ACUTE HD THEORY CLASS FINAL PRACTICE
QUESTIONS AND DETAILED SOLUTIONS
◉ A patient has an open surgical wound on the abdomen that
contains deep pink granulation tissue. How would the nurse
document this wound?
Answer: Red wound
◉ A patient from a long-term care facility is admitted to the hospital
with a sacral pressure ulcer. The base of the wound is yellow and
involves subcutaneous tissue. How should the nurse classify this
pressure ulcer?
Answer: Stage III
◉ A young male patient who is a paraplegic has a stage II sacral
pressure ulcer and is being cared for at home by his mother. To
prevent further tissue damage, what instructions are most
important for the nurse to teach the mother?
Answer: Change the patient's position at least every 2 hours
◉ A new nurse performs a dressing change on a stage II left heel
pressure ulcer. Which action by the new nurse indicates a need for
further teaching about pressure ulcer care?
,Answer: the new nurse cleans the ulcer with a sterile dressing
soaked in half-strength peroxide
◉ Which finding is most important for the nurse to communicate to
the health care provider when caring for a patient who is receiving
negative pressure wound therapy?
Answer: Low serum albumin level
◉ The nurse is caring for a patient with diabetes who had abdominal
surgery 3 days ago. Which finding is most important for the nurse to
report to the health care provider?
Answer: Separation of the proximal wound edges by 1 cm
◉ After receiving a change-of-shift report, which patient should the
nurse assess first?
Answer: The patient who has been receiving chemotherapy and has
a temperature of 102 F
◉ A patient scheduled for an elective hysterectomy tells the nurse, "I
am afraid that i will die in surgery like my mother did." Which
response by the nurse is most appropriate?
Answer: "Tell me more about what happened to your mother"
, ◉ A 38-year-old female is admitted for an elective surgical
procedure. Which information obtained by the nurse during the
preoperative assessment is most important to report to the
anesthesiologist before surgery?
Answer: The patient's statement that her last menstrual period was
8 weeks previously
◉ The nurse is preparing to witness the patient signing the
operative consent form when the patient says, "I do not really
understand what the doctor said," which action is best for the nurse
to take?
Answer: Notify the surgeon that the informed consent process is not
complete
◉ The outpatient surgery nurse reviews the complete blood cell
count (CBC) results from a patient who is scheduled for surgery in a
few days. The results are white blood cell count (WBC)10.2 x
108/uL; hemoglobin 15g/dL; hematocrit 45%; platelets 150 x
103/uL. Which action should the nurse take?
Answer: Send the patient to the holding area when the operating
room calls.
◉ When caring for a preoperative patient on the day of surgery,
which actions included in the plan of care can the nurse delegate to
unlicensed assistive personnel (UAP)? (select all that apply)
Answer: Remove nail polish and apply pulse oximeter
QUESTIONS AND DETAILED SOLUTIONS
◉ A patient has an open surgical wound on the abdomen that
contains deep pink granulation tissue. How would the nurse
document this wound?
Answer: Red wound
◉ A patient from a long-term care facility is admitted to the hospital
with a sacral pressure ulcer. The base of the wound is yellow and
involves subcutaneous tissue. How should the nurse classify this
pressure ulcer?
Answer: Stage III
◉ A young male patient who is a paraplegic has a stage II sacral
pressure ulcer and is being cared for at home by his mother. To
prevent further tissue damage, what instructions are most
important for the nurse to teach the mother?
Answer: Change the patient's position at least every 2 hours
◉ A new nurse performs a dressing change on a stage II left heel
pressure ulcer. Which action by the new nurse indicates a need for
further teaching about pressure ulcer care?
,Answer: the new nurse cleans the ulcer with a sterile dressing
soaked in half-strength peroxide
◉ Which finding is most important for the nurse to communicate to
the health care provider when caring for a patient who is receiving
negative pressure wound therapy?
Answer: Low serum albumin level
◉ The nurse is caring for a patient with diabetes who had abdominal
surgery 3 days ago. Which finding is most important for the nurse to
report to the health care provider?
Answer: Separation of the proximal wound edges by 1 cm
◉ After receiving a change-of-shift report, which patient should the
nurse assess first?
Answer: The patient who has been receiving chemotherapy and has
a temperature of 102 F
◉ A patient scheduled for an elective hysterectomy tells the nurse, "I
am afraid that i will die in surgery like my mother did." Which
response by the nurse is most appropriate?
Answer: "Tell me more about what happened to your mother"
, ◉ A 38-year-old female is admitted for an elective surgical
procedure. Which information obtained by the nurse during the
preoperative assessment is most important to report to the
anesthesiologist before surgery?
Answer: The patient's statement that her last menstrual period was
8 weeks previously
◉ The nurse is preparing to witness the patient signing the
operative consent form when the patient says, "I do not really
understand what the doctor said," which action is best for the nurse
to take?
Answer: Notify the surgeon that the informed consent process is not
complete
◉ The outpatient surgery nurse reviews the complete blood cell
count (CBC) results from a patient who is scheduled for surgery in a
few days. The results are white blood cell count (WBC)10.2 x
108/uL; hemoglobin 15g/dL; hematocrit 45%; platelets 150 x
103/uL. Which action should the nurse take?
Answer: Send the patient to the holding area when the operating
room calls.
◉ When caring for a preoperative patient on the day of surgery,
which actions included in the plan of care can the nurse delegate to
unlicensed assistive personnel (UAP)? (select all that apply)
Answer: Remove nail polish and apply pulse oximeter
