RNSG 1341 - Exam 2 - NCLEX Questions
with verified solutions
A patient 1 day post-op after abdominal surgery has incisional pain, 99.5 (°F)
temperature, slight erythema at the incision margins, & 30 mL serosanguineous
drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion
would the nurse make? - correct answer ✔✔The patient is having a normal
inflammatory response.
The nurse assessing a patient with a chronic leg wound finds local signs of
erythema & the patient complains of pain at the wound site. What would the
nurse anticipate being ordered to assess the patient's systemic response? - correct
answer ✔✔White Blood Cell count and differential
A patient in the unit has a 103.7(°F) temperature. Which intervention would be
most effective in restoring normal body temperature? - correct answer
✔✔Administer antipyretics on an around-the-clock schedule.
A nurse is caring for a patient who has a pressure ulcer that is treated with
debridement, irrigations, & moist gauze dressings. How should the nurse
anticipate healing to occur? - correct answer ✔✔Secondary intention
A nurse is caring for a patient with diabetes who is scheduled for amputation of
his necrotic left great toe. - correct answer ✔✔The patient's White Blood Cell
count is 15.0 (× 106/µL), & he has coolness of the lower extremities, weighs
pounds more than his ideal body weight, & smokes 2 packs of cigarettes per day.
,Which priority nursing diagnosis addresses the primary factor affecting the
patient's ability to heal? - correct answer ✔✔Impaired tissue integrity related to
decreased blood flow secondary to diabetes and smoking
Which one of the orders should a nurse question in the plan of care for an elderly
immobile stroke patient with a stage 3 pressure ulcer? - correct answer ✔✔Clean
the ulcer every shift with Dakin's solution.
An 85-year-old patient is assessed to have a score of 16 on the Braden Scale.
Based on this information, how should the nurse plan for this patient's care? -
correct answer ✔✔Implement a 1 hour turning schedule with skin assessment.
A 65-year-old stroke patient with limited mobility has a purple area of suspected
deep tissue injury on the left greater trochanter. Which nursing diagnoses are
most appropriate (select all that apply)? - correct answer ✔✔Impaired skin
integrity related to immobility and decreased sensation. & Impaired tissue
integrity related to inadequate circulation secondary to pressure
An 82-year-old man is being cared for at home by his family. A pressure ulcer on
his right buttock measures 1 by 2 by 0.8 cm in depth, & pink subcutaneous tissue
is completely visible on the wound bed. Which stage would the nurse document
on the wound assessment form? - correct answer ✔✔Stage 3
Emerging and reemerging infections affect health care by (select all that apply) -
correct answer ✔✔reevaluating vaccine practices., revealing antimicrobial
resistance., & challenging researchers to discover new antimicrobial therapies.
,Which types(s) of isolation precautions is (are) appropriate for a patient with
tuberculosis (select all that apply)? - correct answer ✔✔airborne precautions., &
standard precautions
Which statement(s) about metabolic side effects of ART are true (select all that
apply)? - correct answer ✔✔ART-related body changes include fat redistribution &
peripheral wasting. Lipid abnormalities include increases in triglycerides &
decreases in high-density cholesterol. & Insulin resistance & hyperlipidemia can
be treated with drugs to control glucose and cholesterol.
When repositioning an immobile patient, the nurse notices redness over the hip
bone. What is indicated when a reddened area blanches on fingertip touch? -
correct answer ✔✔Blanching hyperemia, indicating the attempt by the body to
overcome the ischemic episode
stage 1 pressure ulcer., - is Nonblanchable redness of intact skin. Discoloration,
warmth, edema, or pain may also be present. - correct answer ✔✔stage 2
pressure ulcer., - is Partial-thickness skin loss or intact blister with serosanguinous
fluid.
stage 3 pressure ulcer., - is Full-thickness skin loss; subcutaneous fat may be
visible. May include undermining. - correct answer ✔✔stage 4 pressure ulcer., - is
Full thickness tissue loss; muscle and bone visible. May include undermining.
When obtaining a wound culture to determine the presence of a wound infection,
from where should the specimen be taken? - correct answer ✔✔Cleansed wound
After surgery the patient with a closed abdominal wound reports a sudden pop
after coughing. When the nurse examines the surgical wound site, the sutures are
, open, & pieces of small bowel are noted at the bottom of the now-opened
wound. Which are the priority nursing interventions? (Select all that apply.) -
correct answer ✔✔Notify the surgeon. & Cover the area with sterile, saline-
soaked towels immediately.
What is the correct sequence of steps when performing wound irrigation to a
large open wound? - correct answer ✔✔Place waterproof bag near bed. Fill
syringe with irrigation fluid. Attach 19-gauge angiocatheter to syringe. Position
angiocatheter over wound. & Use slow, continuous pressure to irrigate wound.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which
wound-care product helps prevent edema formation, control bleeding, and
anesthetize the body part? - correct answer ✔✔Ice bag
Which skin-care measures are used to manage a patient who is experiencing fecal
and/or urinary incontinence? (Select all that apply.) - correct answer ✔✔Frequent
position changes., Using an incontinence cleaner., & Applying a moisture barrier
ointment
Which of the following describes a hydrocolloid dressing? - correct answer ✔✔A
dressing that forms a gel that interacts with the wound surface
Which of the following is an indication for a binder to be placed around a surgical
patient with a new abdominal wound? (Select all that apply.) - correct answer
✔✔Providing support to abdominal tissues when coughing or walking., &
Reduction of stress on the abdominal incision
with verified solutions
A patient 1 day post-op after abdominal surgery has incisional pain, 99.5 (°F)
temperature, slight erythema at the incision margins, & 30 mL serosanguineous
drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion
would the nurse make? - correct answer ✔✔The patient is having a normal
inflammatory response.
The nurse assessing a patient with a chronic leg wound finds local signs of
erythema & the patient complains of pain at the wound site. What would the
nurse anticipate being ordered to assess the patient's systemic response? - correct
answer ✔✔White Blood Cell count and differential
A patient in the unit has a 103.7(°F) temperature. Which intervention would be
most effective in restoring normal body temperature? - correct answer
✔✔Administer antipyretics on an around-the-clock schedule.
A nurse is caring for a patient who has a pressure ulcer that is treated with
debridement, irrigations, & moist gauze dressings. How should the nurse
anticipate healing to occur? - correct answer ✔✔Secondary intention
A nurse is caring for a patient with diabetes who is scheduled for amputation of
his necrotic left great toe. - correct answer ✔✔The patient's White Blood Cell
count is 15.0 (× 106/µL), & he has coolness of the lower extremities, weighs
pounds more than his ideal body weight, & smokes 2 packs of cigarettes per day.
,Which priority nursing diagnosis addresses the primary factor affecting the
patient's ability to heal? - correct answer ✔✔Impaired tissue integrity related to
decreased blood flow secondary to diabetes and smoking
Which one of the orders should a nurse question in the plan of care for an elderly
immobile stroke patient with a stage 3 pressure ulcer? - correct answer ✔✔Clean
the ulcer every shift with Dakin's solution.
An 85-year-old patient is assessed to have a score of 16 on the Braden Scale.
Based on this information, how should the nurse plan for this patient's care? -
correct answer ✔✔Implement a 1 hour turning schedule with skin assessment.
A 65-year-old stroke patient with limited mobility has a purple area of suspected
deep tissue injury on the left greater trochanter. Which nursing diagnoses are
most appropriate (select all that apply)? - correct answer ✔✔Impaired skin
integrity related to immobility and decreased sensation. & Impaired tissue
integrity related to inadequate circulation secondary to pressure
An 82-year-old man is being cared for at home by his family. A pressure ulcer on
his right buttock measures 1 by 2 by 0.8 cm in depth, & pink subcutaneous tissue
is completely visible on the wound bed. Which stage would the nurse document
on the wound assessment form? - correct answer ✔✔Stage 3
Emerging and reemerging infections affect health care by (select all that apply) -
correct answer ✔✔reevaluating vaccine practices., revealing antimicrobial
resistance., & challenging researchers to discover new antimicrobial therapies.
,Which types(s) of isolation precautions is (are) appropriate for a patient with
tuberculosis (select all that apply)? - correct answer ✔✔airborne precautions., &
standard precautions
Which statement(s) about metabolic side effects of ART are true (select all that
apply)? - correct answer ✔✔ART-related body changes include fat redistribution &
peripheral wasting. Lipid abnormalities include increases in triglycerides &
decreases in high-density cholesterol. & Insulin resistance & hyperlipidemia can
be treated with drugs to control glucose and cholesterol.
When repositioning an immobile patient, the nurse notices redness over the hip
bone. What is indicated when a reddened area blanches on fingertip touch? -
correct answer ✔✔Blanching hyperemia, indicating the attempt by the body to
overcome the ischemic episode
stage 1 pressure ulcer., - is Nonblanchable redness of intact skin. Discoloration,
warmth, edema, or pain may also be present. - correct answer ✔✔stage 2
pressure ulcer., - is Partial-thickness skin loss or intact blister with serosanguinous
fluid.
stage 3 pressure ulcer., - is Full-thickness skin loss; subcutaneous fat may be
visible. May include undermining. - correct answer ✔✔stage 4 pressure ulcer., - is
Full thickness tissue loss; muscle and bone visible. May include undermining.
When obtaining a wound culture to determine the presence of a wound infection,
from where should the specimen be taken? - correct answer ✔✔Cleansed wound
After surgery the patient with a closed abdominal wound reports a sudden pop
after coughing. When the nurse examines the surgical wound site, the sutures are
, open, & pieces of small bowel are noted at the bottom of the now-opened
wound. Which are the priority nursing interventions? (Select all that apply.) -
correct answer ✔✔Notify the surgeon. & Cover the area with sterile, saline-
soaked towels immediately.
What is the correct sequence of steps when performing wound irrigation to a
large open wound? - correct answer ✔✔Place waterproof bag near bed. Fill
syringe with irrigation fluid. Attach 19-gauge angiocatheter to syringe. Position
angiocatheter over wound. & Use slow, continuous pressure to irrigate wound.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which
wound-care product helps prevent edema formation, control bleeding, and
anesthetize the body part? - correct answer ✔✔Ice bag
Which skin-care measures are used to manage a patient who is experiencing fecal
and/or urinary incontinence? (Select all that apply.) - correct answer ✔✔Frequent
position changes., Using an incontinence cleaner., & Applying a moisture barrier
ointment
Which of the following describes a hydrocolloid dressing? - correct answer ✔✔A
dressing that forms a gel that interacts with the wound surface
Which of the following is an indication for a binder to be placed around a surgical
patient with a new abdominal wound? (Select all that apply.) - correct answer
✔✔Providing support to abdominal tissues when coughing or walking., &
Reduction of stress on the abdominal incision
