TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 27: Dressings, Bandages, and Binders Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse applies a circumferential gauze dressing to a patient’s amputated leg. Which
method should the nurse use to decrease edema in the extremity? a. Montgomery straps b. An adhesive tape wrap c. A figure-eight wrap d. A circular turns dressing ANS: C
The nurse applies a dressing around the extremity using the figure-eight method to avoid restriction of blood flow and main venous return. This allows the dressing to be anchored by wrapping gauze in alternating directions that ascend and descend with oblique, overlapping turns. The terminal end of the dressing is secured with a short piece of tape, taking care not to restrict blood flow in any manner. Montgomery straps are contraindicated for dressing an extremity because the circumference is usually too small to make them practical. Adhesive tape potentially constricts blood flow to the extremity if it is wrapped tightly over itself in a circumferential manner. Circular turns dressings are used on small parts like fingers or toes, but are too constricting to use on larger body parts. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
N
2. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care tasks
should the nurse assign to this staff member? a. Apply the hydrocolloid dressing. b. Assess dimensions of the wound. c. Report visible drainage on the dressing. d. Change the first postoperative dressing. ANS: C
The nurse assigns reporting visible drainage on the dressing to the NAP because this individual is trained to perform this wound care task. It is essential to review what needs to be looked for and what to report back to the nurse. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
3. The nurse plans care for the patient’s wound that requires a moist-to-dry dressing. Which
should the nurse use for an expected patient outcome several hours after applying a new dressing? a. The patient states that the dressing feels cold. b. The dressing is dry and intact.
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