Medical-Surgical Nursing Study Guide
Questions with Answers Correct
The nurse sees in the patient's record that the patient has a Braden score of 20. Which
nursing action is the nurse most likely to perform in the care of this patient? -
ANSWERSContinue routine assessments
A thin, malnourished patient requires emergency abdominal surgery. After the surgery,
in order to promote wound healing, what does the nurse encourage? - ANSWERSHigh-
quality protein diet
The nurse is directing the home health unlicensed assistive personnel (UAP) in the care
of an older adult patient. The patient reports dry skin and wants help in applying an
emollient cream. What does the nurse direct the UAP to do? - ANSWERSAssist the
patient to soak for 10 minutes in a warm bath and then apply the cream to slightly damp
skin within 2 to 3 minutes after bathing
Which patients are at risk for pressure ulcers? - ANSWERS-A middle-aged quadriplegic
patient who is alert and conversant
-A bedridden patient who is in the late stage of Alzheimer's
-A very overweight patient who must be assisted to move in the bed
-A thin patient who sits for longer period and refuses meals
The nurse is caring for an obese patient who has been on bedrest for several days. The
nurse observes that the patient is beginning to develop redness on the sacral area.
What intervention is used to decrease the shearing force? - ANSWERSPlace the patient
in a side-lying position
The nurse is reviewing the results of a pressure mapping on patient at high risk for
pressure ulcers. The map shows a red area over the hips. How does the nurse interpret
this evidence? - ANSWERSGreater heat production associated with greater pressure
The nurse is assessing the nutritional status of a patient at risk for skin breakdown who
has been refusing to eat the hospital food. Which indicator is the most sensitive in
identifying inadequate nutrition for this patient? - ANSWERSPrealbumin level of 17.5
mg/dL
Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the
center of the are and see that the area blanches with pressure. The nurse interprets this
finding as changes related to which factor? - ANSWERSBlood vessel dilation
, The nurse is assessing a wound on a patient's abdomen. What is the correct technique?
- ANSWERSAssess the wound as a clock face with 12 o'clock towards the patient's
head and 6 o'cock towards the patient's feet
The nurse is assessing a patient's wound every day for signs of healing or infection.
Which finding is a positive indication that healing is progressing as expected? -
ANSWERSArea appears pale pink, progressing to a spongy texture with a beefy red
color
The nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small
opening in the skin with purulent drainage. Which technique does the nurse use to
check for tunneling? - ANSWERSUse a sterile cotton-tipped applicator to probe gently
for a tunnel
The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the
coccyx with skin intact. These findings suggest which stage of a pressure ulcer? -
ANSWERSSuspected deep tissue injury
When developing a plan of care for a patient who is at high risk for skin breakdown,
what does the nurse include in the plan of care? - ANSWERS-Applying a pressure
reduction overlay to the mattress
-Frequent repositioning of the patient
-Using positioning devices to keep heels pressure-free
Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral
decubitus ulcer? - ANSWERSWound will show granulation and decrease in size
A patient receiving negative pressure wound therapy (NPWT) should be monitored
closely for what potential complication? - ANSWERSBleeding
Which class of medication would exclude a patient from participating in NPWT? -
ANSWERSAnticoagulants
A patient on the unit has herpes zoster. Which staff members would be the best to
assign to the care of this patient? - ANSWERSStaff members who have had chicken
pox
A mother reports that her child has dry skin with itching that seems to worsen at night.
What nonpharmacologic interventions does the nurse teach to the mother? -
ANSWERS-Keep the child's fingernails short and filed to reduce skin damage
-Place mittens or splints on the child's hands at night if the scratching is causing skin
tears
-Read the child a relaxing and familiar story to reduce stress
Questions with Answers Correct
The nurse sees in the patient's record that the patient has a Braden score of 20. Which
nursing action is the nurse most likely to perform in the care of this patient? -
ANSWERSContinue routine assessments
A thin, malnourished patient requires emergency abdominal surgery. After the surgery,
in order to promote wound healing, what does the nurse encourage? - ANSWERSHigh-
quality protein diet
The nurse is directing the home health unlicensed assistive personnel (UAP) in the care
of an older adult patient. The patient reports dry skin and wants help in applying an
emollient cream. What does the nurse direct the UAP to do? - ANSWERSAssist the
patient to soak for 10 minutes in a warm bath and then apply the cream to slightly damp
skin within 2 to 3 minutes after bathing
Which patients are at risk for pressure ulcers? - ANSWERS-A middle-aged quadriplegic
patient who is alert and conversant
-A bedridden patient who is in the late stage of Alzheimer's
-A very overweight patient who must be assisted to move in the bed
-A thin patient who sits for longer period and refuses meals
The nurse is caring for an obese patient who has been on bedrest for several days. The
nurse observes that the patient is beginning to develop redness on the sacral area.
What intervention is used to decrease the shearing force? - ANSWERSPlace the patient
in a side-lying position
The nurse is reviewing the results of a pressure mapping on patient at high risk for
pressure ulcers. The map shows a red area over the hips. How does the nurse interpret
this evidence? - ANSWERSGreater heat production associated with greater pressure
The nurse is assessing the nutritional status of a patient at risk for skin breakdown who
has been refusing to eat the hospital food. Which indicator is the most sensitive in
identifying inadequate nutrition for this patient? - ANSWERSPrealbumin level of 17.5
mg/dL
Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the
center of the are and see that the area blanches with pressure. The nurse interprets this
finding as changes related to which factor? - ANSWERSBlood vessel dilation
, The nurse is assessing a wound on a patient's abdomen. What is the correct technique?
- ANSWERSAssess the wound as a clock face with 12 o'clock towards the patient's
head and 6 o'cock towards the patient's feet
The nurse is assessing a patient's wound every day for signs of healing or infection.
Which finding is a positive indication that healing is progressing as expected? -
ANSWERSArea appears pale pink, progressing to a spongy texture with a beefy red
color
The nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small
opening in the skin with purulent drainage. Which technique does the nurse use to
check for tunneling? - ANSWERSUse a sterile cotton-tipped applicator to probe gently
for a tunnel
The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the
coccyx with skin intact. These findings suggest which stage of a pressure ulcer? -
ANSWERSSuspected deep tissue injury
When developing a plan of care for a patient who is at high risk for skin breakdown,
what does the nurse include in the plan of care? - ANSWERS-Applying a pressure
reduction overlay to the mattress
-Frequent repositioning of the patient
-Using positioning devices to keep heels pressure-free
Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral
decubitus ulcer? - ANSWERSWound will show granulation and decrease in size
A patient receiving negative pressure wound therapy (NPWT) should be monitored
closely for what potential complication? - ANSWERSBleeding
Which class of medication would exclude a patient from participating in NPWT? -
ANSWERSAnticoagulants
A patient on the unit has herpes zoster. Which staff members would be the best to
assign to the care of this patient? - ANSWERSStaff members who have had chicken
pox
A mother reports that her child has dry skin with itching that seems to worsen at night.
What nonpharmacologic interventions does the nurse teach to the mother? -
ANSWERS-Keep the child's fingernails short and filed to reduce skin damage
-Place mittens or splints on the child's hands at night if the scratching is causing skin
tears
-Read the child a relaxing and familiar story to reduce stress
