Wound Care
What is the correct sequence of the stages of wound healing?
What is hemostasis, inflammatory, proliferative, and maturation?
What is the primary purpose of a surgical drain?
What is to remove fluid and exudate to prevent pressure buildup?
What does the P wave represent on the ECG?
What is atrial depolarization?
What is the rate range for sinus bradycardia?
What is less than 60 bpm?
What is the correct way to measure and document wound dimensions?
What is length x width in inches or centimeters?
Which stage of wound healing typically lasts up to 2 weeks and includes cardinal signs like redness and swelling?
What is the inflammatory phase?
A nurse is assessing a JP drain. What is the most appropriate documentation detail?
What is the amount and appearance of drainage (e.g., 50 mL serosanguinous)?
The PR interval is prolonged to 0.24 seconds. What does this indicate?
What is a delay in AV node conduction (possibly 1st-degree heart block)
Which dysrhythmia is characterized by no identifiable P waves and an irregularly irregular rhythm?
What is atrial fibrillation?
A wound has no dressing, the skin is pink and dry, and the patient reports no pain. How is this documented?
What is "Open to air, no complaints of pain"?
A wound is pink, moist, and has partial thickness skin loss with some sloughing. What stage pressure injury is this?
What is Stage 2?
When tracing a drain tube, what must the nurse ensure?
What is patency, no kinks, and proper securement?
What is the normal duration of a QRS complex?
What is ≤ 0.12 seconds?
A patient has SVT and is unstable. What is the first-line treatment?
What is synchronized cardioversion?
Why is frequent reassessment of a drain site critical?
What is to monitor for infection, displacement, or changes in exudate?
Name two types of dressing appropriate for maintaining a moist wound environment.
What are alginate and foam dressings?
Which type of drain relies on gravity and has no suction mechanism?
What is a passive drain?
How many seconds is one large box on ECG paper?
What is 0.20 seconds?
Which rhythm shows wide, bizarre QRS complexes with no discernible P waves, often requiring defibrillation?
What is ventricular fibrillation?
A nurse documents that a wound has “friable tissue and pain with incontinence.” What nursing action is most appropriate next?
What is implement skin protection and schedule regular repositioning?
A patient has a 4.5” wide x 3” long wound with red friable tissue and pain during incontinence. What are 3 priority nursing actions?
What are cleanse the wound, protect surrounding skin, and apply appropriate dressing?
After emptying a Hemovac drain, the nurse notes cloudy, thick green drainage. What is the priority action?
What is report possible infection to the provider?
A nurse sees a QT interval of 0.52 seconds. What condition should be considered?
What is a risk for ventricular arrhythmias (e.g., Torsades de Pointes)?
A patient in V-tach with a pulse is becoming hypotensive. What is your immediate nursing intervention?
What is prepare for cardioversion?
What are three critical elements to document after wound care?
What are wound appearance, dressing type, and patient tolerance?