Author Question: The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by ... (Read 84 times)

fox · **on:** Jul 22, 2018

The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by doing which one of the following?

a. Filling two-thirds of the wound cavity
b. Leaving saline-soaked folded gauze squares in place
c. Putting the dressing in very tightly
d. Extending only to the surface of the wound

Question 2

The nurse is assessing the body alignment of an alert and mobile patient. Which one of the following is the first action the nurse should take?

a. Observe gait.
b. Put the patient at ease.
c. Determine activity tolerance.
d. Determine range of joint motion.

aadams68 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D

Feedback
A The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses.
B The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound.
C The wound should not be packed too tightly. Overpacking the wound may cause pressure on the tissue in the wound bed.
D The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges may cause maceration of the tissue surrounding the wound.

Answer to Question 2

B

Feedback
A When assessing body alignment, the nurse's first action is to put the patient at ease. Later, the nurse can assess the patient's gait to observe the patient's balance, posture, and ability to walk without assistance.
B The first step in assessing body alignment is to put the patient at ease so that unnatural or rigid positions are not assumed.
C Activity tolerance is the kind and amount of exercise or activity a person is able to perform. Determining activity tolerance is not the first step in assessing a patient's body alignment.
D Assessing range of motion (ROM) is one of the first assessment techniques used to determine the degree of damage or injury to a joint. It is not the first step in assessing a patient's body alignment.