When assessing a patient’s surgical dressing on POD #3, the nurse notices a bright-red drainage about 5 cms in diameter. What is your first action?
A. Immediately call the Dr.
B. Reinforce and reassess
C. Circle the drainage with a marker and reassess
D. Check patient and their vitals
D, patient could be hemorrhaging, bleeding, or wound could be dehiscence
You received report from your RN on a POST-OP patient. What is your first initial action upon receiving this patient?
Get report on patient
Assess dr. Orders
Assess VS and pain
Neuro status
You received report from your RN on a POST-OP patient. What is your first initial action upon receiving this patient?
- Get report on your patient
- dr. Order
- vitals and pain assessment
- neuro check
How many stages are in wound healing?
A. 3
B. 4
C. 5
4 stages
Homeostasis
Inflammatory
Proliferation
Maturation
What is not an unexpected post-op wound complication?
A. Redness and bleeding
B. Dehiscence
C. Pro-long pain
D. Evisceration
A, is a common and expected
In planning POST-OP exercises, which action should the nurse recognize will best enable the patient to achieve the desired outcome
A. Proper pain management
B. Asking the patient to demonstrate the exercise back Q1H
C. Reminding the patient the complications if exercises are not peformed
D. Involving family with exercises to promote accountability
A, pain will affect the patient and their participation
How far above the skin should you be for wound irrigation?
A. 1cm
B. 3cm
C. 2.5 cm
C, not too high or low just don’t touch the sterile tip to the wound
How should the nurse document their wound packing?
A. Nuse removed packing as per Dr.
Order. Pt tolerated well.
B. Nurse removed 1x blood soak gauze. Wound care provided and 1x packed NS soaked gauze packed as per orders.
C. Nurse removed 1x blood soaked gauze. Wound care provided as per Dr. order.
D. Nurse removed 1x blood soaked gauze removed. 1x pack inserted as per orders. Pt tolerated well.
B
A, isn’t detailed enough
C, doesn’t inform you how many packings were placed into wound and doesn’t mention packing is soaked in NS
D, doesn’t mention packing is soaked in NS, also doesn’t mention wound care
Pt POD #2 of L ankle arthoplasty. Pt complains of swelling, tingling to their toes and pain. What is the nurse’ next action?
A. Raise their Left foot and reassess
B. Provide PRN pain meds and reasses
C. Perform head to toe and vitals
D. Call dr immediately
E. Peform neurovascular assessment
E, compartment syndrome
what is dehiscence and evisceration and what are the steps to treat both
dehiscence
- when surgical wound re-opens
TX: maintain sterility, cover with sterile gauze and call for help from charge nurse. if you were removing sutures stop it can lead to wound evisceration
evisceration
- organ protrudes out of a wound
TX: cover with sterile saline soaked gauze, call physician/ surgeon, keep patient NPO and ready for surgery
what is compartment syndrome and S/S
is increased pressure due to
A nurse is transfering a patient from bed to wheelchair. What should the nurse quickly assess to see if the patient is tolerating the repositioning?
A. Pts cognition
B. Pts pain
C. Pts vitals
A, patients cognition is important to understand that they are able to follow directions
What are your precautions before getting a patient up, post-op? (Select more than one)
A. Weight-Bearing Status
B. Pain managment
C. Dr’s.Order
D. LOC
E. Healthy Diet
F. Strength
A,B,C,D,F
Healthy didn’t isn’t that important
How should the nurse clean a wound?
A. Clean from outer sides of the wound to its inner
B. Clean the wound twice with different gauze
C. As per the wound care plan
D. From the least containment area to the most.
D, from cleanest to dirtiest u don’t want bring bacteria in
When do you empty a Jackson-Pratt drain?
A. At the end of shift
B. When its full
C. 1/2-2/3 full
D. 1/3-1/2 full
D and always do at the end of shift as best practice and bc you need to record pt’s ins and out records
When can you remove a drain ?
a. After 5 days
b. When there is less than 25mls after 24hrs
c. When there is nothing left.
d. When there is a Drs. Order
D, always need docs order to remove JP drain
What is the most important step right before pulling a drain?
A. Making sure the drain is empty
B. Making sure the suction is off
C. Making sure the drain is intact
D. Making sure the pt is anxious free
B, make sure suction is off bc it can cause internal damage to the intestinal organs
What is your first assessment when receiving a burn victim
A. Neuro assessment
B. Pain Assessment
C. Respiratory Assessment
D. Cardiovascular Assessment
C, inhalation injury is important to ax for
A Pt has a superficial burns to both arms, full thick burns to her chest and groin, and part-thickness to her back. What degree of burn is her back?
3
4
1
2
2
Pt has 3rd degree to their Posterior thorax, posteri L leg and arm. What % of body surface is 3rd degree burn?
A. 31.5%
C. 45%
D. 36%
D. 22.5%
A,
Back 18
Left arm 9
Back of arm 4.6
Surgical patient just came back from PACU, level 2 sedation scale. Sa02 91% on RA. What 02 intervention do you do?
Elderly patient POD#4 THA A+OX3 Sa02 92% on RA. Which 02 route/ intervention will you
A. DB + C + INCENTIVE SPIROMETRY
B. SIMPLE FACE MASK
C. NASAL PRONG
POD#1,Pt SPO2 dropped, SPO2 86% with 10L 02 via simple face mask. Pt decrease LOC, increase confusion. What do you do?
A. Increase oxygen
B. Change to a new simple mask
C. CODE BLUE
D. Call RN/RT
Pt pressed call bell and c/o SOB and chest pain. Sa02 98% on RA. Which 02 route/intervention will you do?
A. Apply 10L simple face mask
B. Apply Nasal Prong
C. Nothing - call the DR
D. Call the RT
