Hallmark ISB BSN 206 Foundations of Nursing Fundamentals Exam Module Week 3 - 11 (Latest Update 2025 / 2026) Questions with Answers & Rationales | 100% Correct | Grade A - Nightingale
Question:
The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse...
Hallmark ISB BSN 206 Foundations
of Nursing Fundamentals Exam
Module Week 3 - 11 (Latest Update
) Questions with Answers
& Rationales | 100% Correct |
Grade A - Nightingale
Question:
The patient complains "It feels like the drain is pulling on my surgical site."
What is the nurse's best action?
Answer:
Make sure there is slack in the tubing from the reservoir to the wound,
allowing the patient movement and avoiding pulling at the insertion site.
Rationale: To avoid pulling at the insertion site, the nurse should be sure
there is slack in the tubing from the reservoir to the wound, allowing the
patient movement. To facilitate drainage, the nurse should secure the drain
below the incision to the dressing with tape and a safety pin and instruct the
patient to keep the drain below the insertion site when ambulating, sitting,
and lying. If the patient is complaining of pain, the nurse should further
assess the patient to determine if there is undue tension on the drain tubing.
The nurse should not advance the tube into the patient because this would
introduce microorganisms.
,Question:
Which of the following is inappropriate to delegate to nursing assistive
personnel (NAP)?
Answer:
Assessment of wound drainage.
Rationale: Assessment of wound drainage and maintenance of drains and
the drainage system require the critical thinking and knowledge application
unique to a nurse and therefore are inappropriate to delegate to NAP.
Question:
Which of the following are functions of dressings? (Select all that apply.)
Answer:
To promote hemostasis.
Wound debridement.
To prevent contamination.
Rationale: Dressings provide several functions, which include debridement,
maintaining a moist wound environment, protecting from outside
contamination and further injury, preventing the spread of microorganisms,
increased patient comfort, and promoting hemostasis by control of bleeding.
Dressings are unable to increase circulation.
,Question:
Which of the following patients would be expected to benefit from a damp-
to-dry dressing? (Select all that apply.)
Answer:
A 24-year-old patient with an open and infected wound from a spider bite.
A 30-year-old after large cyst removal with necrotic tissue present in crater-
type wound.
Rationale: Damp-to-dry dressings are often used with necrotic, infected
wounds requiring debridement. Moist dressings are often used for helping to
heal full-thickness wounds that look like craters. Dry woven gauze dressings,
or nonstick dressings are most often used for abrasions, superficial lacerations
and postoperative incisions when minimal drainage is anticipated.
Question:
A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to
complain of pain. What measures may be taken? (Select all that apply.)
Answer:
Switch to the white polyvinyl alcohol (PVA) soft foam.
Decrease the pressure setting.
Administer pain medication.
Rationale: Patients may experience more pain with the black foam because
of excessive wound contraction. For this reason, they may need to be switched
to the PVA soft foam. Administering pain medication can help alleviate pain,
and decreasing the pressure setting may also help reduce pain.
, Question:
The nurse is observing the patient's wife perform the damp-to-dry dressing
change. Which actions, if made by the patient's wife, indicate that further
instruction is needed? (Select all that apply.)
Answer:
Packs wound tightly.
Leaves contact or primary dressing dripping moist.
Rationale: Inner gauze should be moist to absorb drainage and adhere to
debris. The wound should be loosely packed to facilitate wicking of drainage
into the absorbent outer layer of the dressing. The wound should never be
overpacked because this can cause wound trauma when the dressing is
removed. Premedicating for pain will help provide comfort during the
dressing change. If dressing sticks on a damp-to-dry dressing, the wife should
gently free the dressing and alert the patient of discomfort. The wife was
correct in not wetting the dressing because a damp-to-dry dressing should
debride the wound. The wife is correct to pull the tape towad the wound to
avoid pulling on the wound edges.
Question:
During a sterile dressing change, when are the gloves changed?
Answer:
After the old dressing is removed and before cleansing the wound.
Rationale: Gloves are discarded after removing the old dressing. If required,
a sterile field is then prepared, new sterile gloves are applied, and the wound
is cleansed. It is unnecessary to change the gloves frequently unless they are
accidentally contaminated. Gloves are changed after removing the old
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