NCLEX Practice Questions and Answers Fundamentals Exam 2
Thirty-six hours after having surgery, a pt has a slightly elevated body temp and generalized malaise, as well as pain and redness at the surgical site. Which intervention
is most important to include in this pt's nursing care plan?
a. document the findings and monitor the pt
b. administer antipyretics, as ordered
c. increase the frequency of assessment to every hour and notify the pt's primary care provider
d. increase the frequency of wound care and contact the PCP for an antibiotic order - ANSWER-a. document the findings and monitor the pt
A nurse caring patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply
a. serous drainage is composed of the clear portion of the blood and serous membranes
b. sanguineous drainage is composed of a large number of RBCs and looks like blood
c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
e. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
f. serosanguineous drainage can be dark yellow or green depending on the causative organism - ANSWER-a. serous drainage is composed of the clear portion of the blood and serous membranes
b. sanguineous drainage is composed of a large number of RBCs and looks like blood
c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
A pt who has a large abdominal wound suddenly calls out for help b/c she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last.
a. notify the physician of the situation
b. cover the exposed tissue with sterile towels moistened with sterile NSS
c. place the pt in low Fowler's position - ANSWER-c. place the pt in low Fowler's position
b. cover the exposed tissue with sterile towels moistened with sterile NSS
a. notify the physician of the situation A pt, age 16, was in an automobile accident and received a would across her nose and cheek. After surgery to repair the wound, the pt says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?
a. pain
b. impaired skin integrity
c. disturbed body image
d. disturbed thought process - ANSWER-c. disturbed body image
A pt is admitted with a non healing surgical wound. Which nursing action is most effective in preventing a wound infection?
a. using sterile dressing supplies
b. suggesting dietary supplements
c. applying antibiotic ointment
d. performing careful hand hygiene - ANSWER-d. performing careful hand hygiene
A nurse who is changing dressings of post op pts in the hospital documents various phases of wound healing on the pt charts. Which statements accurately describe these stages? Select all that apply
a. hemostasis occurs immediately after the initial injury
b. a liquid called exudate is formed during the proliferative phase
c. WBCs moe to the wound in the inflammatory phase
d. Granulation tissue forms in the inflammatory phase
e. during the inflammatory phase, the ppt has generalized body response
f. A scar forms during the proliferative phase - ANSWER-a. hemostasis occurs immediately after the initial injury
c. WBCs moe to the wound in the inflammatory phase
e. during the inflammatory phase, the ppt has generalized body response
The nurse assesses the wound of a pt who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply
a. enhanced healing due to the presence of sugars and proteins
b. delayed healing due to dead tissue present in the wound
c. decreased effectiveness of antibiotics against the bacteria
d. impaired skin integrity due to over hydration of the fells of the wound
e. delayed healing due to cells dehydrating and dying
f. decreased effectiveness of the pt's normal immune process - ANSWER-c. decreased effectiveness of antibiotics against the bacteria
f. decreased effectiveness of the pt's normal immune process
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are the accurate steps in this procedure. Select all that apply
a. use standard precautions or transmission-based precautions when indicated
b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution c. clean the wound in full or half circles beginning on the outside working toward the center
d. work outward from the incision in fines that are parallel to it from the dirty area to the clean area
e. clean to at least one inch beyond the end of the new dressing if one is being applied
f. clean to at least three inches beyond the wound if a new dressing is not being applied - ANSWER-a. use standard precautions or transmission-based precautions when indicated
b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution
e. clean to at least one inch beyond the end of the new dressing if one is being applied
A nurse is developing a plan of care for an 86 YO woman who has bene admitted for right hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for pressure ulcer development for this pt? Select all that apply
a. the pt takes time to think about her response to questions
b. the pt's age of 86
c. pt reports inability to control urine
d. a schedule hip arthroplasty
e. lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine .9 (adult female normal .61-1 mg/dL)
f. pt reports increased pain in right hip when repositioning in bed or chair - ANSWER-b. the pt's age of 86
c. pt reports inability to control urine
d. a schedule hip arthroplasty
f. pt reports increased pain in right hip when repositioning in bed or chair
A nurse is explaining to a pt the anticipated effect of the application of cold to an injured area. What response indicates that the pt understands the explanation?
a. "I can expect to have more discomfort in the area where the cold is applied"
b. "I should expect more drainage from the incision after the ice has been in place"
c. "I should see less swelling and redness with the cold treatment"
d. "My incision may bleed more when the ice is first applied" - ANSWER-c. "I should see
less swelling and redness with the cold treatment"
A nurse is providing pt teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate info to the pt?
a. the therapy is used to collect excess blood loss and prevent the formation of a scab
b. the therapy will prevent infection, ensuring that the wound heals with less scar tissue
c. the therapy provides a moist environment and stimulates blood flow to the wound
d. the therapy irrigates the wound to keep it free from debris and excess wound fluid - ANSWER-c. the therapy provides a moist environment and stimulates blood flow to the wound
Thirty-six hours after having surgery, a pt has a slightly elevated body temp and generalized malaise, as well as pain and redness at the surgical site. Which intervention
is most important to include in this pt's nursing care plan?
a. document the findings and monitor the pt
b. administer antipyretics, as ordered
c. increase the frequency of assessment to every hour and notify the pt's primary care provider
d. increase the frequency of wound care and contact the PCP for an antibiotic order - ANSWER-a. document the findings and monitor the pt
A nurse caring patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply
a. serous drainage is composed of the clear portion of the blood and serous membranes
b. sanguineous drainage is composed of a large number of RBCs and looks like blood
c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
e. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
f. serosanguineous drainage can be dark yellow or green depending on the causative organism - ANSWER-a. serous drainage is composed of the clear portion of the blood and serous membranes
b. sanguineous drainage is composed of a large number of RBCs and looks like blood
c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor
A pt who has a large abdominal wound suddenly calls out for help b/c she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last.
a. notify the physician of the situation
b. cover the exposed tissue with sterile towels moistened with sterile NSS
c. place the pt in low Fowler's position - ANSWER-c. place the pt in low Fowler's position
b. cover the exposed tissue with sterile towels moistened with sterile NSS
a. notify the physician of the situation A pt, age 16, was in an automobile accident and received a would across her nose and cheek. After surgery to repair the wound, the pt says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?
a. pain
b. impaired skin integrity
c. disturbed body image
d. disturbed thought process - ANSWER-c. disturbed body image
A pt is admitted with a non healing surgical wound. Which nursing action is most effective in preventing a wound infection?
a. using sterile dressing supplies
b. suggesting dietary supplements
c. applying antibiotic ointment
d. performing careful hand hygiene - ANSWER-d. performing careful hand hygiene
A nurse who is changing dressings of post op pts in the hospital documents various phases of wound healing on the pt charts. Which statements accurately describe these stages? Select all that apply
a. hemostasis occurs immediately after the initial injury
b. a liquid called exudate is formed during the proliferative phase
c. WBCs moe to the wound in the inflammatory phase
d. Granulation tissue forms in the inflammatory phase
e. during the inflammatory phase, the ppt has generalized body response
f. A scar forms during the proliferative phase - ANSWER-a. hemostasis occurs immediately after the initial injury
c. WBCs moe to the wound in the inflammatory phase
e. during the inflammatory phase, the ppt has generalized body response
The nurse assesses the wound of a pt who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply
a. enhanced healing due to the presence of sugars and proteins
b. delayed healing due to dead tissue present in the wound
c. decreased effectiveness of antibiotics against the bacteria
d. impaired skin integrity due to over hydration of the fells of the wound
e. delayed healing due to cells dehydrating and dying
f. decreased effectiveness of the pt's normal immune process - ANSWER-c. decreased effectiveness of antibiotics against the bacteria
f. decreased effectiveness of the pt's normal immune process
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are the accurate steps in this procedure. Select all that apply
a. use standard precautions or transmission-based precautions when indicated
b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution c. clean the wound in full or half circles beginning on the outside working toward the center
d. work outward from the incision in fines that are parallel to it from the dirty area to the clean area
e. clean to at least one inch beyond the end of the new dressing if one is being applied
f. clean to at least three inches beyond the wound if a new dressing is not being applied - ANSWER-a. use standard precautions or transmission-based precautions when indicated
b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution
e. clean to at least one inch beyond the end of the new dressing if one is being applied
A nurse is developing a plan of care for an 86 YO woman who has bene admitted for right hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for pressure ulcer development for this pt? Select all that apply
a. the pt takes time to think about her response to questions
b. the pt's age of 86
c. pt reports inability to control urine
d. a schedule hip arthroplasty
e. lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine .9 (adult female normal .61-1 mg/dL)
f. pt reports increased pain in right hip when repositioning in bed or chair - ANSWER-b. the pt's age of 86
c. pt reports inability to control urine
d. a schedule hip arthroplasty
f. pt reports increased pain in right hip when repositioning in bed or chair
A nurse is explaining to a pt the anticipated effect of the application of cold to an injured area. What response indicates that the pt understands the explanation?
a. "I can expect to have more discomfort in the area where the cold is applied"
b. "I should expect more drainage from the incision after the ice has been in place"
c. "I should see less swelling and redness with the cold treatment"
d. "My incision may bleed more when the ice is first applied" - ANSWER-c. "I should see
less swelling and redness with the cold treatment"
A nurse is providing pt teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate info to the pt?
a. the therapy is used to collect excess blood loss and prevent the formation of a scab
b. the therapy will prevent infection, ensuring that the wound heals with less scar tissue
c. the therapy provides a moist environment and stimulates blood flow to the wound
d. the therapy irrigates the wound to keep it free from debris and excess wound fluid - ANSWER-c. the therapy provides a moist environment and stimulates blood flow to the wound
