Final Exam) NSG 300 Final Exam: NSG 300 Final Exam Study Guide: Questions & Answers: Updated Guide Solution

A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems and thus requiring thorough bathing and skin care? a. A 44-year-old female patient who has had removal of a breast lesion and is having her menstrual period b. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line c. A 60-year-old female patient who experienced a stroke with rightsided paralysis and has an orthopedic brace applied to the left leg d. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool (Correct Answer: d When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? a. A local skin infection requiring antibiotics b. Sensitive skin that requires special bed linen c. A stage 3 pressure injury needing the appropriate dressingd. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode (Correct Answer: d 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, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply) a. Notify the health care provider. b. Allow the area to be exposed to air until all drainage has stopped. c. Place several cold packs over the area, protecting the skin around the wound. d. Cover the area with sterile, saline-soaked towels immediately. e. Cover the area with sterile gauze and apply an abdominal binder (Correct Answer: a & d What is the removal of devitalized tissue from a wound called? a. Debridement b. Pressure distribution c. Negative-pressure wound therapyd. Sanitization (Correct Answer: a Which of the following is not a measure used to reduce tissue damage from shear? a. Use a transfer device (e.g., transfer board) b. Have head of bed elevated when transferring patient c. Have head of bed flat when repositioning patient d. Raise head of bed 30 degrees when patient positioned supine (Correct Answer: b