to the area of most contamination
b. Forcefully into the wound
c. Gently over the skin into the wound
d. From a distance of about 12 inches
ANS: A, B, C, D
Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for
use on wet-to-dry dressings.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 341 OBJ: 7 TOP: Wet-to-dry dressings
KEY: Nursing Process Step: Implementation - ANS-34. Which solution(s) can be used on a
wet-to-dry dressing? (Select all that apply.)
a. Normal saline
b. Lactated Ringer
c. Acetic acid
d. Dakin
e. Lysol
ANS: A, B, C, D
Transparent dressings have the advantages of adhering to undamaged skin, containing the
exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding
epithelial growth.
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