NUR 304 Exam 3 – Study Guide and Exam Review Material
1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What
is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode -
ANS ✔✔4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic
episode
2. Match the pressure injury stages with the correct definition.
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red,
moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not
visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not
present. These injuries commonly result from adverse microclimate and shear in the skin over
the pelvis and shear in the heel. This stage should not be used to describe moisture-associated
skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous
dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears,
burns, abrasions).
,b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in
darkly pigmented skin. Presence of blanchable ery - ANS ✔✔1. Stage 1 - b
Intact skin with a localized area of nonblanchable erythema, which may appear differently in
darkly pigmented skin.
2. Stage 2- a
Partial-thickness loss of skin with exposed dermis.
3. Stage 3- d
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present.
4. Stage 4- c
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage, or bone in the ulcer.
3. After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces
of small bowel are noted at the bottom of the now-opened wound. Which are the priority
nursing interventions? (Select all that apply.)
1. Notify the health care provider.
2. Allow the area to be exposed to air until all drainage has stopped.
3. Place several cold packs over the area, protecting the skin around the wound.
4. Cover the area with sterile, saline-soaked towels immediately.
5. Cover the area with sterile gauze and apply an abdominal binder. - ANS ✔✔1. Notify the
health care provider.
,4. Cover the area with sterile, saline-soaked towels immediately.
4. What is the correct sequence of steps when performing wound irrigation to a large open
wound?
1. Use slow, continuous pressure to irrigate wound.
2. Attach 19-gauge angiocatheter to syringe.
3. Fill syringe with irrigation fluid.
4. Place biohazard bag near bed.
5. Position angiocatheter over wound. - ANS ✔✔4. Place biohazard bag near bed.
3. Fill syringe with irrigation fluid.
2. Attach 19-gauge angiocatheter to syringe.
5. Position angiocatheter over wound.
1. Use slow, continuous pressure to irrigate wound.
5. Which skin-care measures are used to manage a patient who is experiencing fecal and/or
urinary incontinence? (Select all that apply.)
1. Frequent position changes
2. Keeping the buttocks exposed to air at all times
3. Using a large absorbent diaper, changing when saturated
4. Using an incontinence cleaner
5. Applying a moisture barrier ointment - ANS ✔✔1. Frequent position changes
, 4. Using an incontinence cleaner
5. Applying a moisture barrier ointment
6. Which of the following describes a hydrocolloid dressing?
1. A seaweed derivative that is highly absorptive
2. Premoistened gauze placed over a granulating wound
3. A debriding enzyme that is used to remove necrotic tissue
4. A dressing that forms a gel that interacts with the wound surface - ANS ✔✔4. A dressing that
forms a gel that interacts with the wound surface
7. Which of the following is an indication for a binder to be placed around a surgical patient with
a new abdominal wound? (Select all that apply.)
1. Collection of wound drainage
2. Providing support to abdominal tissues when coughing or walking
3. Reduction of abdominal swelling
4. Reduction of stress on the abdominal incision
5. Stimulation of peristalsis (return of bowel function) from direct pressure - ANS ✔✔2.
Providing support to abdominal tissues when coughing or walking
4. Reduction of stress on the abdominal incision
8. When is the application of a warm compress to an ankle muscle sprain indicated? (Select all
that apply.)
1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What
is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode -
ANS ✔✔4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic
episode
2. Match the pressure injury stages with the correct definition.
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red,
moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not
visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not
present. These injuries commonly result from adverse microclimate and shear in the skin over
the pelvis and shear in the heel. This stage should not be used to describe moisture-associated
skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous
dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears,
burns, abrasions).
,b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in
darkly pigmented skin. Presence of blanchable ery - ANS ✔✔1. Stage 1 - b
Intact skin with a localized area of nonblanchable erythema, which may appear differently in
darkly pigmented skin.
2. Stage 2- a
Partial-thickness loss of skin with exposed dermis.
3. Stage 3- d
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present.
4. Stage 4- c
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage, or bone in the ulcer.
3. After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces
of small bowel are noted at the bottom of the now-opened wound. Which are the priority
nursing interventions? (Select all that apply.)
1. Notify the health care provider.
2. Allow the area to be exposed to air until all drainage has stopped.
3. Place several cold packs over the area, protecting the skin around the wound.
4. Cover the area with sterile, saline-soaked towels immediately.
5. Cover the area with sterile gauze and apply an abdominal binder. - ANS ✔✔1. Notify the
health care provider.
,4. Cover the area with sterile, saline-soaked towels immediately.
4. What is the correct sequence of steps when performing wound irrigation to a large open
wound?
1. Use slow, continuous pressure to irrigate wound.
2. Attach 19-gauge angiocatheter to syringe.
3. Fill syringe with irrigation fluid.
4. Place biohazard bag near bed.
5. Position angiocatheter over wound. - ANS ✔✔4. Place biohazard bag near bed.
3. Fill syringe with irrigation fluid.
2. Attach 19-gauge angiocatheter to syringe.
5. Position angiocatheter over wound.
1. Use slow, continuous pressure to irrigate wound.
5. Which skin-care measures are used to manage a patient who is experiencing fecal and/or
urinary incontinence? (Select all that apply.)
1. Frequent position changes
2. Keeping the buttocks exposed to air at all times
3. Using a large absorbent diaper, changing when saturated
4. Using an incontinence cleaner
5. Applying a moisture barrier ointment - ANS ✔✔1. Frequent position changes
, 4. Using an incontinence cleaner
5. Applying a moisture barrier ointment
6. Which of the following describes a hydrocolloid dressing?
1. A seaweed derivative that is highly absorptive
2. Premoistened gauze placed over a granulating wound
3. A debriding enzyme that is used to remove necrotic tissue
4. A dressing that forms a gel that interacts with the wound surface - ANS ✔✔4. A dressing that
forms a gel that interacts with the wound surface
7. Which of the following is an indication for a binder to be placed around a surgical patient with
a new abdominal wound? (Select all that apply.)
1. Collection of wound drainage
2. Providing support to abdominal tissues when coughing or walking
3. Reduction of abdominal swelling
4. Reduction of stress on the abdominal incision
5. Stimulation of peristalsis (return of bowel function) from direct pressure - ANS ✔✔2.
Providing support to abdominal tissues when coughing or walking
4. Reduction of stress on the abdominal incision
8. When is the application of a warm compress to an ankle muscle sprain indicated? (Select all
that apply.)
