NURSING 105: FUNDAMENTALS FINAL LIPPINCOTT
CONCEPTS EXAM WITH COMPLETE SOLUTIONS
The nurse observes the client for signs of stage I pressure injury development,
which most likely will include which finding? - ANSWER nonblanchable redness
A stage I pressure injury is a defined area of intact skin with nonblanchable
redness of a localized area, usually over a bony prominence. A stage II pressure
injury involves partial-thickness loss of dermis and presents as a shallow open
ulcer. A stage III pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed.
A stage IV pressure injury involves full-thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be present on some part of the wound
bed and often includes undermining and tunneling.
A nurse working in long-term care is assessing residents at risk for the
development of a decubitus ulcer. Which one would be most at risk? - ANSWER
an 86-year-old who is bedfast
Most pressure ulcers occur in older adults as a result of a combination of
factors, including aging skin, chronic illness, immobility, malnutrition, fecal and
urinary incontinence, and altered level of consciousness. The bedfast resident
would be most at risk in this situation.
The nurse just completed a dressing change and returned the client to a
comfortable position. What should the nurse do next? - ANSWER Document the
color, odor, amount, and type of wound drainage.
After completing a dressing change and retuning the client to a comfortable
position, it is important to document color, odor, amount, and the type of wound
drainage. Early documentation helps to assure the most accurate information
can be recorded. Determining the extent of wound undermining and measuring
length, width, and depth of the wound should be performed during the dressing
change, while the wound is still exposed. The healthy tissue surrounding the
wound should never be massaged because it could cause further breakdown of
healthy tissue.
Upon responding to the patient's call bell, the nurse discovers the patient's
wound has dehisced. Initial nursing management includes calling the physician
and which of the following? - ANSWER Covering the wound area with sterile
towels moistened with sterile 0.9% saline
,If dehiscence occurs, cover the wound area with sterile towels moistened with
sterile 0.9% saline. The patient should also be placed in the low Fowler's
position, and the exposed abdominal contents should be covered as previously
discussed. Notify the physician immediately because this is a medical
emergency. Do not leave the patient alone.
A 77-year-old client has experienced an ischemic stroke and is now dependent
for all activities of daily living. What components of nursing care will the nurse
initiate to prevent skin breakdown? - ANSWER Implement a 2-hour repositioning
schedule
The nurse must regularly turn and reposition the client who is immobile to
prevent ischemia and consequent skin breakdown. Other skin integrity
interventions include monitoring skin for changes, monitor client's continence
status and prevent or minimize exposure to urine and feces, evaluate need for
positioning devices and specialty mattresses, nutritional status assessment, and
individualize skin care plan. Range-of-motion exercises are good to combat
problems related to immobility. Frequent orientation is helpful for clients with
dementia. Massage may promote circulation, but it is less important than turning
the client on a scheduled basis, and massaging areas over bony prominences
could harm the skin's integrity.
A new mother is asking the nurse about care of her baby's skin. The nurse
should instruct the mother: - ANSWER to apply sunscreen when exposed to
ultraviolet rays.
Sunscreen is necessary to protect against damage caused by ultraviolet rays.
Which activity should the nurse implement to decrease shearing force on a
client's stage II pressure injury? - ANSWER preventing the client from sliding in
bed
Shearing force occurs when tissue layers move on one another, causing vessels
to stretch as they pass through the subcutaneous tissue.
A nurse assessing the wound healing of a client documents that the wound
formed a clean, straight line with little loss of tissue. This wound healed by: -
ANSWER primary intention.
Wounds healing by primary intention form a clean, straight line with little loss of
tissue. Wounds healing by secondary intention are large wounds with
considerable tissue loss. The edges are not approximated. Healing occurs by
formation of granulation tissue. Wounds healing by delayed primary intention or
tertiary intention are left open for several days to allow edema or infection to
, resolve or exudates to drain. They are then closed. Dehiscence is wound
separation, not wound healing.
After 30 minutes, the nurse is preparing to remove the cold therapy application
when the client asks if it can be left on a little longer. What is the best action by
the nurse? - ANSWER Explain that leaving cold therapy on for longer than 30
minutes can cause tissue necrosis.
The best response by the nurse is to explain the possible complications of
leaving cold therapy in place for too long, including cell death and tissue
necrosis. This response not only answers the client's question but teaches at the
same time the rationale and reason for limiting the cold therapy. Leaving the
therapy on for 10 more minutes places the client at increased risk of tissue
injury. Assisting the client out of bed ignores the client's request. Using the
health care provider's prescription as the reason displays lack of understanding
by the nurse and does not aid the client in understanding the rationale for the
time limit.
The nurse is caring for a client with a sacral wound. Upon assessment, the
wound is noted to be intact, reddened, and nonblanchable. What is the best way
to document the nurse's assessment finding? - ANSWER As a stage I pressure
injury
Stage I pressure injuries are characterized by intact but reddened skin that is
nonblanchable. Therefore, the nurse categorizes and documents this pressure
injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a
shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes
muscle and bone. Therefore, the nurse does not categorize this pressure injury
as stage II, III, or IV.
When measuring the size, depth, and wound tunneling of a patient's stage IV
pressure ulcer, what action should the nurse perform first? - ANSWER Perform
hand hygiene.
Hand hygiene should precede any wound assessment or wound treatment.
Of the many topics that may be taught to clients or caregivers about home
wound care, which one is the most significant in preventing wound infections? -
ANSWER thorough hand hygiene
The single most important information on which to educate clients and
caregivers about home wound care is the importance of thorough hand hygiene
to prevent wound infections. Proper intake of fluids and fiber as well as
adequate sleep and rest are general guidelines to promote health. Taking
medications especially antibiotics are important if an infection occurs.
CONCEPTS EXAM WITH COMPLETE SOLUTIONS
The nurse observes the client for signs of stage I pressure injury development,
which most likely will include which finding? - ANSWER nonblanchable redness
A stage I pressure injury is a defined area of intact skin with nonblanchable
redness of a localized area, usually over a bony prominence. A stage II pressure
injury involves partial-thickness loss of dermis and presents as a shallow open
ulcer. A stage III pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed.
A stage IV pressure injury involves full-thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be present on some part of the wound
bed and often includes undermining and tunneling.
A nurse working in long-term care is assessing residents at risk for the
development of a decubitus ulcer. Which one would be most at risk? - ANSWER
an 86-year-old who is bedfast
Most pressure ulcers occur in older adults as a result of a combination of
factors, including aging skin, chronic illness, immobility, malnutrition, fecal and
urinary incontinence, and altered level of consciousness. The bedfast resident
would be most at risk in this situation.
The nurse just completed a dressing change and returned the client to a
comfortable position. What should the nurse do next? - ANSWER Document the
color, odor, amount, and type of wound drainage.
After completing a dressing change and retuning the client to a comfortable
position, it is important to document color, odor, amount, and the type of wound
drainage. Early documentation helps to assure the most accurate information
can be recorded. Determining the extent of wound undermining and measuring
length, width, and depth of the wound should be performed during the dressing
change, while the wound is still exposed. The healthy tissue surrounding the
wound should never be massaged because it could cause further breakdown of
healthy tissue.
Upon responding to the patient's call bell, the nurse discovers the patient's
wound has dehisced. Initial nursing management includes calling the physician
and which of the following? - ANSWER Covering the wound area with sterile
towels moistened with sterile 0.9% saline
,If dehiscence occurs, cover the wound area with sterile towels moistened with
sterile 0.9% saline. The patient should also be placed in the low Fowler's
position, and the exposed abdominal contents should be covered as previously
discussed. Notify the physician immediately because this is a medical
emergency. Do not leave the patient alone.
A 77-year-old client has experienced an ischemic stroke and is now dependent
for all activities of daily living. What components of nursing care will the nurse
initiate to prevent skin breakdown? - ANSWER Implement a 2-hour repositioning
schedule
The nurse must regularly turn and reposition the client who is immobile to
prevent ischemia and consequent skin breakdown. Other skin integrity
interventions include monitoring skin for changes, monitor client's continence
status and prevent or minimize exposure to urine and feces, evaluate need for
positioning devices and specialty mattresses, nutritional status assessment, and
individualize skin care plan. Range-of-motion exercises are good to combat
problems related to immobility. Frequent orientation is helpful for clients with
dementia. Massage may promote circulation, but it is less important than turning
the client on a scheduled basis, and massaging areas over bony prominences
could harm the skin's integrity.
A new mother is asking the nurse about care of her baby's skin. The nurse
should instruct the mother: - ANSWER to apply sunscreen when exposed to
ultraviolet rays.
Sunscreen is necessary to protect against damage caused by ultraviolet rays.
Which activity should the nurse implement to decrease shearing force on a
client's stage II pressure injury? - ANSWER preventing the client from sliding in
bed
Shearing force occurs when tissue layers move on one another, causing vessels
to stretch as they pass through the subcutaneous tissue.
A nurse assessing the wound healing of a client documents that the wound
formed a clean, straight line with little loss of tissue. This wound healed by: -
ANSWER primary intention.
Wounds healing by primary intention form a clean, straight line with little loss of
tissue. Wounds healing by secondary intention are large wounds with
considerable tissue loss. The edges are not approximated. Healing occurs by
formation of granulation tissue. Wounds healing by delayed primary intention or
tertiary intention are left open for several days to allow edema or infection to
, resolve or exudates to drain. They are then closed. Dehiscence is wound
separation, not wound healing.
After 30 minutes, the nurse is preparing to remove the cold therapy application
when the client asks if it can be left on a little longer. What is the best action by
the nurse? - ANSWER Explain that leaving cold therapy on for longer than 30
minutes can cause tissue necrosis.
The best response by the nurse is to explain the possible complications of
leaving cold therapy in place for too long, including cell death and tissue
necrosis. This response not only answers the client's question but teaches at the
same time the rationale and reason for limiting the cold therapy. Leaving the
therapy on for 10 more minutes places the client at increased risk of tissue
injury. Assisting the client out of bed ignores the client's request. Using the
health care provider's prescription as the reason displays lack of understanding
by the nurse and does not aid the client in understanding the rationale for the
time limit.
The nurse is caring for a client with a sacral wound. Upon assessment, the
wound is noted to be intact, reddened, and nonblanchable. What is the best way
to document the nurse's assessment finding? - ANSWER As a stage I pressure
injury
Stage I pressure injuries are characterized by intact but reddened skin that is
nonblanchable. Therefore, the nurse categorizes and documents this pressure
injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a
shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes
muscle and bone. Therefore, the nurse does not categorize this pressure injury
as stage II, III, or IV.
When measuring the size, depth, and wound tunneling of a patient's stage IV
pressure ulcer, what action should the nurse perform first? - ANSWER Perform
hand hygiene.
Hand hygiene should precede any wound assessment or wound treatment.
Of the many topics that may be taught to clients or caregivers about home
wound care, which one is the most significant in preventing wound infections? -
ANSWER thorough hand hygiene
The single most important information on which to educate clients and
caregivers about home wound care is the importance of thorough hand hygiene
to prevent wound infections. Proper intake of fluids and fiber as well as
adequate sleep and rest are general guidelines to promote health. Taking
medications especially antibiotics are important if an infection occurs.
