VSIM #3 - JOSEPHINE MORROW CASE TEST WITH
ANSWERS
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure? - correct answer "I will gently direct a
stream of fluid into the wound, keeping the syringe tip at least 1 inch from the upper tip
of the wound."
The nurse is reviewing a patient's laboratory results to determine the current nutritional
status. Which of the following will negatively affect wound healing? - correct answer
Protein deficiency
Vitamin B excess
The nurse removes a dressing and assesses yellow, foul-smelling drainage. How would
the nurse document this finding? - correct answer Purulent
Which of the following sign(s) and symptom(s) would the nurse expect in a patient with
chronic venous insufficiency? - correct answer Wound exudate
Lower extremity edema
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? - correct answer 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. When assessing the wound, the nurse will include which of the following? -
correct answer Length, width, and depth in centimeters
Condition of surrounding skin
Presence of undermining or tunneling
The nurse is conducting a skin assessment using the Braden Scale. How would the
nurse interpret a score of 12? - correct answer High risk
The home health nurse is completing an admission assessment on a patient admitted
for impaired skin integrity. Which question(s) would be appropriate for the nurse to ask
the patient? - correct answer "Have you used pads or special pants because you can't
control your urine?"
"Do you have any sores on your body?"
"Do some areas of your skin seem warmer or colder than others?"
"Have you noticed any swelling on your feet, ankles, or fingers?"
The nurse is reviewing Josephine Morrow's medical records before initiating her plan of
care. Which of the following factor(s) contributed to the development of her venous
stasis ulcer? - correct answer Poor circulation
ANSWERS
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure? - correct answer "I will gently direct a
stream of fluid into the wound, keeping the syringe tip at least 1 inch from the upper tip
of the wound."
The nurse is reviewing a patient's laboratory results to determine the current nutritional
status. Which of the following will negatively affect wound healing? - correct answer
Protein deficiency
Vitamin B excess
The nurse removes a dressing and assesses yellow, foul-smelling drainage. How would
the nurse document this finding? - correct answer Purulent
Which of the following sign(s) and symptom(s) would the nurse expect in a patient with
chronic venous insufficiency? - correct answer Wound exudate
Lower extremity edema
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? - correct answer 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. When assessing the wound, the nurse will include which of the following? -
correct answer Length, width, and depth in centimeters
Condition of surrounding skin
Presence of undermining or tunneling
The nurse is conducting a skin assessment using the Braden Scale. How would the
nurse interpret a score of 12? - correct answer High risk
The home health nurse is completing an admission assessment on a patient admitted
for impaired skin integrity. Which question(s) would be appropriate for the nurse to ask
the patient? - correct answer "Have you used pads or special pants because you can't
control your urine?"
"Do you have any sores on your body?"
"Do some areas of your skin seem warmer or colder than others?"
"Have you noticed any swelling on your feet, ankles, or fingers?"
The nurse is reviewing Josephine Morrow's medical records before initiating her plan of
care. Which of the following factor(s) contributed to the development of her venous
stasis ulcer? - correct answer Poor circulation
