NUR 3110 EXAM 2 WITH
COMPLETE SOLUTION
An older adult client has been admitted to the hospital with dehydration, and
the nurse has inserted a peripheral intravenous line into the client's forearm
in order to facilitate rehydration. What type of dressing should the nurse
apply over the client's venous access site?
a. a gauze dressing premedicated with antibiotics
b. a gauze dressing precut halfway to fit around the IV line
c. a dressing with a nonadherent coating
d. a transparent film - ANSWER d
When clients are pulled up in bed rather than lifted, they are at increased risk
for the development of decubitus ulcers. What is the name given to the
factor responsible for this risk?
a. ischemia
b. shearing force
c. friction
d. necrosis of tissue - ANSWER b
A nurse is caring for a client with dehydration at the health care facility. The
,client is receiving glucose intravenously. What type of dressing should the
nurse use to cover the IV insertion site?
a. hydrocolloid
b. bandage
c. gauze
d. transparent - ANSWER d
A nurse removing sutures from a client's traumatic wound notices that the
sutures are encrusted with blood and difficult to remove. What would be the
nurse's most appropriate action?
a. Wash the sutures with warm, sterile water and an antimicrobial soap
before removing them.
b. Do not attempt to remove the sutures because the wound needs more
time to heal.
c. Moisten sterile gauze with sterile saline to gently loosen crusts before
removing sutures.
d. Carefully pick the crusts off the sutures with the forceps before removing
them. - ANSWER c
The nurse is providing care for a client with a wound that has purulent
drainage. Which interventions will the nurse provide when caring for this
client? Select all that apply.
,a. Apply another layer of protective ointment or paste on top of the previous
layer when changing dressings.
b. Apply a protective ointment or paste, if appropriate, to cleansed skin
surrounding the draining wound.
c. Apply a nonabsorbent material over the first layer of absorbent material.
d. Administer a prescribed analgesic 30 to 45 minutes before changing the
dressing, if necessary.
e. Apply an absorbent dressing material as the first layer of the dressing.
f. Change the dressing midway between meals. - ANSWER b
d
f
A client with vaginal itching and burning has been scheduled for an
examination and Pap procedure. Which teaching regarding douching will the
nurse provide to the client to prepare for the appointment?
a. "Douching is recommended so that you are clean for the examination."
b. "Plan to begin douching routinely immediately after your procedure."
c. "The Pap procedure includes application of a douche."
d. "Do not douche for 24-48 hours before the procedure." - ANSWER d
A client reports acute pain while negative pressure wound therapy is in place.
, What should the nurse do first?
a. Notify the health care provider of the pain.
b. Assess the client's wound and vital signs.
c. Administer the prescribed analgesic.
d. Document the pain and vital signs. - ANSWER b
The nurse is performing frequent skin assessment at the site where cold
therapy has been in place. The nurse notes pallor at the site and the client
reports "it feels numb." What is the best action by the nurse at this time?
a. Gently rub and massage the area to warm it up.
b. Discontinue the therapy and assess the client.
c. Document the findings in the client's medical record.
d. Notify the health care provider of the findings. - ANSWER b
A nurse is caring for clients on a medical-surgical unit. On the basis of known
risk factors, the nurse understands that which client has the highest risk for
developing a pressure injury?
a. 65-year-old incontinent client, who eats over half the meals, with a hip
fracture on bed rest
b. 70-year-old client with Alzheimer disease who wanders the nursing unit
using a walker and refuses to sit and eat meals
COMPLETE SOLUTION
An older adult client has been admitted to the hospital with dehydration, and
the nurse has inserted a peripheral intravenous line into the client's forearm
in order to facilitate rehydration. What type of dressing should the nurse
apply over the client's venous access site?
a. a gauze dressing premedicated with antibiotics
b. a gauze dressing precut halfway to fit around the IV line
c. a dressing with a nonadherent coating
d. a transparent film - ANSWER d
When clients are pulled up in bed rather than lifted, they are at increased risk
for the development of decubitus ulcers. What is the name given to the
factor responsible for this risk?
a. ischemia
b. shearing force
c. friction
d. necrosis of tissue - ANSWER b
A nurse is caring for a client with dehydration at the health care facility. The
,client is receiving glucose intravenously. What type of dressing should the
nurse use to cover the IV insertion site?
a. hydrocolloid
b. bandage
c. gauze
d. transparent - ANSWER d
A nurse removing sutures from a client's traumatic wound notices that the
sutures are encrusted with blood and difficult to remove. What would be the
nurse's most appropriate action?
a. Wash the sutures with warm, sterile water and an antimicrobial soap
before removing them.
b. Do not attempt to remove the sutures because the wound needs more
time to heal.
c. Moisten sterile gauze with sterile saline to gently loosen crusts before
removing sutures.
d. Carefully pick the crusts off the sutures with the forceps before removing
them. - ANSWER c
The nurse is providing care for a client with a wound that has purulent
drainage. Which interventions will the nurse provide when caring for this
client? Select all that apply.
,a. Apply another layer of protective ointment or paste on top of the previous
layer when changing dressings.
b. Apply a protective ointment or paste, if appropriate, to cleansed skin
surrounding the draining wound.
c. Apply a nonabsorbent material over the first layer of absorbent material.
d. Administer a prescribed analgesic 30 to 45 minutes before changing the
dressing, if necessary.
e. Apply an absorbent dressing material as the first layer of the dressing.
f. Change the dressing midway between meals. - ANSWER b
d
f
A client with vaginal itching and burning has been scheduled for an
examination and Pap procedure. Which teaching regarding douching will the
nurse provide to the client to prepare for the appointment?
a. "Douching is recommended so that you are clean for the examination."
b. "Plan to begin douching routinely immediately after your procedure."
c. "The Pap procedure includes application of a douche."
d. "Do not douche for 24-48 hours before the procedure." - ANSWER d
A client reports acute pain while negative pressure wound therapy is in place.
, What should the nurse do first?
a. Notify the health care provider of the pain.
b. Assess the client's wound and vital signs.
c. Administer the prescribed analgesic.
d. Document the pain and vital signs. - ANSWER b
The nurse is performing frequent skin assessment at the site where cold
therapy has been in place. The nurse notes pallor at the site and the client
reports "it feels numb." What is the best action by the nurse at this time?
a. Gently rub and massage the area to warm it up.
b. Discontinue the therapy and assess the client.
c. Document the findings in the client's medical record.
d. Notify the health care provider of the findings. - ANSWER b
A nurse is caring for clients on a medical-surgical unit. On the basis of known
risk factors, the nurse understands that which client has the highest risk for
developing a pressure injury?
a. 65-year-old incontinent client, who eats over half the meals, with a hip
fracture on bed rest
b. 70-year-old client with Alzheimer disease who wanders the nursing unit
using a walker and refuses to sit and eat meals
