CLINICAL SKILLS #2 EXAM
QUESTIONS WITH CORRECT
ANSWERS
A patient has a pressure ulcer that contains necrotic tissue. Nursing care for this
patient would be correct if which measure was taken to remove dead tissue from the
wound bed?
1. Use of hydrogen peroxide to loosen the necrotic tissue
2. Use of a wick to remove moisture from the decayed tissue
3. Vigorous sterile scrubbing of the wound bed
4. A gentle topical method that removes dead tissue - Answer-4
Obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which
strategy should the nurse who is caring for this patient include in his care?
1. Using a lift sheet and maintaining the HOB no higher than 30°
2. Increasing the patients vitamin and mineral intake and keeping the patient in high
fowler's position
3. Turning the patient every 4 hours and increasing caloric intake to maintain normal
tissue status
4. Decreasing dietary protein intake and increasing his fluid intake to 2000ml per day
- Answer-1
A patent has nonreactive hyperemia. What would be expected to be included in the
patient's immediate care
1. Immediate transfer to a special pressure mattress
2. An ordered increase in the amount of protein consumed
3. Padding around the area susceptible to breakdown
4. Use of the Braden scale - Answer-4
The nurse is checking for discolouration on a patient who has darkly pigmented skin.
The nurse would be administering appropriate care if which technique was used?
1. The nurse checks for discolouration an hour after the patient is turned
2. The nurse uses fluorescent light for the skin assessment
3. The nurse places the patient in a 30-degree lateral position for the assessment
4. The nurse uses a gloved hand to feel for warmth or change in tissue texture -
Answer-4
The patient asks the nurse why he has a drain in his abdomen after surgery. Which
response by the nurse is most accurate?
1. The drain allows the antibiotics that were instilled in the wound to drain.
2. You have a drain to prevent any swelling of surgical area
3. The drain removed abdominal fluids to reduce stress on the suture like
4. The drain removes fluid form the surgical area to promote healing - Answer-4
A patient with a large abdominal incision is being discharged. Which statement by
the patient indicates the teaching by the nurse has been effective?
1. "I need to avoid lifting anything heavy for a least several weeks"
,2. "I don't have to worry about further drainage, now that the staples are ouT"
3. Now that my incision is without staples, it is healing strong"
4. " as long as I don't have any pain, I can do just about anything I want" - Answer-1
While removing the patients staples, the nurse notices that the incision starts to open
larger than the width of 2 staples. Which action should the nurse initially take?
1. Notify the health care provider
2. Place several sterile-strip to close the open area
3. Remove one more staple to see weather the open are enlarges
4.Palpate the edges of the wound - Answer-2
Patient needs to have his abdominal wound irrigated. Which part of the procedure
may the nurse delegate to the NAP?
1. Packing the wound with sterile gauze pads
2. Preforming wound irrigation
3. Taping the dressing one the wound is covered
4. Documenting the description of the would - Answer-3 (tape)
An older diabetic patient with a lot of abdominal fat underwent abdominal surgery
four days ago involving an 8 inch vertical incision. The nurse will be most concerned
if which observation of the incision was made?
1 serosanguineous drainage has increased since 2 days ago
2. The incision light is slightly pink and elevated where the staples are located
3. The incision like has a light crust on it
4. The patients pain level has changed from a 5 yesterday to a 2 today - Answer-1
Patient developed the 2 cm stage one pressure ulcer over the sacrum. A transparent
dressing has been in place for two days. The nurse on the evening shift notes that
the skin under the dressing appears broken. The patient complains of tenderness
when the nurse palpates the skin. The nurse also notices drainage under the
transparent film. Which action should the nurse take in the situation?
1. Remove the dressing and obtain an order for a wound culture
2. Consider irrigating the wound
3. Increase frequency of changing the transparent wound
4. Record observations and keep dressing in place - Answer-1
During the removal of a nontunneled CVAD, having the patient preform the valsalva
maneuver leads to:
1. Increase removal time
2. Increase ease of removal
3. Prevention of air entry into the vein
4. Decreased anxiety - Answer-3
Blood cultures are ordered for which type of patient?
1. One for whom the central venous access has been discontinued
2. One with IV site infiltration
3. One suspected of having CLABSI
4. One in need of antibiotics - Answer-3
, After blood specimens are obtained for a CVAD, the minimum volume of solution
recorded for flushing is:
1. 10ml
2. 3ml
3. 5ml
4. 20ml - Answer-1
Which of the following is considered a primary cause of transfusion reactions?
1. Use of leukocyte reduction filter
2. Use of Y tubing
3. Use of mislabeled unit
4. Use on 0.9% NSS - Answer-3
Blood obtained from the blood bank must be used within what time limit?
1. 30mins
2. 20mins
3. 10mins
4. 60mins - Answer-1
One unit of PRBC (packed red blood cells) can hang no longer than:
1. 4hrs
2. 3hrs
3. 2hrs
4. 1hrs - Answer-1
To decrease the incidence of Rh antigen transfer between mother and fetus, which
medication is administered?
1. Methylprednisone
2. Methotrexate
3. Benadryl
4. RhoGam - Answer-4
Onset of transfusion-related acute lung injury can occur within 6 hours of transfusion.
True or False - Answer-True
Which of the following manifestations would be an early sign of silent aspiration?
1. Resp rate 30
2. Temp 38.2°C
3. BP 90/60
4. Heart rate 129 - Answer-1
Which of the following places is the patient at risk for aspiration pneumonia? Select
all that apply
1. Fatigue
2. Distractions
3. Pocketing food
4. Poor oral hygiene
5. Cough - Answer-1,2,3,4
QUESTIONS WITH CORRECT
ANSWERS
A patient has a pressure ulcer that contains necrotic tissue. Nursing care for this
patient would be correct if which measure was taken to remove dead tissue from the
wound bed?
1. Use of hydrogen peroxide to loosen the necrotic tissue
2. Use of a wick to remove moisture from the decayed tissue
3. Vigorous sterile scrubbing of the wound bed
4. A gentle topical method that removes dead tissue - Answer-4
Obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which
strategy should the nurse who is caring for this patient include in his care?
1. Using a lift sheet and maintaining the HOB no higher than 30°
2. Increasing the patients vitamin and mineral intake and keeping the patient in high
fowler's position
3. Turning the patient every 4 hours and increasing caloric intake to maintain normal
tissue status
4. Decreasing dietary protein intake and increasing his fluid intake to 2000ml per day
- Answer-1
A patent has nonreactive hyperemia. What would be expected to be included in the
patient's immediate care
1. Immediate transfer to a special pressure mattress
2. An ordered increase in the amount of protein consumed
3. Padding around the area susceptible to breakdown
4. Use of the Braden scale - Answer-4
The nurse is checking for discolouration on a patient who has darkly pigmented skin.
The nurse would be administering appropriate care if which technique was used?
1. The nurse checks for discolouration an hour after the patient is turned
2. The nurse uses fluorescent light for the skin assessment
3. The nurse places the patient in a 30-degree lateral position for the assessment
4. The nurse uses a gloved hand to feel for warmth or change in tissue texture -
Answer-4
The patient asks the nurse why he has a drain in his abdomen after surgery. Which
response by the nurse is most accurate?
1. The drain allows the antibiotics that were instilled in the wound to drain.
2. You have a drain to prevent any swelling of surgical area
3. The drain removed abdominal fluids to reduce stress on the suture like
4. The drain removes fluid form the surgical area to promote healing - Answer-4
A patient with a large abdominal incision is being discharged. Which statement by
the patient indicates the teaching by the nurse has been effective?
1. "I need to avoid lifting anything heavy for a least several weeks"
,2. "I don't have to worry about further drainage, now that the staples are ouT"
3. Now that my incision is without staples, it is healing strong"
4. " as long as I don't have any pain, I can do just about anything I want" - Answer-1
While removing the patients staples, the nurse notices that the incision starts to open
larger than the width of 2 staples. Which action should the nurse initially take?
1. Notify the health care provider
2. Place several sterile-strip to close the open area
3. Remove one more staple to see weather the open are enlarges
4.Palpate the edges of the wound - Answer-2
Patient needs to have his abdominal wound irrigated. Which part of the procedure
may the nurse delegate to the NAP?
1. Packing the wound with sterile gauze pads
2. Preforming wound irrigation
3. Taping the dressing one the wound is covered
4. Documenting the description of the would - Answer-3 (tape)
An older diabetic patient with a lot of abdominal fat underwent abdominal surgery
four days ago involving an 8 inch vertical incision. The nurse will be most concerned
if which observation of the incision was made?
1 serosanguineous drainage has increased since 2 days ago
2. The incision light is slightly pink and elevated where the staples are located
3. The incision like has a light crust on it
4. The patients pain level has changed from a 5 yesterday to a 2 today - Answer-1
Patient developed the 2 cm stage one pressure ulcer over the sacrum. A transparent
dressing has been in place for two days. The nurse on the evening shift notes that
the skin under the dressing appears broken. The patient complains of tenderness
when the nurse palpates the skin. The nurse also notices drainage under the
transparent film. Which action should the nurse take in the situation?
1. Remove the dressing and obtain an order for a wound culture
2. Consider irrigating the wound
3. Increase frequency of changing the transparent wound
4. Record observations and keep dressing in place - Answer-1
During the removal of a nontunneled CVAD, having the patient preform the valsalva
maneuver leads to:
1. Increase removal time
2. Increase ease of removal
3. Prevention of air entry into the vein
4. Decreased anxiety - Answer-3
Blood cultures are ordered for which type of patient?
1. One for whom the central venous access has been discontinued
2. One with IV site infiltration
3. One suspected of having CLABSI
4. One in need of antibiotics - Answer-3
, After blood specimens are obtained for a CVAD, the minimum volume of solution
recorded for flushing is:
1. 10ml
2. 3ml
3. 5ml
4. 20ml - Answer-1
Which of the following is considered a primary cause of transfusion reactions?
1. Use of leukocyte reduction filter
2. Use of Y tubing
3. Use of mislabeled unit
4. Use on 0.9% NSS - Answer-3
Blood obtained from the blood bank must be used within what time limit?
1. 30mins
2. 20mins
3. 10mins
4. 60mins - Answer-1
One unit of PRBC (packed red blood cells) can hang no longer than:
1. 4hrs
2. 3hrs
3. 2hrs
4. 1hrs - Answer-1
To decrease the incidence of Rh antigen transfer between mother and fetus, which
medication is administered?
1. Methylprednisone
2. Methotrexate
3. Benadryl
4. RhoGam - Answer-4
Onset of transfusion-related acute lung injury can occur within 6 hours of transfusion.
True or False - Answer-True
Which of the following manifestations would be an early sign of silent aspiration?
1. Resp rate 30
2. Temp 38.2°C
3. BP 90/60
4. Heart rate 129 - Answer-1
Which of the following places is the patient at risk for aspiration pneumonia? Select
all that apply
1. Fatigue
2. Distractions
3. Pocketing food
4. Poor oral hygiene
5. Cough - Answer-1,2,3,4
