VSIM Josephine Morrow Pre-Sim & Post-Sim Answers
Complete
The nurse is reviewing the patient's laboratory results. Which lab test most accurately
represents current nutritional status?
Prealbumin
The nurse is completing an admission assessment on a patient admitted for impaired
skin integrity. Which questions would be appropriate for the nurse to ask the patient?
-Have you noticed any swelling on your feet, ankles, or fingers?
-Do some areas of your skin seem warmer or colder than others?
-Have you used pads or special pants because you can't control your urine?
-Do you have any sores on your body?
The nurse is caring for a patient admitted with bilateral lower extremity edema. What
questions should the nurse ask when completing a health history?
-When did the edema start?
-Can you describe the edema?
-Do you have any recent history of surgery or illness?
The nurse is conducting a skin assessment using the Braden scale. How would the
nurse interpret a score of 12?
High Risk
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower
extremity. What would the nurse expect to find when assessing the leg?
Dark discoloration of the skin surrounding the wound site
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure?
I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one
inch from the upper tip of the wound.
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would
the nurse document this finding?
Purulent
The nurse is performing a sterile dressing change. After donning sterile gloves, the
nurse drops the dressing on the bed and does not have a replacement. What is the
appropriate action at this time?
Ask the patient to press the call bell to summon a co-worker to obtain another dressing.
The nurse is completing an admission assessment on a patient for an infected, non-
healing wound. Which factors in the patient's history may contribute to this condition?
-Diabetes Mellitus
-Obesity
-Poor Hygiene
-Poor Circulation
The nurse assesses a wound and documents it as stage III. What did the nurse observe
when the wound was assessed?
Full-thickness tissue loss, possibly with subcutaneous fat.
The nurse is performing an assessment of Ms. Morrow's wound. What should be
included in the documentation?
Complete
The nurse is reviewing the patient's laboratory results. Which lab test most accurately
represents current nutritional status?
Prealbumin
The nurse is completing an admission assessment on a patient admitted for impaired
skin integrity. Which questions would be appropriate for the nurse to ask the patient?
-Have you noticed any swelling on your feet, ankles, or fingers?
-Do some areas of your skin seem warmer or colder than others?
-Have you used pads or special pants because you can't control your urine?
-Do you have any sores on your body?
The nurse is caring for a patient admitted with bilateral lower extremity edema. What
questions should the nurse ask when completing a health history?
-When did the edema start?
-Can you describe the edema?
-Do you have any recent history of surgery or illness?
The nurse is conducting a skin assessment using the Braden scale. How would the
nurse interpret a score of 12?
High Risk
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower
extremity. What would the nurse expect to find when assessing the leg?
Dark discoloration of the skin surrounding the wound site
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure?
I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one
inch from the upper tip of the wound.
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would
the nurse document this finding?
Purulent
The nurse is performing a sterile dressing change. After donning sterile gloves, the
nurse drops the dressing on the bed and does not have a replacement. What is the
appropriate action at this time?
Ask the patient to press the call bell to summon a co-worker to obtain another dressing.
The nurse is completing an admission assessment on a patient for an infected, non-
healing wound. Which factors in the patient's history may contribute to this condition?
-Diabetes Mellitus
-Obesity
-Poor Hygiene
-Poor Circulation
The nurse assesses a wound and documents it as stage III. What did the nurse observe
when the wound was assessed?
Full-thickness tissue loss, possibly with subcutaneous fat.
The nurse is performing an assessment of Ms. Morrow's wound. What should be
included in the documentation?
