Question

A nurse performing a right eye irrigation will position the patient:

Answer 1

Correct Answers:

Supine with the head tilted toward the right eye.

Rationale :

🟢 The nurse should position the client supine with the head tilted toward the affected (right) eye to ensure the irrigation solution flows away from the unaffected eye.

🟢 This position helps prevent contamination of the other eye and promotes effective drainage.

🟢 Tilting the head away or hyperextending can cause discomfort or improper irrigation.

🟢 Proper positioning supports client safety and comfort during eye irrigation.

🟢 This technique is critical to prevent injury and maximize treatment effectiveness.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Empty the reservoir.

Rationale :

⚫ When the Jackson-Pratt drain reservoir is half full, it should be emptied to maintain negative pressure (suction) essential for proper drainage of blood and fluids.

⚫ Failure to empty the reservoir can result in backflow, impaired drainage, and increased risk of infection or hematoma.

⚫ Immediate emptying is necessary to maintain the functionality of the drainage system.

⚫ Removing the drain or delaying notification without emptying is inappropriate unless significant bleeding occurs.

⚫ Proper management promotes wound healing and prevents complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Add normal saline to loosen it.

Rationale :

🔵 The nurse should add normal saline to moisten the old dressing that is stuck to the wound bed, allowing it to loosen gently without damaging healing tissue.

🔵 This intervention prevents trauma to new granulation tissue and reduces pain during dressing removal.

🔵 Using povidone-iodine or forcefully pulling the dressing risks delaying healing and causing tissue injury.

🔵 Leaving the old dressing in place and adding wet dressings can promote bacterial growth and infection.

🔵 Moistening with saline supports optimal wound care and client comfort.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

From the outer abdomen toward the wound.

Rationale :

🟠 When cleansing a wound, the nurse should clean from the cleanest area (outer abdomen) toward the contaminated area (wound) to avoid introducing bacteria into the wound bed.

🟠 This technique reduces the risk of infection by minimizing contamination.

🟠 Cleaning in a circular motion or directly over the wound can cause cross-contamination and trauma.

🟠 Following proper cleansing protocols is essential to promote healing and client safety.

🟠 Maintaining aseptic technique prevents healthcare-associated infections.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Intact skin with localized erythema.

Rationale :

🟡 A stage 1 pressure injury is characterized by intact skin with localized redness (erythema) that does not blanch when pressure is applied.

🟡 This early sign indicates tissue damage without skin breakdown.

🟡 Full-thickness skin loss with visible fat or bone indicates more advanced stage 3 or 4 injuries.

🟡 Partial-thickness skin loss with red tissue corresponds to a stage 2 pressure injury.

🟡 Early identification and intervention at stage 1 can prevent progression to more severe injuries.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Change gloves after removing the old dressing.

Rationale :

🟡 Changing gloves after removing the old dressing is essential to prevent cross-contamination and maintain sterile technique during the dressing change.

🟡 Wearing the same gloves increases the risk of introducing pathogens to the wound.

🟡 While patient cooperation and positioning are important, maintaining sterility is paramount.

🟡 Having a discard bag nearby facilitates efficient disposal but is secondary to infection control practices.

🟡 Minimizing talking is helpful but does not substitute proper aseptic technique.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Assist the patient in a supine position.

Rationale :

🔵 If the patient reports a sensation that “something let go,” the nurse should immediately assist the patient to a supine position to reduce abdominal pressure and risk of injury.

🔵 This position helps stabilize the abdomen and prevents strain on any possible wound dehiscence.

🔵 Applying an abdominal binder or seating the patient is secondary to ensuring immediate safety.

🔵 Panting can reduce abdominal pressure but first priority is positioning to avoid further damage.

🔵 Prompt positioning supports patient safety and allows for further assessment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Drawing the wound edges together by negative pressure.

Rationale :

🟠 Vacuum-assisted closure (VAC) devices support wound healing by applying negative pressure to draw wound edges together.

🟠 This suction promotes increased blood flow, reduced edema, and stimulation of granulation tissue.

🟠 VAC does not directly strengthen wound walls or create occlusive covers.

🟠 It helps reduce bacterial colonization indirectly by promoting wound healing.

🟠 Understanding VAC mechanics guides appropriate wound care choices.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Dilating the blood vessels.

Rationale :

🟣 Moist heat causes vasodilation, which increases blood flow to the treated area.

🟣 Increased circulation aids in tissue repair, muscle relaxation, and pain relief.

🟣 Moist heat does not numb the area or constrict vessels; it promotes fluid movement but does not “draw” fluid to the site.

🟣 Proper use of moist heat facilitates healing and comfort.

🟣 Nurses must educate clients on safe application to avoid burns.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Apply oxygen at 2L/min via nasal cannula.

Rationale :

⚫ During the initial inflammatory phase of wound healing, adequate oxygen delivery is critical to support cell metabolism and tissue repair.

⚫ Oxygen therapy enhances collagen synthesis and immune function in the wound area.

⚫ Leaving wounds open to air can increase infection risk.

⚫ Corticosteroids impair healing by suppressing inflammation and are generally avoided.

⚫ Mechanical debridement is a later intervention, not initial care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse performing a right eye irrigation will position the patient:

2 :
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

3 :
The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

4 :
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

5 :
A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

6 :
When preparing to change a sterile dressing over an incision, it is most important to remember to:

7 :
A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

8 :
The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

9 :
Moist heat has the physiological effect of:

10 :
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

QLexNursing

1 : A nurse performing a right eye irrigation will position the patient:

2 : While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

3 : The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

4 : The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

5 : A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

6 : When preparing to change a sterile dressing over an incision, it is most important to remember to:

7 : A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

8 : The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

9 : Moist heat has the physiological effect of:

10 : A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

1 :
A nurse performing a right eye irrigation will position the patient:

2 :
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

3 :
The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

4 :
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

5 :
A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

6 :
When preparing to change a sterile dressing over an incision, it is most important to remember to:

7 :
A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

8 :
The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

9 :
Moist heat has the physiological effect of:

10 :
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?