Answer to Question 1
D
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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
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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.
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