Skills lab exam

Question 1

Which of the following is the primary purpose of Negative Pressure Wound Therapy (NPWT)?
A. To increase the size of the wound
B. To promote healing by reducing edema and removing exudate
C. To apply pressure directly on the wound bed
D. To prevent infection through chemical sterilization

Answer 1

B. To promote healing by reducing edema and removing exudate - Negative Pressure Wound Therapy helps by creating a vacuum that removes fluids and promotes tissue granulation.

Question 2

What is the correct order of steps when performing a sterile wound irrigation and dressing application?
A. Clean the wound, apply sterile dressing, irrigate the wound
B. Apply sterile dressing, clean the wound, irrigate the wound
C. Irrigate the wound, clean the wound, apply sterile dressing
D. Irrigate the wound, apply sterile dressing, clean the wound

Answer 2

C. Irrigate the wound, clean the wound, apply sterile dressing - The correct order ensures the wound is cleansed, and the sterile dressing is applied afterward to prevent contamination.

Question 3

True or False: The main goal of treating a pressure injury is to relieve pressure, maintain a moist wound environment, and prevent infection.

Answer 3

True - The goals of pressure injury treatment include relieving pressure, keeping the wound moist, and preventing infection.

Question 4

Which of the following is the correct method for removing a dry dressing?
A. Remove the dressing slowly from the outer edges inward
B. Remove the dressing quickly to avoid causing pain
C. Soak the dressing in saline before removing it
D. Remove the dressing by pulling toward the wound bed

Answer 4

A. Remove the dressing slowly from the outer edges inward - This technique reduces the risk of damaging new tissue during dressing removal.

Question 5

What is the purpose of wet-to-moist dressing in wound care?
A. To allow the wound to dry and form a scab
B. To keep the wound moist, promoting tissue granulation
C. To prevent further infection using antiseptic solutions
D. To increase the pressure on the wound bed to stop bleeding

Answer 5

B. To keep the wound moist, promoting tissue granulation - Wet-to-moist dressings maintain a moist environment conducive to tissue growth and healing.

Question 6

Which of the following steps are essential to observe when performing a sterile dressing change? (Select all that apply)
A. Performing hand hygiene before and after the procedure
B. Keeping sterile gloves on until the dressing is completely applied
C. Reaching over the sterile field when gathering supplies
D. Discarding the dressing in a biohazard bag after removal

Answer 6

A, B, D - Maintaining sterile technique and proper disposal of contaminated dressings are essential in preventing infection.

Question 7

Which of the following is an appropriate intervention when caring for a closed wound drainage system?
A. Empty the drainage system when it is full
B. Maintain the drainage system above the level of the wound
C. Compress the drainage system after emptying it to maintain suction
D. Remove the drainage system every two hours to prevent blockage

Answer 7

C. Compress the drainage system after emptying it to maintain suction - This ensures that the vacuum effect continues to drain the wound effectively.

Question 8

What is the correct way to document a wound assessment in the EHR?
A. Only record the size and depth of the wound
B. Include the wound location, size, exudate type, odor, and surrounding skin condition
C. Document the patient’s pain level and skip wound details
D. Only document the type of dressing used

Answer 8

B. Include the wound location, size, exudate type, odor, and surrounding skin condition - Comprehensive documentation provides a clear picture of the wound’s condition.

Question 9

True or False: When performing a dressing change with irrigation and packing, sterile technique must be maintained throughout the procedure.

Answer 9

True - Sterile technique must be maintained throughout irrigation and packing to prevent contamination and infection.

Question 10

What are the key principles of surgical asepsis when applying a sterile dressing? (Select all that apply)
A. Touching only sterile surfaces with sterile gloves
B. Keeping sterile items below the waist level
C. Turning your back on the sterile field
D. Keeping hands above the waist and avoiding contamination

Answer 10

A, D - Surgical asepsis requires that only sterile objects touch the wound and hands remain above waist level to avoid contamination.

Question 11

What type of wound dressing is most appropriate for a heavily exudating wound?
A. Dry dressing
B. Hydrocolloid dressing
C. Foam dressing
D. Transparent dressing

Answer 11

C. Foam dressing - Foam dressings are highly absorbent and are used for wounds with heavy exudate.

Question 12

Which of the following actions would be appropriate when treating a Stage 2 pressure injury?
A. Applying a hydrocolloid dressing to protect the wound
B. Using dry gauze only
C. Applying an occlusive dressing to prevent further breakdown
D. Keeping the wound open to air for faster healing

Answer 12

A. Applying a hydrocolloid dressing to protect the wound - A hydrocolloid dressing is appropriate for Stage 2 pressure injuries as it maintains moisture and protects the wound.

Question 13

True or False: Emptying a closed wound drainage system requires the use of clean gloves, while maintaining surgical asepsis for the wound care itself.

Answer 13

True - While emptying the drainage system requires clean technique, wound care demands sterile technique to prevent infection.

Question 14

Which of the following are steps involved in applying Negative Pressure Wound Therapy (NPWT)? (Select all that apply)
A. Cutting foam dressing to the size of the wound
B. Applying a transparent adhesive film over the wound
C. Connecting the tubing and creating a vacuum seal
D. Pouring saline into the wound before applying the NPWT system

Answer 14

A, B, C - These are the key steps in applying NPWT, which includes creating a vacuum-sealed environment to promote wound healing.

Question 15

True or False: A sterile wound irrigation involves directing a stream of sterile solution over the wound bed to remove debris while preventing contamination.

Answer 15

True - Sterile wound irrigation involves using sterile saline to clean the wound and remove debris while maintaining a sterile environment.

Question 16

What should the nurse assess when monitoring a wound with a drainage system? (Select all that apply)
A. The amount and color of drainage
B. The suction function of the drainage system
C. The odor of the wound
D. The location and size of the wound only

Answer 16

A, B, C - Monitoring drainage and the function of the drainage system is critical to assessing the healing process and preventing complications.

Question 17

Which of the following is an example of proper sterile technique when irrigating a wound?
A. Irrigating the wound with tap water
B. Using a 60 mL syringe with sterile normal saline for irrigation
C. Irrigating the wound from the bottom to the top
D. Using sterile gloves for irrigation but non-sterile gloves for applying the dressing

Answer 17

B. Using a 60 mL syringe with sterile normal saline for irrigation - Sterile normal saline is the appropriate solution for irrigating wounds, and a 60 mL syringe provides adequate pressure.

Question 18

What is the primary purpose of packing a wound during dressing changes?
A. To stop excessive bleeding
B. To prevent infection by filling dead space and promoting healing
C. To dry out the wound
D. To reduce edema and swelling

Answer 18

B. To prevent infection by filling dead space and promoting healing - Wound packing helps prevent abscess formation by ensuring that dead space is filled and healing is supported.

Question 19

When changing a wet-to-moist dressing, what is the most appropriate technique?
A. Allow the old dressing to dry completely before removing it
B. Ensure the new dressing is moist but not saturated
C. Use dry sterile gauze to pack the wound
D. Always change the dressing every four hours regardless of the wound condition

Answer 19

B. Ensure the new dressing is moist but not saturated - Wet-to-moist dressings should be moist to support healing but not overly saturated.

Question 20

True or False: When assessing pressure injuries, the nurse should use a standardized tool like the Braden Scale to evaluate risk factors for further skin breakdown.

Answer 20

True - Tools like the Braden Scale help nurses assess the risk of skin breakdown and guide preventive measures in patients at risk for pressure injuries.

Question 21

What is the primary purpose of surgical asepsis during invasive procedures?
A. To reduce discomfort for the client
B. To sterilize the client’s skin
C. To maintain a sterile environment free from pathogens
D. To disinfect the surgical instruments

Answer 21

C. To maintain a sterile environment free from pathogens
Surgical asepsis ensures that the sterile field and equipment are free of microorganisms to prevent infection.

Question 22

True or False: The outer 1-inch border of a sterile field is considered sterile and can be touched by non-sterile gloves.

Answer 22

False
The outer 1-inch border of the sterile field is considered contaminated.

Question 23

Which of the following is considered a break in sterile technique? (Select all that apply)
A. Touching the sterile field with a non-sterile glove
B. Pouring sterile solution directly onto a contaminated surface
C. Turning your back on the sterile field
D. Keeping hands above the waist while wearing sterile gloves

Answer 23

A, B, C
Touching the field with a non-sterile glove, pouring solution on a contaminated surface, and turning your back on the sterile field all break sterile technique.

Question 24

Which method of sterilization is most effective for heat-sensitive medical instruments?
A. Autoclaving
B. Dry heat
C. Chemical sterilization
D. Radiation

Answer 24

C. Chemical sterilization
Chemical sterilization is used for heat-sensitive medical instruments.

Question 25

True or False: When opening a sterile package, the first flap should always be opened toward your body.

Answer 25

False The first flap should always be opened away from your body to prevent contamination.

Question 26

. During a sterile procedure, which of the following actions would result in contamination of the sterile field? (Select all that apply) A. Reaching over the sterile field to grab a supply B. Dropping sterile gauze from 5 inches above the field C. A sterile item touches the 1-inch border of the field D. Adjusting the sterile drape after placing sterile items on it

Answer 26

A, C, D Reaching over the sterile field, touching the 1-inch border, or adjusting the sterile drape after placing items all result in contamination.

Question 27

What is the correct order of steps for donning sterile gloves? A. Wash hands, open sterile glove package, grasp the glove’s cuff, and don gloves B. Open sterile glove package, apply sterile gloves, then wash hands C. Wash hands, apply sterile gown, open glove package, and don gloves D. Wash hands, don non-sterile gloves, open sterile glove package, and apply sterile gloves

Answer 27

A. Wash hands, open sterile glove package, grasp the glove’s cuff, and don gloves Hand hygiene should be performed first before donning sterile gloves.

Question 28

Which of the following should be done if a sterile field becomes wet during a procedure? A. Continue the procedure, but avoid the wet area B. Cover the wet area with additional sterile drapes C. Consider the sterile field contaminated and start the procedure over D. Allow the field to air dry before continuing

Answer 28

C. Consider the sterile field contaminated and start the procedure over Wetness on the sterile field is considered contamination.

Question 29

True or False: When using sterile solutions, the bottle should be held with the label facing away from the palm of the hand to avoid smudging.

Answer 29

False The label should be facing the palm of the hand to prevent it from getting wet or smudged.

Question 30

Which of the following procedures requires surgical asepsis? (Select all that apply) A. Inserting a urinary catheter B. Administering a subcutaneous injection C. Performing a lumbar puncture D. Changing a wet-to-dry dressing

Answer 30

A, C, D Inserting a catheter, performing a lumbar puncture, and changing wet-to-dry dressings require surgical asepsis.

Question 31

When setting up a sterile field, what should the nurse do first? A. Put on sterile gloves B. Check the expiration date on all sterile packages C. Open the sterile drape D. Wash their hands

Answer 31

B. Check the expiration date on all sterile packages Expired packages can no longer be considered sterile.

Question 32

True or False: It is acceptable to turn your back on a sterile field as long as you do not touch the field.

Answer 32

False Turning your back on the sterile field can result in contamination as it is no longer within view.

Question 32

Which of the following items should always be sterilized before use in a surgical procedure? A. Hospital-grade disinfectants B. Surgical instruments C. Non-sterile gloves D. Surgical drapes

Answer 32

B. Surgical instruments Surgical instruments must be sterile before use in any procedure.

Question 33

True or False: It is acceptable to use an autoclaved instrument pack that is wet from condensation.

Answer 33

False Wet packs are considered non-sterile and should not be used.

Question 34

How should a nurse open the first flap of a sterile package when preparing a sterile field? A. Toward the body B. Away from the body C. To the left side D. To the right side

Answer 34

B. Away from the body This prevents reaching over the sterile field and contaminating it.

Question 35

What is the main difference between medical asepsis and surgical asepsis? A. Medical asepsis aims to keep the surgical field sterile B. Medical asepsis reduces microorganisms, while surgical asepsis eliminates all microorganisms C. Medical asepsis uses sterile gloves, while surgical asepsis uses non-sterile gloves D. There is no difference between medical and surgical asepsis

Answer 35

B. Medical asepsis reduces microorganisms, while surgical asepsis eliminates all microorganisms Medical asepsis minimizes microorganisms, while surgical asepsis eliminates them.

Question 36

Which of the following statements is true regarding sterilization of surgical instruments? A. Sterilization is necessary for all medical equipment, including bedpans B. Instruments must be cleaned of visible soil before sterilization C. Disinfection is sufficient for surgical instruments used in major surgeries D. Surgical instruments should only be sterilized once a week

Answer 36

B. Instruments must be cleaned of visible soil before sterilization Cleaning is essential before sterilization to remove organic material.

Question 36

Which type of sterilization is commonly used for single-use medical equipment? A. Thermal sterilization B. Radiation C. Chemical sterilization D. Disinfection

Answer 36

B. Radiation Radiation sterilization is often used for single-use items that are heat-sensitive.

Question 36

True or False: A sterile gown should be donned before sterile gloves when preparing for surgery.

Answer 36

True The sterile gown should be donned before sterile gloves when preparing for surgery.

Question 37

True or False: When adding sterile solutions to a sterile field, the nurse should pour the solution from at least 12 inches above the field.

Answer 37

False Sterile solutions should be poured from a height of 4-6 inches to avoid contamination from splashing.

Question 38

21. Which of the following items can be used to create a sterile field? (Select all that apply) A. A sterile drape B. A disposable sterile gown C. A package of sterile gloves D. A sterile syringe

Answer 38

A, B, C, D All of these can be used to prepare a sterile field

Question 39

22. Which of the following principles is true regarding the use of a sterile field? (Select all that apply) A. Any sterile object that touches a non-sterile object becomes contaminated B. A sterile object remains sterile even if it touches the 1-inch border of the sterile field C. Sterile objects must always be kept within view D. The sterile field is considered contaminated if left unattended

Answer 39

A, C, D Sterile objects become contaminated if they touch non-sterile objects, and the field should remain in view and not be left unattended.

Question 40

23. True or False: Surgical asepsis must be maintained when inserting a central venous catheter.

Answer 40

True Central venous catheter insertion requires maintaining surgical asepsis.

Question 41

. Which of the following actions should the nurse take if they suspect the sterile field has been contaminated? A. Continue the procedure without interruption B. Ask the client to confirm if they observed contamination C. Stop the procedure and establish a new sterile field D. Ignore the suspicion unless contamination is visible

Answer 41

C. Stop the procedure and establish a new sterile field Suspected contamination requires starting the procedure over to maintain sterility.

Question 42

26. Which of the following methods of disinfection is used for respiratory therapy equipment? A. Thermal sterilization B. High-level disinfection C. Low-level disinfection D. Radiation

Answer 42

B. High-level disinfection High-level disinfection is required for respiratory equipment that comes into contact with mucous membranes but not sterile body cavities.

Question 43

25. What should be done with sterile gloves that are dropped on the floor before a procedure? A. Re-sterilize the gloves and use them B. Use the gloves as long as they appear clean C. Discard the gloves and open a new sterile package D. Dust off the gloves and proceed with the procedure

Answer 43

C. Discard the gloves and open a new sterile package Once sterile gloves touch the floor, they are considered contaminated and should not be used.

Question 44

27. Which step should be taken if a sterile item touches the outer 1-inch border of a sterile field during a procedure? A. Remove the item and continue the procedure B. Leave the item on the sterile field C. Remove the item and consider it contaminated D. Continue using the item since the 1-inch border is sterile

Answer 44

C. Remove the item and consider it contaminated Any item that touches the 1-inch border is contaminated and should not be used.

Question 45

28. Which type of sterilization is used when heat-sensitive medical instruments cannot tolerate high temperatures? A. Dry heat B. Steam under pressure C. Ethylene oxide gas D. UV light

Answer 45

C. Ethylene oxide gas Ethylene oxide is used for heat-sensitive medical instruments that cannot tolerate high temperatures.

Question 46

29. True or False: If sterile gloves touch the non-sterile outer packaging of a sterile item, the gloves remain sterile.

Answer 46

False If sterile gloves touch a non-sterile outer package, they are contaminated.

Question 47

30. Which of the following are appropriate practices for maintaining sterility during a procedure? (Select all that apply) A. Avoid reaching over the sterile field B. Keep the sterile field above waist level C. Adjust the sterile field as needed during the procedure D. Discard items that come into contact with non-sterile objects

Answer 47

A, B, D Maintaining sterility includes keeping items above waist level, avoiding contact with non-sterile objects, and discarding contaminated items.

Question 48

31. True or False: Sterile gloves are not required when placing a sterile drape for a wound dressing change.

Answer 48

False Sterile gloves are required when placing a sterile drape during a dressing change.

Question 49

32. Which of the following is the most appropriate response if you see a co-worker reach across a sterile field during a procedure? A. Continue the procedure without saying anything B. Inform the co-worker that the field is now contaminated C. Move the sterile items away from the area that was reached over D. Discard the sterile field and begin the procedure again

Answer 49

B. Inform the co-worker that the field is now contaminated Any breach of sterility should be addressed immediately to prevent infection.

Question 50

33. Which of the following items should undergo high-level disinfection instead of sterilization? A. Surgical forceps B. Endoscopes C. Scalpels D. Injection syringes

Answer 50

B. Endoscopes Endoscopes require high-level disinfection rather than sterilization since they do not enter sterile body cavities.

Question 51

35. True or False: Once a sterile item is added to the sterile field, it can be moved freely as long as it is handled with sterile gloves.

Answer 51

False Sterile items should not be moved freely once placed on the sterile field to prevent contamination.

Question 52

36. Which of the following actions would break surgical asepsis during a sterile dressing change? A. Wearing sterile gloves during the dressing change B. Turning your back on the sterile field while collecting supplies C. Keeping the sterile field at

Answer 52

B. Turning your back on the sterile field while collecting supplies Turning your back on the sterile field can lead to contamination.

Question 53

True or False: Latex gloves are suitable for all patients

Answer 53

False Latex can cause allergic reactions in some patients, so it is important to check for allergies before using latex gloves.

Question 53

What is the primary purpose of wearing sterile gloves during a sterile procedure? A. To reduce the spread of microorganisms and protect against infection B. To increase comfort during procedures C. To assist in faster wound healing D. To prevent the transfer of moisture from hands to the patient

Answer 53

A. To reduce the spread of microorganisms and protect against infection Sterile gloves are used to maintain a sterile environment and prevent infection.

Question 54

Which of the following are important steps when donning sterile gloves? (Select all that apply) A. Only touch the inside surface of the glove when putting it on B. Pinch the outer surface of the first glove when donning the second glove C. Perform hand hygiene before opening the glove package D. Open the glove package by touching only the outer edges of the wrapper

Answer 54

A, C, D Only touch the inside of the glove to avoid contamination, perform hand hygiene before starting, and touch only the outer edges of the wrapper to maintain sterility.

Question 54

Which of the following should be done before donning sterile gloves? A. Perform hand hygiene and dry hands thoroughly B. Obtain the client’s signature for consent C. Apply a layer of antiseptic on the gloves D. Clean the glove packaging with a disinfectant

Answer 54

A. Perform hand hygiene and dry hands thoroughly Hand hygiene is critical to prevent contamination of the sterile gloves during the donning process.

Question 55

True or False: If sterile gloves come into contact with any non-sterile surface while donning, they are still considered sterile as long as the surface was clean.

Answer 55

False Any contact with non-sterile surfaces contaminates sterile gloves, requiring a new pair to be used.

Question 56

What should you do if the sterile gloves touch a non-sterile surface while putting them on? A. Continue with the procedure as long as no visible contamination is present B. Remove the gloves and apply hand sanitizer C. Discard the gloves and obtain a new pair D. Wipe the gloves with an alcohol pad

Answer 56

C. Discard the gloves and obtain a new pair If the gloves touch a non-sterile surface, they are considered contaminated and must be discarded

Question 57

Which of the following is necessary before beginning a sterile procedure? (Select all that apply) A. Review the client’s medical record to check for latex allergies B. Ensure that the sterile gloves are the correct size C. Perform hand hygiene thoroughly before donning gloves D. Touch the outer wrapper of the sterile glove package with sterile gloves

Answer 57

A, B, C Reviewing the client’s allergy history, ensuring the correct glove size, and performing hand hygiene are essential steps in preparing for sterile procedures.

Question 58

What is the appropriate way to remove sterile gloves after the procedure? A. Grasp the outside of the first glove with your gloved hand and pull it off B. Use non-sterile hands to remove the gloves C. Pull the gloves off by the fingers to avoid contact with the outer surface D. Use hand sanitizer before removing gloves

Answer 58

A. Grasp the outside of the first glove with your gloved hand and pull it off This method prevents contact between your bare hand and the outside of the glove, maintaining cleanliness.

Question 58

True or False: A flat, clean surface is necessary for laying out the sterile glove package to maintain sterility.

Answer 58

True A clean, flat surface ensures that the sterile glove package remains uncontaminated while being opened.

Question 59

Why is it important to verify a client's allergies before applying sterile gloves? A. To ensure the client does not experience an allergic reaction B. To avoid using gloves that are too tight C. To ensure the procedure is completed within the allotted time D. To match the gloves with the procedure being performed

Answer 59

A. To ensure the client does not experience an allergic reaction Using latex-free gloves for clients with a latex allergy is critical to avoid allergic reactions.

Question 59

Which of the following materials are used for sterile gloves? (Select all that apply) A. Latex B. Vinyl C. Nitrile D. Cloth

Answer 59

A, B, C Sterile gloves can be made from latex, vinyl, or nitrile. Cloth is not used for sterile gloves.

Question 60

True or False: Sterile gloves should be donned before setting up a sterile field to avoid contamination.

Answer 60

False Sterile gloves are donned after setting up a sterile field to prevent contamination.

Question 61

During the application of sterile gloves, the nurse accidentally touches the outer surface of the sterile glove with their bare hand. What should the nurse do? A. Continue with the procedure, as only the inner glove is sterile B. Remove the glove, discard it, and start with a new glove C. Clean the outer surface of the glove with an antiseptic wipe D. Inform the client and continue with the procedure

Answer 61

B. Remove the glove, discard it, and start with a new glove If the outer surface of a glove is touched by bare skin, it is contaminated and must be discarded.

Question 62

Which step is required after donning sterile gloves to ensure correct finger placement and comfort? A. Adjust the gloves by touching the outer surface of each glove with the other gloved hand B. Remove the gloves and try again C. Touch the glove edges with bare hands to reposition them D. Avoid adjusting the gloves to maintain sterility

Answer 62

A. Adjust the gloves by touching the outer surface of each glove with the other gloved hand Once both gloves are on, adjust them by touching only sterile-to-sterile surfaces to maintain sterility.

Question 63

Which of the following safety measures should be taken when performing sterile gloving? select all that apply A. Avoid touching the outer surface of the gloves with bare hands B. Perform hand hygiene after removing the gloves C. Discard the gloves if they become torn D. Double-glove for added protection during minor procedures

Answer 63

15. A, B, C Avoid touching the outer surface of the gloves, perform hand hygiene after glove removal, and discard torn gloves to maintain sterility and safety.

Question 64

True or False: Performing hand hygiene before donning sterile gloves is optional if the gloves are sterile.

Answer 64

False Performing hand hygiene is a crucial step in preventing contamination before donning sterile gloves.

Question 65

When adjusting sterile gloves, which part of the gloves should be touched? A. The inner surface of the glove B. The outer cuff of the glove C. The sterile surface with a sterile-gloved hand D. The edges of the gloves with clean, bare hands

Answer 65

C. The sterile surface with a sterile-gloved hand To maintain sterility, adjust gloves only by using sterile-to-sterile contact.

Question 66

Why is it important to perform hand hygiene before donning sterile gloves? A. To keep the gloves from becoming loose B. To prevent the transfer of bacteria or microorganisms to the gloves C. To make the gloves easier to apply D. To improve the fit of the gloves

Answer 66

. B. To prevent the transfer of bacteria or microorganisms to the gloves Hand hygiene helps prevent contamination of the gloves during donning.

Question 67

Which of the following situations would require the use of sterile gloves? (Select all that apply) A. Inserting a urinary catheter B. Administering a subcutaneous injection C. Changing a sterile wound dressing D. Taking a patient’s temperature

Answer 67

A, C Inserting a urinary catheter and changing a sterile wound dressing require sterile gloves, while administering an injection and taking a temperature do not.

Question 67

What should be done if the sterile glove package is found to be wet or damaged before a procedure? A. Use the gloves as long as the gloves themselves appear intact B. Discard the package and obtain a new one C. Dry the package before using it D. Open the package carefully to preserve sterility

Answer 67

B. Discard the package and obtain a new one A wet or damaged sterile package is considered contaminated and should not be used.

Question 68

True or False: The inner surface of sterile gloves can be touched by bare hands while applying them.

Answer 68

True The inner surface of sterile gloves can be touched by bare hands because this surface will be in contact with the wearer’s skin.

Question 69

When opening the sterile glove package, the nurse should: A. Open the package by touching the gloves directly B. Open the package and remove the gloves with bare hands C. Touch only the outer edges of the package and avoid touching the gloves directly D. Use sterile forceps to remove the gloves from the package

Answer 69

C. Touch only the outer edges of the package and avoid touching the gloves directly Touching the outer edges of the sterile package prevents contamination of the gloves inside.

Question 70

True or False: Sterile gloves can be reused for multiple procedures on the same patient if they do not become visibly soiled.

Answer 70

False Sterile gloves are single-use items and cannot be reused, even if they appear clean.

Question 70

In which of the following situations would a nurse need to discard sterile gloves and use a new pair? (Select all that apply) A. The gloves touched a non-sterile surface B. The gloves were applied but the procedure was delayed for over an hour C. The gloves were punctured or torn during the procedure D. The client is allergic to latex and the gloves are latex

Answer 70

A, B, C, D All these situations would require the gloves to be discarded and replaced with a new pair to maintain sterility and prevent allergic reactions.

Question 71

What is the rationale for folding back the edges of the inner wrapper of a sterile glove package? A. To make it easier to apply the gloves B. To prevent the gloves from sticking together C. To maintain the sterility of the gloves by minimizing contact D. To ensure proper alignment of the gloves

Answer 71

C. To maintain the sterility of the gloves by minimizing contact Folding back the edges of the inner wrapper ensures the sterile gloves are not contaminated during the donning process.

Question 72

True or False: If a sterile glove touches a sterile field, the glove remains sterile.

Answer 72

True Sterile gloves remain sterile when they come into contact with a sterile field.

Question 73

Which of the following steps is performed after donning sterile gloves during a sterile procedure? A. Reposition the sterile glove package B. Open additional sterile packages using bare hands C. Begin the sterile procedure as prescribed D. Clean the surface of the gloves with an antiseptic wipe

Answer 73

C. Begin the sterile procedure as prescribed After donning sterile gloves, the nurse should proceed with the sterile procedure while maintaining asepsis

Question 74

What is the correct action if a glove becomes contaminated during a sterile procedure? A. Remove both gloves, perform hand hygiene, and don new sterile gloves B. Wipe the glove with an alcohol pad and continue C. Remove only the contaminated glove and continue with the procedure D. Stop the procedure and document the contamination

Answer 74

A. Remove both gloves, perform hand hygiene, and don new sterile gloves If gloves become contaminated during a procedure, they must be removed, and hand hygiene should be performed before donning new gloves.

Question 75

True or False: The client should be informed to avoid touching any part of the sterile field during the procedure.

Answer 75

True Clients and family members should be informed to avoid touching the sterile field to prevent contamination

Question 76

Which of the following would break sterile technique during a procedure? (Select all that apply) A. Touching the sterile field with a sterile-gloved hand B. Adjusting the sterile field with non-sterile gloves C. Brushing a sterile glove against the non-sterile part of the body D. Using non-sterile gloves to open sterile packages

Answer 76

B, C, D Adjusting the sterile field with non-sterile gloves, brushing against a non-sterile surface, and using non-sterile gloves to open sterile packages would all break sterile technique.

Question 77

Which type of dressing is recommended for wounds with moderate to heavy exudate? A. Hydrocolloid dressings B. Film dressings C. Alginate dressings D. Transparent dressings

Answer 77

C. Alginate dressings Alginate dressings are highly absorbent and are ideal for wounds with moderate to heavy exudate.

Question 78

True or False: A moist wound bed is essential for optimal healing, but excessive moisture can cause maceration of surrounding tissue.

Answer 78

True A moist wound bed is necessary for healing, but too much moisture can lead to maceration.

Question 79

Which of the following dressings are classified as semi-occlusive dressings? (Select all that apply) A. Hydrocolloid dressings B. Alginate dressings C. Gauze dressings D. Foam dressings

Answer 79

A, B, D Hydrocolloid, alginate, and foam dressings are examples of semi-occlusive dressings.

Question 80

When would a nurse most likely use a hydrocolloid dressing? A. On a dry, necrotic wound that needs debridement B. For a highly exudative wound with infection C. For a small abrasion or superficial burn D. On an open wound with heavy bleeding

Answer 80

C. For a small abrasion or superficial burn Hydrocolloid dressings are often used for superficial wounds like abrasions and burns.

Question 81

True or False: Wet-to-dry dressings are frequently used today because they efficiently remove necrotic tissue without affecting healthy tissue

Answer 81

False Wet-to-dry dressings can damage healthy tissue along with necrotic tissue and are not frequently used today.

Question 82

Which of the following are advantages of using hydrocolloid dressings? (Select all that apply) A. Maintains a moist wound bed B. Allows oxygen to enter the wound C. Promotes the growth of granulation tissue D. Does not cause maceration of surrounding tissue

Answer 82

A, C, D Hydrocolloids maintain a moist wound bed, promote granulation tissue, and cause less maceration.

Question 83

What is the primary disadvantage of wet-to-dry dressings? A. They dry out the wound bed completely B. They can damage healthy granulation tissue C. They cannot be used with wounds that are infected D. They must be changed every few hours

Answer 83

B. They can damage healthy granulation tissue Wet-to-dry dressings may remove healthy granulation tissue when removed, which is a significant disadvantage.

Question 84

True or False: Alginate dressings require a secondary dressing to cover the wound.

Answer 84

True Alginate dressings require a secondary dressing to cover the wound and manage exudate.

Question 85

Which type of dressing is best suited for a wound with minimal exudate and allows the healthcare provider to visualize the wound? A. Hydrocolloid dressing B. Transparent film dressing C. Foam dressing D. Alginate dressing

Answer 85

Transparent film dressing Transparent film dressings allow for wound visualization and are suitable for wounds with minimal exudate

Question 86

Which of the following statements about hydrofiber dressings is accurate? A. Hydrofiber dressings are only used for dry wounds B. They are primarily used for wounds with low exudate C. Hydrofiber dressings have a high absorbency and stay in the wound for several days D. Hydrofiber dressings must be changed every 2 hours

Answer 86

C. Hydrofiber dressings have a high absorbency and stay in the wound for several days Hydrofiber dressings are used for wounds with moderate to heavy exudate and can stay in place for several days.

Question 87

A client with a sacral pressure injury is placed on a silicone-foam dressing. What is a key benefit of this type of dressing? A. It absorbs high amounts of exudate B. It is designed to prevent hospital-acquired pressure injuries (HAPIs) C. It increases the risk of infection D. It is only used for dry wounds

Answer 87

B. It is designed to prevent hospital-acquired pressure injuries (HAPIs) Silicone-foam dressings are used to reduce the risk of HAPIs, particularly when applied to the sacrum within 24 hours of admission.

Question 87

What is the purpose of using a negative pressure wound therapy (NPWT) device? A. To prevent wound infections in dry wounds B. To draw fluid and reduce edema in large wounds C. To provide warmth and moisture to necrotic tissue D. To increase the likelihood of wound dehiscence

Answer 87

B. To draw fluid and reduce edema in large wounds Negative pressure wound therapy (NPWT) uses suction to draw fluid and reduce edema, promoting wound healing.

Question 88

True or False: When using a film dressing over a wound with significant exudate, leakage can occur, potentially leading to skin maceration.

Answer 88

True Film dressings are not appropriate for wounds with significant exudate because leakage can cause maceration.

Question 89

Which of the following are examples of wound closures? (Select all that apply) A. Sutures B. Staples C. Hydrocolloid dressings D. Skin adhesives

Answer 89

A, B, D Sutures, staples, and skin adhesives are used to close and secure wounds.

Question 89

True or False: After 48 hours, most surgical wounds are considered colonized by the environment and are managed using clean technique.

Answer 89

True After 48 hours, surgical wounds are considered colonized, and clean technique is used for dressing changes

Question 89

Which type of wound dressing contains water and can be used for either adding moisture to dry wounds or absorbing excess moisture from wet wounds? A. Alginate dressing B. Hydrogel dressing C. Foam dressing D. Gauze dressing

Answer 89

B. Hydrogel dressing Hydrogels can either add moisture to dry wounds or absorb excess moisture from wet wounds, depending on the wound’s needs.

Question 90

Which of the following statements about Penrose drains is correct? A. Penrose drains are closed systems B. Penrose drains rely on negative pressure to remove fluid C. Penrose drains use gravity to remove fluid from the wound D. Penrose drains are the preferred method for wounds with significant exudate

Answer 90

C. Penrose drains use gravity to remove fluid from the wound Penrose drains are passive drains that rely on gravity to drain fluid from the wound.

Question 91

Which type of drain uses a bulb to create negative pressure and remove fluid from a wound? A. Penrose drain B. Jackson-Pratt (JP) drain C. Circular portable wound suction device D. Bottle drain

Answer 91

B. Jackson-Pratt (JP) drain JP drains use a bulb to create negative suction to remove fluid from the wound.

Question 92

True or False: A Penrose drain is an active, closed system that relies on negative pressure.

Answer 92

False Penrose drains are passive, open systems that use gravity, not negative pressure.

Question 93

A wound is producing a moderate amount of exudate. Which type of dressing should be used to manage the exudate and reduce the need for frequent dressing changes? A. Hydrogel dressing B. Foam dressing C. Transparent film dressing D. Alginate dressing

Answer 93

D. Alginate dressing Alginate dressings are appropriate for managing moderate exudate and reduce the frequency of dressing changes.

Question 94

What is the primary role of sutures and staples in wound care? A. To absorb excess exudate B. To promote granulation tissue formation C. To keep wound edges secure and intact D. To maintain a moist wound environment

Answer 94

C. To keep wound edges secure and intact The primary role of sutures and staples is to secure wound edges, facilitating faster healing.

Question 95

Which of the following is a disadvantage of using hydrocolloid dressings? A. High risk of infection B. Can cause contact dermatitis C. Increases maceration D. Inability to maintain a moist wound bed

Answer 95

B. Can cause contact dermatitis Hydrocolloid dressings can sometimes cause contact dermatitis in sensitive individuals.

Question 96

What should be done if a Penrose drain dressing becomes saturated within the first 24-48 hours? A. Leave the dressing in place for 48 hours B. Change the dressing using sterile technique C. Notify the provider immediately D. Remove the drain

Answer 96

B. Change the dressing using sterile technique If a Penrose drain dressing becomes saturated, it should be changed using sterile technique to prevent infection.

Question 97

True or False: Portable wound bulb suction devices must be emptied when they are more than half full.

Answer 97

True Portable wound bulb suction devices should be emptied when they are more than half full to maintain effective suction.

Question 98

Which of the following are potential complications associated with the use of wound drains? (Select all that apply) A. Clot formation at the insertion site B. Accidental removal of the drain C. Increased wound healing rate D. Obstruction of the tubing by tissue fragments

Answer 98

A, B, D Complications of wound drains include clot formation, accidental removal, and tubing obstruction by tissue fragments

Question 99

Which of the following are correct steps in the care of a circular portable wound suction device? (Select all that apply) A. Empty the drained fluid into a measuring container B. Squeeze the drain flat after emptying C. Remove the drain once it is half full D. Secure the drain with adhesive tape

Answer 99

A, B Proper care of a circular portable wound suction device includes emptying the drained fluid into a measuring container and squeezing the drain flat to maintain suction.

Question 100

What is the expected daily drainage output before wound drains are typically removed? A. 10-30 mL B. 30-100 mL C. 100-150 mL D. 150-200 mL

Answer 100

B. 30-100 mL Wound drains are typically removed when the drainage is less than 30-100 mL per day.

Question 100

True or False: After wound drain removal, the site should be left open to the air after 24 hours if no signs of infection are present.

Answer 100

True After 24 hours, if no signs of infection are present, the site can be left open to the air.

Question 101

Which type of drain is most likely to be used for large amounts of drainage from a wound? A. Penrose drain B. Jackson-Pratt (JP) drain C. Bottle drain D. Circular portable wound suction device

Answer 101

C. Bottle drain Bottle drains are used for wounds with large amounts of drainage.

Question 102

What should the nurse do if there is a sudden increase in wound drainage and the fluid appears cloudy and has a foul odor? A. Document the finding as a normal healing process B. Notify the provider as these could be signs of infection C. Flush the drain to clear any blockages D. Change the dressing and continue monitoring

Answer 102

B. Notify the provider as these could be signs of infection Cloudy, foul-smelling wound drainage may indicate infection, and the provider should be notified.

Question 103

What is the primary purpose of a Negative Pressure Wound Therapy (NPWT) device? A. To promote wound healing by decreasing edema and removing exudate B. To prevent wound infections C. To increase oxygenation to the wound bed D. To reduce the need for wound dressing changes

Answer 103

A. To promote wound healing by decreasing edema and removing exudate NPWT decreases edema and removes exudate, promoting the formation of granulation tissue.

Question 104

True or False: NPWT devices can be applied by assistive personnel (AP) under the supervision of an RN.

Answer 104

False NPWT cannot be applied by assistive personnel (AP); it must be done by an RN or under RN supervision.

Question 105

Which of the following tasks related to NPWT can a practical nurse (PN) perform under RN supervision? A. Applying the NPWT dressing B. Changing the collection canister C. Maintaining and monitoring the NPWT device D. Discontinuing NPWT therapy

Answer 105

C. Maintaining and monitoring the NPWT device A PN can maintain and monitor NPWT under supervision, but application and discontinuation require an RN.

Question 106

True or False: A foam dressing is used to absorb drainage and promote granulation tissue formation in NPWT.

Answer 106

True Foam dressings are used in NPWT to absorb exudate and promote tissue granulation.

Question 107

Which of the following is a key safety consideration before applying NPWT? A. Ensuring the wound is dry B. Checking the client’s allergy status C. Administering antibiotics prophylactically D. Applying barrier cream around the wound

Answer 107

B. Checking the client’s allergy status Ensuring there are no allergies, especially to latex or materials in the dressing, is essential to prevent allergic reactions.

Question 108

. True or False: The transparent dressing used in NPWT should extend 3-4 cm beyond the edges of the wound.

Answer 108

True The transparent dressing used in NPWT should extend 3-4 cm beyond the edges of the wound to maintain an airtight seal.

Question 109

What should be done if the NPWT foam dressing adheres to the wound during removal? A. Pull it off quickly to minimize client discomfort B. Wet the foam with sterile normal saline C. Cut around the adhered foam and leave it in place D. Apply additional pressure to loosen it

Answer 109

B. Wet the foam with sterile normal saline If the foam is adhered to the wound, wetting it with sterile normal saline will help loosen it, preventing tissue damage.

Question 110

Which of the following is a contraindication for NPWT? A. Presence of necrotic tissue B. Granulating wound bed C. Highly exudative wounds D. Clean surgical wound

Answer 110

A. Presence of necrotic tissue NPWT is contraindicated in wounds with necrotic tissue as the wound bed must be free of necrosis for effective healing

Question 111

Which of the following are appropriate steps in preparing the wound for NPWT application? (Select all that apply) A. Cleaning the wound with antiseptic B. Irrigating the wound C. Removing excess moisture from the wound bed D. Applying antibiotic ointment before applying foam

Answer 111

B, C The wound should be irrigated, and excess moisture should be removed to prepare the wound bed for NPWT.

Question 112

True or False: NPWT should be turned off immediately if there is a sudden increase in bright red drainage from the wound.

Answer 112

True If there is a sudden increase in bright red drainage, it could indicate hemorrhage, and NPWT should be stopped immediately

Question 113

How is NPWT tubing connected to the wound dressing? A. By suturing the tubing into the wound B. By inserting the tubing into a 1-inch hole in the transparent dressing C. By taping the tubing onto the foam dressing D. By placing the tubing directly on the wound bed

Answer 113

B. By inserting the tubing into a 1-inch hole in the transparent dressing A 1-inch round hole is cut in the transparent dressing to connect the NPWT tubing to the wound for drainage.

Question 114

Which of the following findings would indicate the NPWT device is working correctly? A. Foam dressing expands outward B. Foam dressing collapses inward C. Dressing fills with air bubbles D. Increased exudate around the wound edges

Answer 114

. B. Foam dressing collapses inward Foam collapsing inward indicates that negative pressure is being properly applied to the wound.

Question 115

What should the nurse do if the foam pieces removed from the wound are fewer than the number inserted during the previous dressing change? A. Document the findings and continue the procedure B. Notify the provider immediately C. Leave the wound open to air for further assessment D. Insert additional foam pieces to match the previous count

Answer 115

B. Notify the provider immediately If fewer foam pieces are removed than inserted, it may indicate that some foam remains in the wound, which could cause infection or delayed healing.

Question 116

True or False: The NPWT collection canister should be changed when it is more than half full.

Answer 116

True The NPWT collection canister should be emptied when it is more than half full to ensure optimal functioning of the device.

Question 117

Which of the following should be included in client education about NPWT? (Select all that apply) A. The purpose of the NPWT device B. The expected duration of therapy C. The need to avoid showering while the device is in place D. How to recognize signs of infection

Answer 117

A, B, D Client education should include the purpose of the NPWT device, expected duration of therapy, and how to recognize signs of infection.

Question 118

When should NPWT be discontinued? A. When granulation tissue begins to form B. If there are signs of hemorrhage or infection C. When the wound is completely closed D. If exudate is minimal

Answer 118

B. If there are signs of hemorrhage or infection NPWT should be discontinued if there are signs of hemorrhage or infection, as these can be serious complications.

Question 119

True or False: Pain management should be provided before NPWT dressing changes as pain is often associated with this procedure.

Answer 119

True Pain management should be provided before NPWT dressing changes, as the procedure can cause discomfort.

Question 120

What is the primary role of the foam dressing in NPWT? A. To debride the wound B. To promote granulation tissue formation C. To provide a barrier to infection D. To maintain the moisture balance in the wound bed

Answer 120

B. To promote granulation tissue formation The foam dressing in NPWT promotes granulation tissue formation, which is essential for wound healing

Question 121

Which of the following can indicate an infection in a wound being treated with NPWT? (Select all that apply) A. Foul-smelling exudate B. Increased warmth and redness around the wound C. Formation of new granulation tissue D. Increased pain at the wound site

Answer 121

A, B, D Foul-smelling exudate, increased warmth/redness, and increased pain can indicate an infection in the wound being treated with NPWT.

Question 122

True or False: NPWT devices can be used for both acute and chronic wounds.

Answer 122

True NPWT can be used for both acute and chronic wounds to assist in wound healing.

Question 123

How should the NPWT foam dressing be packed into the wound? A. Tightly packed to ensure full contact with the wound bed B. Lightly packed to allow exudate to drain easily C. Left outside the wound to cover the wound edges only D. Cut into small pieces and scattered over the wound bed

Answer 123

B. Lightly packed to allow exudate to drain easily The foam dressing should be lightly packed into the wound bed to allow for drainage and prevent excessive pressure on the tissue.

Question 124

Which of the following would be an unexpected outcome that requires immediate intervention when using NPWT? A. Foam dressing collapsing inward B. Exudate turning from serosanguinous to purulent C. Exudate drainage increasing in the first 24 hours D. A small amount of blood present in the canister

Answer 124

B. Exudate turning from serosanguinous to purulent A change in exudate to purulent (indicating infection) is an unexpected outcome that requires immediate intervention.

Question 125

What should be documented after an NPWT dressing change? (Select all that apply) A. Number of foam pieces used B. Volume and characteristics of drainage in the canister C. Condition of the wound bed D. Amount of air bubbles in the tubing

Answer 125

A, B, C Documentation after an NPWT dressing change should include the number of foam pieces used, the volume and characteristics of drainage, and the condition of the wound bed.

Question 126

True or False: NPWT tubing should always be clamped before turning off the vacuum pump.

Answer 126

True Tubing should always be clamped before turning off the vacuum pump to prevent exudate from flowing back into the wound bed.

Question 127

Which of the following interventions is appropriate if the NPWT device stops functioning during therapy? A. Disconnect the tubing and leave the wound open to air B. Contact biomedical engineering to inspect the device C. Remove the NPWT dressing and apply a gauze dressing D. Increase the suction pressure to restart the device

Answer 127

B. Contact biomedical engineering to inspect the device If the NPWT device stops functioning, biomedical engineering should be contacted to inspect and repair the device

Question 128

How should the nurse check the effectiveness of NPWT after the vacuum pump is turned on? A. By ensuring the transparent dressing is fully adhered to the skin B. By observing for foam collapse inward C. By assessing the volume of exudate immediately D. By checking the client’s pain level

Answer 128

B. By observing for foam collapse inward Foam collapse inward indicates that negative pressure is being applied correctly, ensuring the device is functioning as intended

Question 129

Which of the following can help maintain an airtight seal during NPWT? (Select all that apply) A. Applying a barrier film around the wound edges B. Ensuring the transparent dressing extends 1.2 to 1.6 inches beyond the wound C. Applying additional adhesive to the transparent dressing D. Keeping the foam dressing dry

Answer 129

A, B Applying a barrier film around the wound edges and ensuring the transparent dressing extends beyond the wound helps maintain an airtight seal during NPWT.

Question 130

True or False: NPWT promotes healing by increasing vascularization and stimulating granulation tissue formation.

Answer 130

True NPWT promotes healing by increasing vascularization and stimulating granulation tissue formation, both key processes in wound repair.

Question 131

3. Which of the following are benefits of NPWT? (Select all that apply) A. Decreased edema B. Increased vascularization C. Removal of exudate D. Formation of necrotic tissue

Answer 131

A, B, C NPWT decreases edema, increases vascularization, and removes exudate to promote healing.

Question 132

6. What is the rationale for using a transparent dressing in NPWT? A. To protect the wound from environmental contaminants B. To maintain an airtight seal and negative pressure C. To add moisture to the wound D. To allow oxygen to reach the wound bed

Answer 132

B. To maintain an airtight seal and negative pressure Transparent dressings help maintain negative pressure and an airtight seal.

Question 133

What is the primary rationale for using sterile technique during a dry dressing change? A. To protect the nurse from contamination B. To prevent the transmission of microorganisms to the wound C. To ensure wound exudate is properly absorbed D. To increase the speed of wound healing

Answer 133

B. To prevent the transmission of microorganisms to the wound Aseptic technique ensures the wound remains free from contamination during the dressing change.

Question 134

True or False: Assistive personnel (AP) who have demonstrated competency can perform dry dressing changes under the supervision of an RN or PN.

Answer 134

True AP can perform dry dressing changes under supervision if they have demonstrated competency.

Question 135

Which of the following safety considerations must be verified before starting a dry dressing change? (Select all that apply) A. Client allergy status B. Client’s level of pain C. Type of wound cleanser prescribed D. Client identification

Answer 135

A, C, D Allergy status, prescribed cleansers, and client identification are critical safety checks.

Question 136

Which of the following is appropriate PPE to use during a dry dressing change? A. Nonsterile gloves B. Sterile gloves C. Face shield and gown D. Both A and B, depending on the stage of the dressing change

Answer 136

D. Both A and B, depending on the stage of the dressing change Nonsterile gloves are used to remove the old dressing, and sterile gloves are used when applying the new dressing.

Question 136

True or False: It is necessary to measure the wound at each dressing change.

Answer 136

True Wound measurement allows for tracking healing progress over time.

Question 137

What is the rationale for placing an absorbent pad under the client before a dry dressing change? A. To create a sterile field B. To protect the bed linen from becoming soiled C. To promote healing by maintaining a moist environment D. To prevent infection from contaminating the surrounding area

Answer 137

B. To protect the bed linen from becoming soiled An absorbent pad protects the bed linen during the dressing change.

Question 138

What is the appropriate method for removing a dressing that is stuck to the wound? A. Forcefully pull the dressing off to prevent any delays in care B. Apply sterile water to loosen the dressing C. Remove the dressing in the opposite direction of hair growth D. Use an adhesive remover and leave it on the skin to soften the dressing

Answer 138

B. Apply sterile water to loosen the dressing Applying sterile water prevents damage to the wound bed when the dressing is stuck.

Question 139

True or False: After the wound is cleaned, skin protectant should be applied to healthy skin surrounding the wound.

Answer 139

True Skin protectant is applied to the surrounding skin to protect from adhesive damage.

Question 140

When assessing a wound during a dressing change, which of the following should be documented? (Select all that apply) A. Presence of sutures or drains B. Color, odor, and amount of drainage C. Length, width, and depth of the wound D. Client’s oxygen saturation level

Answer 140

A, B, C Wound assessment should include documentation of appearance, drainage, and wound measurements.

Question 140

True or False: After removing the old dressing, it should be placed in a red biohazard bag for disposal.

Answer 140

True Soiled dressings should be placed in a biohazard bag to prevent contamination.

Question 140

Which of the following is the correct sequence when cleaning a wound during a dry dressing change? A. From the most contaminated area to the least contaminated area B. From the wound edges to the center C. From top to bottom, or from the center to the outside D. From the outside of the wound toward the center

Answer 140

C. From top to bottom, or from the center to the outside This technique prevents bacteria from being spread into the wound.

Question 141

What is the rationale for applying skin protectant on the healthy skin around the wound before applying the new dressing? A. To enhance the wound healing process B. To prevent the dressing from sticking to the wound C. To protect the surrounding skin from adhesive-related injuries D. To ensure the new dressing adheres properly to the wound

Answer 141

C. To protect the surrounding skin from adhesive-related injuries Skin protectant helps prevent irritation and damage from adhesives.

Question 142

When applying a new sterile dressing, how much should the dressing extend beyond the edges of the wound? A. 0.5 cm B. 1 inch C. 2 inches D. 4 cm

Answer 142

B. 1 inch The dressing should extend at least 1 inch beyond the wound edges.

Question 143

Which of the following would indicate an unexpected outcome during a dry dressing change? A. Minimal drainage noted B. Wound bed is pink with granulation tissue C. Increased redness and warmth around the wound D. Dressing removed easily without discomfort

Answer 143

C. Increased redness and warmth around the wound Redness and warmth can indicate infection and should be reported.

Question 143

Which of the following steps should be taken if the client reports increased pain during the dressing change? (Select all that apply) A. Pause the dressing change and assess the client’s pain level B. Administer prescribed analgesics if appropriate C. Proceed with the dressing change to avoid delays D. Apply a cold compress to the wound area

Answer 143

A, B If the client experiences increased pain, pause the procedure and address pain management.

Question 144

True or False: The nurse should perform hand hygiene after removing soiled gloves and before applying sterile gloves.

Answer 144

True Hand hygiene must be performed after removing soiled gloves and before putting on sterile gloves.

Question 145

What is the purpose of sterile saline wipes during a dressing change? A. To cleanse the wound B. To remove adhesive residue C. To dry the wound bed D. To moisten the wound bed

Answer 145

B. To remove adhesive residue Sterile wipes help remove any adhesive residue left on the skin.

Question 146

True or False: The client should be repositioned for comfort and the bed height lowered after the dressing change is completed.

Answer 146

True Repositioning the client and lowering the bed help ensure safety and comfort.

Question 147

Which of the following should be included in client education about wound care? (Select all that apply) A. How to recognize signs of infection B. The importance of changing the dressing daily C. Proper hand hygiene before touching the wound D. How to apply antibiotic ointment if necessary

Answer 147

A, C, D A. How to recognize signs of infection, C. Proper hand hygiene before touching the wound, and D. How to apply antibiotic ointment if necessary are key aspects of wound care education. Changing the dressing daily depends on the wound type and provider's prescription.

Question 148

What should the nurse do if the wound appears to be worsening with increased drainage and the client reports worsening pain? A. Continue with the dressing change and document findings B. Notify the provider immediately C. Re-dress the wound with additional gauze for more absorption D. Wait for the next scheduled dressing change to reassess the wound

Answer 148

B. Notify the provider immediately Increased pain, drainage, and signs of infection or worsening wound condition should prompt immediate provider notification.

Question 149

True or False: Tape or a binder should be applied to the dressing to ensure it stays in place.

Answer 149

True Tape or a binder helps secure the dressing in place to ensure it covers the wound properly and stays in position.

Question 150

Which of the following should be included in the documentation of the dressing change? (Select all that apply) A. Date and time of dressing change B. Wound appearance and characteristics C. Client’s response to the procedure D. Specific tools and solutions used

Answer 150

A, B, C, D A. Date and time of dressing change, B. Wound appearance and characteristics, C. Client’s response to the procedure, and D. Specific tools and solutions used should all be included in the documentation to ensure comprehensive records and continuity of care.

Question 151

Which of the following steps must be performed when draining the contents of a closed wound drainage system?select all that apply A. Squeeze the drainage reservoir tightly to ensure all fluid is expelled. B. Turn off external suction if it is being used. C. Clean the drainage port with alcohol wipes after emptying the contents. D. Position the reservoir above the drainage port before emptying.

Answer 151

Correct Answer: B, C Rationale: Turning off external suction ensures the contents can be emptied safely, and cleaning the drainage port reduces contamination risk. The reservoir should be positioned below the drainage port for proper drainage.

Question 152

Which of the following is considered a sign of potential wound infection? A. Decreased pain at the wound site B. Foul-smelling drainage C. Pink granulation tissue D. Decreased amount of exudate

Answer 152

B. Foul-smelling drainage Foul-smelling drainage is a sign of possible infection. Other signs include increased redness, warmth, and purulent discharge.

Question 153

True or False: Only sterile gloves are required when dressing a chronic wound.

Answer 153

False Sterile gloves are not always required for chronic wound care, as clean gloves may be used in certain situations based on the wound condition and healthcare provider's guidance.

Question 154

Which of the following steps should the nurse take if adhesive remover is used during the dressing change? A. Allow the adhesive remover to dry on the skin to enhance its effect B. Remove any adhesive remover residue from the skin using sterile wipes C. Apply the new dressing directly on top of the adhesive remover D. Discontinue the dressing change and notify the provider

Answer 154

B. Remove any adhesive remover residue from the skin using sterile wipes After using adhesive remover, it’s important to clean any residue from the skin to prevent irritation or interference with the new dressing’s adhesion.

Question 155

1. Which of the following are safety considerations when emptying a closed wound drainage system? (Select all that apply) A. Verify client identification. B. Perform hand hygiene and apply appropriate PPE. C. Avoid using gloves to better manipulate the drain. D. Determine if the client has any allergies. E. Elevate the drainage system above the wound level

Answer 155

Correct Answer: A, B, D Rationale: Verifying client identification, using proper PPE, and checking for allergies are key safety steps. Gloves must always be used, and the drainage system should be kept below the wound to promote gravity drainage.

Question 156

3. True or False: Once the drainage system is emptied, the tubing should be positioned above the wound to promote proper suction.

Answer 156

Correct Answer: False Rationale: The tubing should be positioned below the wound to allow gravity to assist in drainage.

Question 157

What should the nurse do if the drainage from a closed wound system appears thick and yellow? A. Continue monitoring the patient; this is normal. B. Notify the provider immediately and assess for infection. C. Add more sterile solution to the wound. D. Reduce suction on the drain system.

Answer 157

Correct Answer: B Rationale: Thick, yellow drainage may indicate an infection. The provider should be notified, and further assessment is needed.

Question 158

Which action should the nurse take to ensure proper function of a closed wound drainage system? A. Keep the drainage reservoir level with the wound. B. Compress the reservoir and close the drainage port to create suction. C. Allow the reservoir to refill with air before closing the drainage port. D. Clamp the tubing for the entire shift to prevent accidental dislodgment.

Answer 158

Correct Answer: B Rationale: Compressing the reservoir and closing the port ensures negative pressure is created to facilitate drainage.

Question 159

Which of the following is important to document after emptying a closed wound drainage system? (Select all that apply) A. Date and time the drain was emptied. B. Color, consistency, and amount of drainage. C. Patient’s respiratory rate and blood pressure. D. Any unexpected findings, such as signs of infection.

Answer 159

Correct Answer: A, B, D Rationale: The nurse must document when the drain was emptied, details about the drainage, and any unexpected findings. Routine vital signs may be noted separately but are not typically included in the specific documentation for this procedure.

Question 160

True or False: The presence of green or foul-smelling drainage in a closed wound system is a normal finding and does not require action.

Answer 160

Correct Answer: False Rationale: Green or foul-smelling drainage suggests infection and should be reported to the provider immediately.

Question 161

When emptying the contents of a Hemovac drain, what should the nurse do to prevent contamination? A. Empty the drain onto a clean gauze pad. B. Wipe the drainage port with an alcohol wipe after emptying. C. Pour the drainage directly into a clean biohazard bag. D. Avoid using gloves to maintain dexterity

Answer 161

Correct Answer: B Rationale: Wiping the drainage port with alcohol after emptying reduces the risk of contamination. Gloves should always be worn, and drainage is measured in a graduated container.

Question 162

. True or False: It is unnecessary to notify the provider if the amount of drainage from a wound decreases significantly.

Answer 162

Correct Answer: False Rationale: A significant decrease in drainage could indicate a blockage in the system and should be reported to the provider for further evaluation.

Question 163

Which of the following findings would indicate a potential infection at the wound site when monitoring a closed wound drainage system? (Select all that apply) A. Increased amount of drainage B. Purulent or foul-smelling drainage C. Clear, thin drainage D. Redness and swelling at the wound site

Answer 163

Correct Answer: A, B, D Rationale: Increased drainage, purulent drainage, and redness/swelling are signs of infection and should be reported to the provider. Clear, thin drainage is generally normal.

Question 164

What should the nurse assess for after emptying a closed wound drainage system? A. Patient’s oxygen saturation levels B. Patency of the tubing C. Patient’s intake and output D. Length of the incision

Answer 164

Correct Answer: B Rationale: After emptying the drain, the nurse should check for any kinks or obstructions in the tubing to ensure proper drainage.

Question 165

True or False: Emptying a closed wound drainage system should only be done when it is completely full.

Answer 165

Correct Answer: False Rationale: The drainage system should be emptied regularly or when it is more than half-full to ensure optimal suction and reduce infection risk.

Question 166

What should the nurse do if the wound drainage becomes bright red and increases rapidly? A. Continue to monitor the client. B. Notify the provider immediately. C. Lower the suction setting on the drain. D. Apply a cold compress to the wound

Answer 166

Correct Answer: B Rationale: Bright red and rapidly increasing drainage may indicate hemorrhage, and the provider should be notified immediately.

Question 166

Which action by the nurse would most likely reduce the risk of infection when handling a closed wound drainage system? A. Emptying the drain every hour B. Cleaning the drainage port with an antiseptic wipe after emptying C. Positioning the reservoir above the wound D. Replacing the drain tubing daily

Answer 166

Correct Answer: B Rationale: Cleaning the drainage port after emptying reduces the risk of introducing contaminants into the closed wound system, thus preventing infection.

Question 167

True or False: Standard precautions are not necessary when emptying a closed wound drainage system.

Answer 167

Correct Answer: False Rationale: Standard precautions, including gloves, must be used to prevent contamination and exposure to body fluids.

Question 168

18. True or False: When performing hand hygiene before emptying a closed wound drainage system, alcohol-based hand rub is an acceptable method.

Answer 168

Correct Answer: True Rationale: Alcohol-based hand rub is effective for hand hygiene in this context unless hands are visibly soiled, in which case soap and water should be used.

Question 168

The client’s drainage from a Hemovac drain has suddenly stopped. What is the first action the nurse should take? A. Increase the suction pressure. B. Inspect the tubing for kinks or obstructions. C. Notify the provider immediately. D. Elevate the drainage system above the wound.

Answer 168

Correct Answer: B Rationale: The first action should be to check the tubing for kinks or obstructions, which can block the flow of drainage.

Question 168

When should the nurse empty a closed wound drainage system? A. Every 4 hours B. When the reservoir is more than half full C. At the end of the shift D. When the client complains of discomfort

Answer 168

Correct Answer: B Rationale: The drainage system should be emptied when it is more than half full to ensure optimal suction.

Question 169

Which of the following are included in a client's intake measurements? (Select all that apply) A. Oral fluids consumed during meals B. Intravenous fluids administered C. Urine output D. Tube feeding E. Fluid flushed through a nasogastric tube

Answer 169

Correct Answer: A, B, D, E Rationale: Intake includes anything the client ingests orally, receives via IV fluids, tube feedings, or fluid used in NG tube irrigation. Urine output is not considered intake.

Question 169

Which of the following outputs should be measured when calculating a client’s output? (Select all that apply) A. Urine B. Nasogastric tube drainage C. Emesis D. Oral fluids consumed E. Stool from an ostomy

Answer 169

Correct Answer: A, B, C, E Rationale: Output includes anything excreted from the body, such as urine, NG tube drainage, emesis, and stool from an ostomy. Oral fluids consumed are considered intake, not output.

Question 171

True or False: A wound drain output should be measured in a graduated container and assessed at eye level.

Answer 171

Correct Answer: True Rationale: To ensure accuracy, wound drain output should be measured in a calibrated container and viewed at eye level.

Question 172

How often should intake and output (I&O) totals be documented in a clinical setting? A. Every 4 hours B. Every 6 hours C. Every 8 hours or as per facility policy D. Every 24 hours

Answer 172

Correct Answer: C Rationale: I&O totals should be recorded at least every 8 hours or as required by the facility’s policy.

Question 172

True or False: To calculate a client’s fluid balance, subtract the intake from the output. A negative result indicates an intake surplus.

Answer 172

Correct Answer: False Rationale: A negative result from subtracting output from intake indicates a deficit, meaning the client has excreted more fluid than they have taken in.

Question 173

What is the appropriate conversion for fluid intake when a client reports drinking an 8-ounce cup of water? A. 200 mL B. 250 mL C. 180 mL D. 240 mL

Answer 173

Correct Answer: D Rationale: One ounce is equal to 30 mL, so an 8-ounce cup equals 240 mL.

Question 173

True or False: In pediatric clients, each 1 gram of diaper weight is equal to 1 mL of urine output.

Answer 173

Correct Answer: True Rationale: In pediatric care, the conversion of 1 gram of diaper weight is equivalent to 1 mL of fluid output.

Question 174

Which of the following should be used to measure urine output for a client who is catheterized and requires hourly measurements? A. Emesis basin B. Collection bag with urometer C. Graduated cylinder D. Collection basin

Answer 174

Correct Answer: B Rationale: A collection bag with a urometer is designed to measure urine output hourly for clients who are catheterized.

Question 175

True or False: In older adults, monitoring I&O is vital due to decreased kidney function and the risk of fluid overload.

Answer 175

Correct Answer: True Rationale: Older adults are at higher risk for fluid imbalances due to reduced kidney function and a diminished thirst response, making accurate I&O monitoring essential.

Question 176

What should the nurse do to measure the output from a client wearing an incontinence brief? A. Visually estimate the amount of urine in the brief B. Weigh the soiled brief and subtract the dry weight of the brief C. Record output only if the brief is fully saturated D. Use a graduated cylinder to measure the contents

Answer 176

Correct Answer: B Rationale: The output from an incontinence brief should be measured by weighing the soiled brief, subtracting the dry weight, and converting the difference (1 gram equals 1 mL of fluid).

Question 177

. Which of the following fluids should be included in the intake calculation for a client on enteral feeding? (Select all that apply) A. Water flushed through the feeding tube B. Tube feeding formula C. Water consumed with meals D. IV medications

Answer 177

Correct Answer: A, B, C, D Rationale: All forms of fluid, including water flushes, tube feeding formula, oral intake, and IV medications, should be included in the intake calculation.

Question 178

Which client population is at increased risk for fluid imbalance due to a higher water-to-body-weight ratio? A. Older adults B. Pediatric clients C. Clients with kidney disease D. Clients on fluid restrictions

Answer 178

Correct Answer: B Rationale: Pediatric clients are at a higher risk for fluid imbalance because of their high water-to-body-weight ratio, especially infants.

Question 179

. Which of the following should be used to measure output for a client who has undergone a bowel resection and has an ostomy? A. Urinal B. Emesis basin C. Graduated cylinder D. Collection cup

Answer 179

Correct Answer: C Rationale: A graduated cylinder is used to measure output from an ostomy, ensuring accurate measurement.

Question 180

What should the nurse encourage when a client is at risk for dehydration and can tolerate oral fluids? A. Increase their IV fluid intake B. Encourage the client to drink appropriate beverages to maintain hydration C. Offer only solid foods D. Limit fluids to prevent overhydration

Answer 180

Correct Answer: B Rationale: Encouraging clients to drink appropriate fluids helps maintain hydration and can prevent dehydration.

Question 181

Which of the following methods should be used when measuring the output from a wound drain? A. Visually estimate the amount of drainage B. Use a graduated container and measure at eye level C. Place a tissue over the drain and assess the saturation level D. Empty the drainage into an emesis basin for visual estimation

Answer 181

Correct Answer: B Rationale: Measuring wound drain output requires using a graduated container and assessing the level at eye level for accuracy.