SOLUTIONS #5
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?
A. Pick up the dressing and use the side that did not touch the bed.
B. Remove gloves and go to the supply room to obtain more supplies.
C. Ask the patient to press the call bell to summon a co-worker to obtain another
dressing.
D. Reapply the original dressing until a new one can be obtained. - correct answer C.
Ask the patient to press the call bell to summon a co-worker to obtain another dressing.
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?
A. Pale, white toes with decreased sensation.
B. Shiny skin with hair loss over legs, feet, and toes.
C. Dark discoloration of the skin surrounding the wound site.
D. Scaly rash between the toes with itchiness. - correct answer C. Dark discoloration of
the skin surrounding the wound site.
The nurse is reviewing the patient's laboratory results. Which lab test most accurately
represents current nutritional status?
A. Albumin
B. Pre-albumin
C. Calcium
D. Iron - correct answer Pre-albumin
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure?
In order to debride the wound, I will use a moderate amount of force to instill the
solution.
I will make sure the tip of the syringe touches the wound bed while performing the
irrigation.
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.
I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound
bed. - correct answer 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.