ADULT HEALTH I,11,111 FINAL EXAM
ALL 500+ QUESTIONS AND CORRECT
ANSWERS LATEST UPDATE THIS
YEAR.p
ADULT HEALTH I
How would you stage this wound?
Stage 4
Unstageable
Stage 3
Stage 2 - ✔✔✔ANSW✔✔..B. Unstageable
2. Arterial ulcers tend to be symmetrical and form a ___ whereas venous
ulcers tend to be asymmetrical and form a ___ - ✔✔✔ANSW✔✔..deep
crater
shallow wound
The nurse is caring for a client who is admitted to the medical unit for the
treatment of a venous ulcer in the area of her lateral malleolus that has
been unresponsive to treatment. What is the nurse most likely to find
during an assessment of this client's wound?
hemorrhage
deep wound bed
pale colored wound bed
heavy exudate - ✔✔✔ANSW✔✔..heavy exudate
The nurse is providing care for a client who has just been diagnosed with
peripheral arterial occlusive disease (PAD). What assessment finding is
most consistent with this diagnosis?
,unequal peripheral pulses between extremities
Reddened extremities with muscle atrophy
Visible clubbing of the fingers and toes - ✔✔✔ANSW✔✔..unequal
peripheral pulses between extremities
You have been asked to change your client's pressure wound and use a
wet-to-dry dressing. What is the purpose of this type of dressing?
The packed gauze is a temporary fix before surgery
The packed gauze works to remove (debride) the dead or injured tissue
The packed gauze is works in wounds that have eschar.
The packed gauze liquefies the slough so it can be cleansed from the
wound - ✔✔✔ANSW✔✔..The packed gauze works to remove (debride)
the dead or injured tissue
A nurse is assessing her client's wound. What is the width of the wound
in this picture?
4cm
5cm
7cm
6cm - ✔✔✔ANSW✔✔..5cm
A superficial burn injury that is at the epidermal level is considered what
degree of burn?
first degree
third degree
second degree
full thickness - ✔✔✔ANSW✔✔..first degree
A deep partial and full thickness burn is usually very painful.
True
False - ✔✔✔ANSW✔✔..False
,Regarding burn injuries, what is the number one intervention the nurse
does after assuring the scene is safe and the client is no longer on fire?
cover the wound with a dry dressing
chest compressions
Airway management
call 911 - ✔✔✔ANSW✔✔..Airway management
A nurse is caring for a client in the emergent/resuscitative phase of burn
injury. During this phase, the nurse should monitor for evidence of what
alteration in laboratory values?
hypokalemia
hypocalcemia
hyperkalemia
hypercalcemia - ✔✔✔ANSW✔✔..hyperkalemia
The nurse is caring for a client who sustained third degree burns to the
front side of the left arm and hand, and the front side of the chest and
abdomen. Using the rule of nines, what percentage of the body surface
area is burned?
27%
22.5%
36%
18% - ✔✔✔ANSW✔✔..22.5%
The nurse is caring for a client who sustained 2nd degree burns to the
front and back of the head. What percentage of body surface area is
burned?
18%
9%
10%
we don't use percentage of BSA when it comes to the head -
✔✔✔ANSW✔✔..9%
, A client is brought to the emergency department with a burn injury. The
nurse knows that the first systemic event after a major burn injury is
what?
respiratory arrest
hemodynamic instability
GI hypermotility
hypokalemia - ✔✔✔ANSW✔✔..hemodynamic instability
The nurse is providing home care instruction to the client with cellulitis.
Which statement, if made by the client, should concern the nurse?
"I will be sure to get enough rest and stay off my affected leg."
"I will keep all follow-up appointments with my healthcare provider."
"I will take my antibiotics until the affected area looks less red."'
"I will keep my affected leg elevated to keep swelling down." -
✔✔✔ANSW✔✔.."I will take my antibiotics until the affected area looks
less red."'
The nurse is performing a health history for a new client. Which should
the nurse identify as a risk factor for cellulitis in an adult?
Impetigo
GERD
Peripheral vascular disease
hypotension - ✔✔✔ANSW✔✔..Peripheral vascular disease
The nurse collects a drainage sample to be cultured from the affected
area of a client with cellulitis. Which organism should the nurse suspect
is the most likely cause of the cellulitis?
Escherichia coli
Bacillus subtilis
Staphylococcus aureus
C-diff - ✔✔✔ANSW✔✔..Staphylococcus aureus
ALL 500+ QUESTIONS AND CORRECT
ANSWERS LATEST UPDATE THIS
YEAR.p
ADULT HEALTH I
How would you stage this wound?
Stage 4
Unstageable
Stage 3
Stage 2 - ✔✔✔ANSW✔✔..B. Unstageable
2. Arterial ulcers tend to be symmetrical and form a ___ whereas venous
ulcers tend to be asymmetrical and form a ___ - ✔✔✔ANSW✔✔..deep
crater
shallow wound
The nurse is caring for a client who is admitted to the medical unit for the
treatment of a venous ulcer in the area of her lateral malleolus that has
been unresponsive to treatment. What is the nurse most likely to find
during an assessment of this client's wound?
hemorrhage
deep wound bed
pale colored wound bed
heavy exudate - ✔✔✔ANSW✔✔..heavy exudate
The nurse is providing care for a client who has just been diagnosed with
peripheral arterial occlusive disease (PAD). What assessment finding is
most consistent with this diagnosis?
,unequal peripheral pulses between extremities
Reddened extremities with muscle atrophy
Visible clubbing of the fingers and toes - ✔✔✔ANSW✔✔..unequal
peripheral pulses between extremities
You have been asked to change your client's pressure wound and use a
wet-to-dry dressing. What is the purpose of this type of dressing?
The packed gauze is a temporary fix before surgery
The packed gauze works to remove (debride) the dead or injured tissue
The packed gauze is works in wounds that have eschar.
The packed gauze liquefies the slough so it can be cleansed from the
wound - ✔✔✔ANSW✔✔..The packed gauze works to remove (debride)
the dead or injured tissue
A nurse is assessing her client's wound. What is the width of the wound
in this picture?
4cm
5cm
7cm
6cm - ✔✔✔ANSW✔✔..5cm
A superficial burn injury that is at the epidermal level is considered what
degree of burn?
first degree
third degree
second degree
full thickness - ✔✔✔ANSW✔✔..first degree
A deep partial and full thickness burn is usually very painful.
True
False - ✔✔✔ANSW✔✔..False
,Regarding burn injuries, what is the number one intervention the nurse
does after assuring the scene is safe and the client is no longer on fire?
cover the wound with a dry dressing
chest compressions
Airway management
call 911 - ✔✔✔ANSW✔✔..Airway management
A nurse is caring for a client in the emergent/resuscitative phase of burn
injury. During this phase, the nurse should monitor for evidence of what
alteration in laboratory values?
hypokalemia
hypocalcemia
hyperkalemia
hypercalcemia - ✔✔✔ANSW✔✔..hyperkalemia
The nurse is caring for a client who sustained third degree burns to the
front side of the left arm and hand, and the front side of the chest and
abdomen. Using the rule of nines, what percentage of the body surface
area is burned?
27%
22.5%
36%
18% - ✔✔✔ANSW✔✔..22.5%
The nurse is caring for a client who sustained 2nd degree burns to the
front and back of the head. What percentage of body surface area is
burned?
18%
9%
10%
we don't use percentage of BSA when it comes to the head -
✔✔✔ANSW✔✔..9%
, A client is brought to the emergency department with a burn injury. The
nurse knows that the first systemic event after a major burn injury is
what?
respiratory arrest
hemodynamic instability
GI hypermotility
hypokalemia - ✔✔✔ANSW✔✔..hemodynamic instability
The nurse is providing home care instruction to the client with cellulitis.
Which statement, if made by the client, should concern the nurse?
"I will be sure to get enough rest and stay off my affected leg."
"I will keep all follow-up appointments with my healthcare provider."
"I will take my antibiotics until the affected area looks less red."'
"I will keep my affected leg elevated to keep swelling down." -
✔✔✔ANSW✔✔.."I will take my antibiotics until the affected area looks
less red."'
The nurse is performing a health history for a new client. Which should
the nurse identify as a risk factor for cellulitis in an adult?
Impetigo
GERD
Peripheral vascular disease
hypotension - ✔✔✔ANSW✔✔..Peripheral vascular disease
The nurse collects a drainage sample to be cultured from the affected
area of a client with cellulitis. Which organism should the nurse suspect
is the most likely cause of the cellulitis?
Escherichia coli
Bacillus subtilis
Staphylococcus aureus
C-diff - ✔✔✔ANSW✔✔..Staphylococcus aureus
