NU 311 Exam 3 Questions and
Answers.
A sterile dressing with no absorbent capacity that is impermeable to fluids and bacteria and is
used as prophylaxis for high-risk intact skin (high risk friction areas), superficial wounds with
minimal or no exudate best describes: - Answer Transparent film
When aseptic procedures are performed, the nurse must have a sterile work area or sterile
field. Which statement regarding maintenance of sterile fields is true? - Answer Once a
sterile field is outside of the vision of the nurse, the sterile field is considered contaminated.
The RN caring for a client following recent abdominal surgery finds the wound edges of the
incision well approximated. The RN knows the wound is healing by: - Answer Primary
intention
Dr. Swanzy is at the bedside with a clinical student preparing to perform a sterile procedure. The
student makes an A in clinical for the day when he/she: - Answer Opens the outermost flap
of the sterile field away from the body, keeping arm outstretched and avoiding crossing the
sterile field.
The nurse assesses a Stage I pressure injury as: - Answer intact skin with nonblanchable
redness.
When repositioning an immobile client, the student nurse notices a deep red-maroon color over
a bony prominence. When the area is further assessed, it does not blanch indicating: - Answer
a deep tissue pressure injury.
Which statement/s regarding the application of ice, or cryotherapy is/are true? - Answer -
Cold therapy is one of the most widely used therapeutic modalities in the management of acute
musculoskeletal injuries.
-Cold applications must be removed from areas that have turned red or blue during therapy
related to the possibility of worsening ischemia.
The RN is caring for a client recovering from major abdominal surgery 2 days ago. The RN
realizes factors affecting surgical wound healing include: - Answer -Nutritional status
-Diabetes
-Advanced age
-Wound Infection
, The RN is performing a pressure injury risk assessment using the Braden Scale. The Braden Scale
predicts client risk for pressure injury by evaluating: - Answer Friction and Shear, Nutrition,
Mobility, Activity, Moisture, and Sensory Perception.
Serosanguineous drainage from a wound may be described as: - Answer pale red, watery
drainage.
The RN finds the post cardiac catheterization client with a large amount of bright red blood
soaking the femoral dressing. What is the priority action of the nurse? - Answer Look
underneath the dressing and then apply pressure to the bleeding site.
Which intervention is most beneficial in preventing pressure injury in the immobile client? -
Answer Reposition the client every 1-2 hours
Which statement/s is/are TRUE regarding wound irrigations? - Answer -Wound irrigations are
useful for decreasing bacterial counts.
-Protective equipment such as a gown and eye wear should be used by the nurse.
The RN is caring for a client with a transparent film dressing (Tegaderm) over a wound that is
showing a large amount of drainage. How should the nurse proceed? - Answer Recommend
another type of dressing for the wound.
Which statement made by the student nurse regarding moist-to-dry dressings will make Dr.
Lynch happy? - Answer "I know that the purpose of moist-to-dry dressings is to mechanically
debride the wound."
When would the RN consider obtaining a wound culture? - Answer When the surrounding
area is red and the wound has yellow drainage and foul odor.
The postoperative client with a closed abdominal wound reports a sudden "pop" after coughing.
The student nurse examines the surgical site and sees separation of the wound layers and
internal organs protruding through the wound. The priority nursing action is to: - Answer
cover the wound with a moist sterile saline dressing, notify the surgeon immediately, prepare
for emergent surgery.
The student nurse is changing a dressing and is preparing to cleanse the intact suture line. The
proper technique for cleaning an intact suture line includes: - Answer cleaning the wound
from an area of least contamination to an area of most contamination.
Pressure injuries occur: - Answer -because of tissue ischemia.
-from poorly positioned medical devices.
Answers.
A sterile dressing with no absorbent capacity that is impermeable to fluids and bacteria and is
used as prophylaxis for high-risk intact skin (high risk friction areas), superficial wounds with
minimal or no exudate best describes: - Answer Transparent film
When aseptic procedures are performed, the nurse must have a sterile work area or sterile
field. Which statement regarding maintenance of sterile fields is true? - Answer Once a
sterile field is outside of the vision of the nurse, the sterile field is considered contaminated.
The RN caring for a client following recent abdominal surgery finds the wound edges of the
incision well approximated. The RN knows the wound is healing by: - Answer Primary
intention
Dr. Swanzy is at the bedside with a clinical student preparing to perform a sterile procedure. The
student makes an A in clinical for the day when he/she: - Answer Opens the outermost flap
of the sterile field away from the body, keeping arm outstretched and avoiding crossing the
sterile field.
The nurse assesses a Stage I pressure injury as: - Answer intact skin with nonblanchable
redness.
When repositioning an immobile client, the student nurse notices a deep red-maroon color over
a bony prominence. When the area is further assessed, it does not blanch indicating: - Answer
a deep tissue pressure injury.
Which statement/s regarding the application of ice, or cryotherapy is/are true? - Answer -
Cold therapy is one of the most widely used therapeutic modalities in the management of acute
musculoskeletal injuries.
-Cold applications must be removed from areas that have turned red or blue during therapy
related to the possibility of worsening ischemia.
The RN is caring for a client recovering from major abdominal surgery 2 days ago. The RN
realizes factors affecting surgical wound healing include: - Answer -Nutritional status
-Diabetes
-Advanced age
-Wound Infection
, The RN is performing a pressure injury risk assessment using the Braden Scale. The Braden Scale
predicts client risk for pressure injury by evaluating: - Answer Friction and Shear, Nutrition,
Mobility, Activity, Moisture, and Sensory Perception.
Serosanguineous drainage from a wound may be described as: - Answer pale red, watery
drainage.
The RN finds the post cardiac catheterization client with a large amount of bright red blood
soaking the femoral dressing. What is the priority action of the nurse? - Answer Look
underneath the dressing and then apply pressure to the bleeding site.
Which intervention is most beneficial in preventing pressure injury in the immobile client? -
Answer Reposition the client every 1-2 hours
Which statement/s is/are TRUE regarding wound irrigations? - Answer -Wound irrigations are
useful for decreasing bacterial counts.
-Protective equipment such as a gown and eye wear should be used by the nurse.
The RN is caring for a client with a transparent film dressing (Tegaderm) over a wound that is
showing a large amount of drainage. How should the nurse proceed? - Answer Recommend
another type of dressing for the wound.
Which statement made by the student nurse regarding moist-to-dry dressings will make Dr.
Lynch happy? - Answer "I know that the purpose of moist-to-dry dressings is to mechanically
debride the wound."
When would the RN consider obtaining a wound culture? - Answer When the surrounding
area is red and the wound has yellow drainage and foul odor.
The postoperative client with a closed abdominal wound reports a sudden "pop" after coughing.
The student nurse examines the surgical site and sees separation of the wound layers and
internal organs protruding through the wound. The priority nursing action is to: - Answer
cover the wound with a moist sterile saline dressing, notify the surgeon immediately, prepare
for emergent surgery.
The student nurse is changing a dressing and is preparing to cleanse the intact suture line. The
proper technique for cleaning an intact suture line includes: - Answer cleaning the wound
from an area of least contamination to an area of most contamination.
Pressure injuries occur: - Answer -because of tissue ischemia.
-from poorly positioned medical devices.
