MED SURG EXAM 3 QUESTIONS AND
ANSWERS
The0nurse0assesses0a0patient's0surgical0wound0on0the0first0postoperative0day0and0not
es0redness0and0warmth0around0the0incision.0Which0action0by0the0nurse0is0most0appro
priate?0-0ans✔Document0the0assessment.
A0patient0with0an0open0leg0wound0has0a0white0blood0cell0(WBC)0count0of013,500/
L0and0a0band0count0of011%.0Which0action0should0the0nurse0take0first?0-
0ans✔Obtain0wound0cultures.
A0patient0with0a0systemic0bacterial0infection0feels0cold0and0has0a0shaking0chill.0Which0
assessment0finding0will0the0nurse0expect0next?0-0ans✔Rising0body0temperature.
A0young0adult0patient0who0is0receiving0antibiotics0for0an0infected0leg0wound0has0a0te
mperature0of0101.80F0(38.70C).0Which0action0by0the0nurse0is0most0appropriate?0-
0ans✔Check0the0patient's0oral0temperature0again0in040hours.
A0patient's0430cm0leg0wound0has0a00.40cm0black0area0in0the0center0of0the0wound0surr
ounded0by0yellow-
green0semiliquid0material.0Which0dressing0should0the0nurse0apply0to0the0wound?0-
0ans✔Hydrocolloid0dressing0(DuoDerm)
A0patient0has0an0open0surgical0wound0on0the0abdomen0that0contains0deep0pink0granu
lation0tissue.0How0would0the0nurse0document0this0wound?0-0ans✔Red0wound
A0patient0with0rheumatoid0arthritis0has0been0taking0corticosteroids0for0110months.0Whi
ch0nursing0action0is0most0likely0to0detect0early0signs0of0infection0in0this0patient?0-
0ans✔Ask0about0fatigue0or0feelings0of0malaise.
The0nurse0should0plan0to0use0a0wet-to-dry0dressing0for0which0patient?0-
0ans✔A0patient0who0has0a0wound0with0purulent0drainage0and0dry0brown0areas
A0patient0from0a0long-
term0care0facility0is0admitted0to0the0hospital0with0a0sacral0pressure0ulcer.0The0base0of0
, the0wound0is0yellow0and0involves0subcutaneous0tissue.0How0should0the0nurse0classify
0this0pressure0ulcer?0-0ans✔Stage0III
A0young0male0patient0who0is0paraplegic0has0a0stage0II0sacral0pressure0ulcer0and0is0b
eing0cared0for0at0home0by0his0mother.0To0prevent0further0tissue0damage,0what0instruc
tions0are0most0important0for0the0nurse0to0teach0the0mother?0-
0ans✔Change0the0patient's0position0at0least0every020hours.
The0nurse0will0perform0which0action0when0doing0a0wet-to-
dry0dressing0change0on0a0patient's0stage0III0sacral0pressure0ulcer?0-
0ans✔Administer0the0ordered0PRN0hydrocodone0(Lortab)0300minutes0before0the0dress
ing0change.
A0new0nurse0performs0a0dressing0change0on0a0stage0II0left0heel0pressure0ulcer.0Whic
h0action0by0the0new0nurse0indicates0a0need0for0further0teaching0about0pressure0ulcer0
care?0-0ans✔The0new0nurse0cleans0the0ulcer0with0a0sterile0dressing0soaked0in0half-
strength0peroxide.
A0patient0arrives0in0the0emergency0department0with0a0swollen0ankle0after0an0injury0inc
urred0while0playing0soccer.0Which0action0by0the0nurse0is0most0appropriate?0-
0ans✔Elevate0the0ankle0above0heart0level.
When0admitting0a0patient0with0stage0III0pressure0ulcers0on0both0heels,0which0informati
on0obtained0by0the0nurse0will0have0the0most0impact0on0wound0healing?0-
0ans✔The0patient0takes0insulin0daily.
After0receiving0a0change-of-shift0report,0which0patient0should0the0nurse0assess0first?0-
0ans✔The0patient0who0has0been0receiving0chemotherapy0and0has0a0temperature0of01
020F
The0nurse0should0delegate0care0of0which0patient0to0a0licensed0practical/
vocational0nurse0(LPN/LVN)?0-
0ans✔The0patient0who0requires0a0hydrocolloid0dressing0change0for0stage0III0sacral0ulc
er
The0nurse0is0caring0for0a0patient0with0diabetes0who0has0abdominal0surgery030days0ag
o.0Which0finding0is0most0important0for0the0nurse0to0report0to0the0health0care0provider?
0-0ans✔Separation0of0the0proximal0wound0edges0by010cm
A0patient0who0has0diabetes0is0admitted0for0an0exploratory0laparotomy0for0abdominal0p
ain.0When0planning0interventions0to0promote0wound0healing,0what0is0the0nurse's0highe
st0priority?0-0ans✔Maintaining0the0patient's0blood0glucose0within0a0normal0range
Which0finding0is0most0important0for0the0nurse0to0communicate0to0the0health0care0provi
der0when0caring0for0a0patient0who0is0receiving0negative0pressure0wound0therapy?0-
0ans✔Low0serum0albumin0level
ANSWERS
The0nurse0assesses0a0patient's0surgical0wound0on0the0first0postoperative0day0and0not
es0redness0and0warmth0around0the0incision.0Which0action0by0the0nurse0is0most0appro
priate?0-0ans✔Document0the0assessment.
A0patient0with0an0open0leg0wound0has0a0white0blood0cell0(WBC)0count0of013,500/
L0and0a0band0count0of011%.0Which0action0should0the0nurse0take0first?0-
0ans✔Obtain0wound0cultures.
A0patient0with0a0systemic0bacterial0infection0feels0cold0and0has0a0shaking0chill.0Which0
assessment0finding0will0the0nurse0expect0next?0-0ans✔Rising0body0temperature.
A0young0adult0patient0who0is0receiving0antibiotics0for0an0infected0leg0wound0has0a0te
mperature0of0101.80F0(38.70C).0Which0action0by0the0nurse0is0most0appropriate?0-
0ans✔Check0the0patient's0oral0temperature0again0in040hours.
A0patient's0430cm0leg0wound0has0a00.40cm0black0area0in0the0center0of0the0wound0surr
ounded0by0yellow-
green0semiliquid0material.0Which0dressing0should0the0nurse0apply0to0the0wound?0-
0ans✔Hydrocolloid0dressing0(DuoDerm)
A0patient0has0an0open0surgical0wound0on0the0abdomen0that0contains0deep0pink0granu
lation0tissue.0How0would0the0nurse0document0this0wound?0-0ans✔Red0wound
A0patient0with0rheumatoid0arthritis0has0been0taking0corticosteroids0for0110months.0Whi
ch0nursing0action0is0most0likely0to0detect0early0signs0of0infection0in0this0patient?0-
0ans✔Ask0about0fatigue0or0feelings0of0malaise.
The0nurse0should0plan0to0use0a0wet-to-dry0dressing0for0which0patient?0-
0ans✔A0patient0who0has0a0wound0with0purulent0drainage0and0dry0brown0areas
A0patient0from0a0long-
term0care0facility0is0admitted0to0the0hospital0with0a0sacral0pressure0ulcer.0The0base0of0
, the0wound0is0yellow0and0involves0subcutaneous0tissue.0How0should0the0nurse0classify
0this0pressure0ulcer?0-0ans✔Stage0III
A0young0male0patient0who0is0paraplegic0has0a0stage0II0sacral0pressure0ulcer0and0is0b
eing0cared0for0at0home0by0his0mother.0To0prevent0further0tissue0damage,0what0instruc
tions0are0most0important0for0the0nurse0to0teach0the0mother?0-
0ans✔Change0the0patient's0position0at0least0every020hours.
The0nurse0will0perform0which0action0when0doing0a0wet-to-
dry0dressing0change0on0a0patient's0stage0III0sacral0pressure0ulcer?0-
0ans✔Administer0the0ordered0PRN0hydrocodone0(Lortab)0300minutes0before0the0dress
ing0change.
A0new0nurse0performs0a0dressing0change0on0a0stage0II0left0heel0pressure0ulcer.0Whic
h0action0by0the0new0nurse0indicates0a0need0for0further0teaching0about0pressure0ulcer0
care?0-0ans✔The0new0nurse0cleans0the0ulcer0with0a0sterile0dressing0soaked0in0half-
strength0peroxide.
A0patient0arrives0in0the0emergency0department0with0a0swollen0ankle0after0an0injury0inc
urred0while0playing0soccer.0Which0action0by0the0nurse0is0most0appropriate?0-
0ans✔Elevate0the0ankle0above0heart0level.
When0admitting0a0patient0with0stage0III0pressure0ulcers0on0both0heels,0which0informati
on0obtained0by0the0nurse0will0have0the0most0impact0on0wound0healing?0-
0ans✔The0patient0takes0insulin0daily.
After0receiving0a0change-of-shift0report,0which0patient0should0the0nurse0assess0first?0-
0ans✔The0patient0who0has0been0receiving0chemotherapy0and0has0a0temperature0of01
020F
The0nurse0should0delegate0care0of0which0patient0to0a0licensed0practical/
vocational0nurse0(LPN/LVN)?0-
0ans✔The0patient0who0requires0a0hydrocolloid0dressing0change0for0stage0III0sacral0ulc
er
The0nurse0is0caring0for0a0patient0with0diabetes0who0has0abdominal0surgery030days0ag
o.0Which0finding0is0most0important0for0the0nurse0to0report0to0the0health0care0provider?
0-0ans✔Separation0of0the0proximal0wound0edges0by010cm
A0patient0who0has0diabetes0is0admitted0for0an0exploratory0laparotomy0for0abdominal0p
ain.0When0planning0interventions0to0promote0wound0healing,0what0is0the0nurse's0highe
st0priority?0-0ans✔Maintaining0the0patient's0blood0glucose0within0a0normal0range
Which0finding0is0most0important0for0the0nurse0to0communicate0to0the0health0care0provi
der0when0caring0for0a0patient0who0is0receiving0negative0pressure0wound0therapy?0-
0ans✔Low0serum0albumin0level
