Exam 2:Fundamentals of Nursing Exam 2: Questions &
Answers
The patient has been diagnosed with gastrointestinal bacteria obtained from drinking contaminated
water. In the chain of infection, the water is the:
A.portal of entry.
B.reservoir.
C.portal of exit.
D.infectious agent. - ANSWER:B. Reservoir
The nurse is taking care of a patient who has a respiratory infection with a productive cough. The most
effective infection control method is for the nurse to:
A.monitor the patient temperature at least every 4 hrs.
B.push oral fluids every shift to 1000 mL or more.
C.listen to the patient's lung sounds every 4hrs.
D.instruct patient to cover mouth with tissue when coughing. - ANSWER:D Instruct patient to cover
mouth with tissue when coughing
The nurse notes the patient's abdominal dressing has a moderate amount of watery/bloody drainage
and a very foul odor. In planning for the dressing change related to the chain of infection, it is most
important for the nurse to:
A.apply extra dressings to the wound.
B.use sterile gloves to change the dressing.
C.wash her hands before and after the dressing change.
D.change the abdominal dressing more frequently. - ANSWER:C Wash her hands before and after the
dressing change
Acute wound - ANSWER:short duration
Chronic wound - ANSWER:exceed anticipated length of recovery, pressure, arterial, venous, and diabetic
ulcers
Clean wound - ANSWER:uninfected wound, free of purulent drainage, minimal inflammation, not in GI,
GU or respiratory tract
Clean contaminated wound - ANSWER:surgical incisions that enter the GI, respiratory, or GU tracts
Closed wounds - ANSWER:no breaks in skin
, Colonized - ANSWER:the presences of bacteria on surface or in tissue of a wound without indications of
infection. All stage II, III, IV pressure ulcers are considered colonized
Contaminated - ANSWER:Containing bacteria, other microorganisms or foreign material. The term
usually refers to bacterial contamination. Wounds with bacteria counts of < or equal to 100k organisms
per gram of tissue are considered contaminated. Those with counts >100k are considered infected.
Crepitus - ANSWER:trapped gas under the skin, feels spongy
Debridment - ANSWER:removal of devitalized tissue and foreign matter from a wound
autolytic debridement - ANSWER:the use of synthetic dressings to cover a wound and allow eschar to
self-digest by the action of enzymes present in wound fluids
Enzymatic debridement - ANSWER:using topical substances that break down dead tissue
Mechanical debridement - ANSWER:Physical removal of debris by irrigation, hydrotherapy or wet-to-dry
dressing application
Sharp debridement - ANSWER:the removal of necrotic tissue using scissors, scalpel or laser
Denude - ANSWER:loss of epidermis
Epitheliazation - ANSWER:-regeneration of the external layer of the skin
Erythemia - ANSWER:redness of the skin produced by vasodilation
Eschar - ANSWER:thick leathery necrotic devitalized tissue BLACK
Excoriation - ANSWER:Skin sore or abrasion produced by scratching or scraping
Exudate - ANSWER:fluid, such as pus, that leaks out of an infected wound. High in proteins and WBCs
Friction - ANSWER:Mechanical force exerted when skin is dragged across coarse surface such as bed
linens
Full Thickness - ANSWER:extend into the subcutaneous tissue and beyond
Granulation - ANSWER:the formation or growth of small blood vessels and connective tissue in full
thickness wound. BEEFY RED
Hyperemia - ANSWER:presence of excess blood in vessels, engorgement
Infected - ANSWER:bacterial count >100k per gram tissue, evidence of infection
Ischemia - ANSWER:an inadequate blood supply to an organ or part of the body,
Maceration - ANSWER:softening of tissue by soaking in fluids, skin will appear pale and wrinkled which
may flake and peel
Necrotic - ANSWER:dead, avascular, BLACK
partial thickness - ANSWER:extends through epidermis to dermis
Penetrating - ANSWER:wound involving internal organs
Answers
The patient has been diagnosed with gastrointestinal bacteria obtained from drinking contaminated
water. In the chain of infection, the water is the:
A.portal of entry.
B.reservoir.
C.portal of exit.
D.infectious agent. - ANSWER:B. Reservoir
The nurse is taking care of a patient who has a respiratory infection with a productive cough. The most
effective infection control method is for the nurse to:
A.monitor the patient temperature at least every 4 hrs.
B.push oral fluids every shift to 1000 mL or more.
C.listen to the patient's lung sounds every 4hrs.
D.instruct patient to cover mouth with tissue when coughing. - ANSWER:D Instruct patient to cover
mouth with tissue when coughing
The nurse notes the patient's abdominal dressing has a moderate amount of watery/bloody drainage
and a very foul odor. In planning for the dressing change related to the chain of infection, it is most
important for the nurse to:
A.apply extra dressings to the wound.
B.use sterile gloves to change the dressing.
C.wash her hands before and after the dressing change.
D.change the abdominal dressing more frequently. - ANSWER:C Wash her hands before and after the
dressing change
Acute wound - ANSWER:short duration
Chronic wound - ANSWER:exceed anticipated length of recovery, pressure, arterial, venous, and diabetic
ulcers
Clean wound - ANSWER:uninfected wound, free of purulent drainage, minimal inflammation, not in GI,
GU or respiratory tract
Clean contaminated wound - ANSWER:surgical incisions that enter the GI, respiratory, or GU tracts
Closed wounds - ANSWER:no breaks in skin
, Colonized - ANSWER:the presences of bacteria on surface or in tissue of a wound without indications of
infection. All stage II, III, IV pressure ulcers are considered colonized
Contaminated - ANSWER:Containing bacteria, other microorganisms or foreign material. The term
usually refers to bacterial contamination. Wounds with bacteria counts of < or equal to 100k organisms
per gram of tissue are considered contaminated. Those with counts >100k are considered infected.
Crepitus - ANSWER:trapped gas under the skin, feels spongy
Debridment - ANSWER:removal of devitalized tissue and foreign matter from a wound
autolytic debridement - ANSWER:the use of synthetic dressings to cover a wound and allow eschar to
self-digest by the action of enzymes present in wound fluids
Enzymatic debridement - ANSWER:using topical substances that break down dead tissue
Mechanical debridement - ANSWER:Physical removal of debris by irrigation, hydrotherapy or wet-to-dry
dressing application
Sharp debridement - ANSWER:the removal of necrotic tissue using scissors, scalpel or laser
Denude - ANSWER:loss of epidermis
Epitheliazation - ANSWER:-regeneration of the external layer of the skin
Erythemia - ANSWER:redness of the skin produced by vasodilation
Eschar - ANSWER:thick leathery necrotic devitalized tissue BLACK
Excoriation - ANSWER:Skin sore or abrasion produced by scratching or scraping
Exudate - ANSWER:fluid, such as pus, that leaks out of an infected wound. High in proteins and WBCs
Friction - ANSWER:Mechanical force exerted when skin is dragged across coarse surface such as bed
linens
Full Thickness - ANSWER:extend into the subcutaneous tissue and beyond
Granulation - ANSWER:the formation or growth of small blood vessels and connective tissue in full
thickness wound. BEEFY RED
Hyperemia - ANSWER:presence of excess blood in vessels, engorgement
Infected - ANSWER:bacterial count >100k per gram tissue, evidence of infection
Ischemia - ANSWER:an inadequate blood supply to an organ or part of the body,
Maceration - ANSWER:softening of tissue by soaking in fluids, skin will appear pale and wrinkled which
may flake and peel
Necrotic - ANSWER:dead, avascular, BLACK
partial thickness - ANSWER:extends through epidermis to dermis
Penetrating - ANSWER:wound involving internal organs
