ADULT HEALTH 1 FINAL EXAM QUESTIONS WITH
CORRECT ANSWERS UPDATE
1.How would you stage this wound?
A. Stage 4
B. Unstageable
C. Stage 3
D. Stage 2 - CORRECT ANSWER-B. Unstageable
2. Arterial ulcers tend to be symmetrical and form a ___ whereas venous ulcers tend to be
asymmetrical and form a ___ - CORRECT ANSWER-deep crater
shallow wound
3.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?
A. hemorrhage
B. deep wound bed
C. pale colored wound bed
D. heavy exudate - CORRECT ANSWER-D. heavy exudate
4.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?
A. unequal peripheral pulses between extremities
B. Reddened extremities with muscle atrophy
C. Visible clubbing of the fingers and toes - CORRECT ANSWER-A. unequal peripheral pulses
between extremities
,5.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?
A. The packed gauze is a temporary fix before surgery
B. The packed gauze works to remove (debride) the dead or injured tissue
C. The packed gauze is works in wounds that have eschar.
D. The packed gauze liquefies the slough so it can be cleansed from the wound - CORRECT
ANSWER-B. 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?
A. 4cm
B. 5cm
C. 7cm
D. 6cm - CORRECT ANSWER-B. 5cm
A superficial burn injury that is at the epidermal level is considered what degree of burn?
A. first degree
B. third degree
C. second degree
D. full thickness - CORRECT ANSWER-A. first degree
A deep partial and full thickness burn is usually very painful.
True
False - CORRECT ANSWER-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?
A. cover the wound with a dry dressing
,B. chest compressions
C. Airway management
D. call 911 - CORRECT ANSWER-C. 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?
A. hypokalemia
B. hypocalcemia
C. hyperkalemia
D. hypercalcemia - CORRECT ANSWER-B. 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?
A. 27%
B. 22.5%
C. 36%
D. 18% - CORRECT ANSWER-B. 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?
A. 18%
B. 9%
C. 10%
D. we don't use percentage of BSA when it comes to the head - CORRECT ANSWER-B. 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?
A. respiratory arrest
B. hemodynamic instability
C. GI hypermotility
D. hypokalemia - CORRECT ANSWER-B. 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?
A. "I will be sure to get enough rest and stay off my affected leg."
B. "I will keep all follow-up appointments with my healthcare provider."
C. "I will take my antibiotics until the affected area looks less red."'
D. "I will keep my affected leg elevated to keep swelling down." - CORRECT ANSWER-C. "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?
A. Impetigo
B. GERD
C. Peripheral vascular disease
D. hypotension - CORRECT ANSWER-C. 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?
A. Escherichia coli
B. Bacillus subtilis
C. Staphylococcus aureus
CORRECT ANSWERS UPDATE
1.How would you stage this wound?
A. Stage 4
B. Unstageable
C. Stage 3
D. Stage 2 - CORRECT ANSWER-B. Unstageable
2. Arterial ulcers tend to be symmetrical and form a ___ whereas venous ulcers tend to be
asymmetrical and form a ___ - CORRECT ANSWER-deep crater
shallow wound
3.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?
A. hemorrhage
B. deep wound bed
C. pale colored wound bed
D. heavy exudate - CORRECT ANSWER-D. heavy exudate
4.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?
A. unequal peripheral pulses between extremities
B. Reddened extremities with muscle atrophy
C. Visible clubbing of the fingers and toes - CORRECT ANSWER-A. unequal peripheral pulses
between extremities
,5.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?
A. The packed gauze is a temporary fix before surgery
B. The packed gauze works to remove (debride) the dead or injured tissue
C. The packed gauze is works in wounds that have eschar.
D. The packed gauze liquefies the slough so it can be cleansed from the wound - CORRECT
ANSWER-B. 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?
A. 4cm
B. 5cm
C. 7cm
D. 6cm - CORRECT ANSWER-B. 5cm
A superficial burn injury that is at the epidermal level is considered what degree of burn?
A. first degree
B. third degree
C. second degree
D. full thickness - CORRECT ANSWER-A. first degree
A deep partial and full thickness burn is usually very painful.
True
False - CORRECT ANSWER-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?
A. cover the wound with a dry dressing
,B. chest compressions
C. Airway management
D. call 911 - CORRECT ANSWER-C. 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?
A. hypokalemia
B. hypocalcemia
C. hyperkalemia
D. hypercalcemia - CORRECT ANSWER-B. 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?
A. 27%
B. 22.5%
C. 36%
D. 18% - CORRECT ANSWER-B. 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?
A. 18%
B. 9%
C. 10%
D. we don't use percentage of BSA when it comes to the head - CORRECT ANSWER-B. 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?
A. respiratory arrest
B. hemodynamic instability
C. GI hypermotility
D. hypokalemia - CORRECT ANSWER-B. 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?
A. "I will be sure to get enough rest and stay off my affected leg."
B. "I will keep all follow-up appointments with my healthcare provider."
C. "I will take my antibiotics until the affected area looks less red."'
D. "I will keep my affected leg elevated to keep swelling down." - CORRECT ANSWER-C. "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?
A. Impetigo
B. GERD
C. Peripheral vascular disease
D. hypotension - CORRECT ANSWER-C. 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?
A. Escherichia coli
B. Bacillus subtilis
C. Staphylococcus aureus
