NUR 3280 Exam 2 Review – Questions With Proper
Solutions
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Terms in this set (47)
When repositioning an immobile 4
patient, the nurse notices redness
over the hip bone. What is indicated
when a reddened area blanches on
fingertip touch?
1. A local skin infection requiring
antibiotics
2. Sensitive skin that requires special
bed linen
3. A Stage 3 pressure injury needing
the appropriate dressing
4. Blanching hyperemia, indicating the
attempt by the body to overcome the
ischemic episode
,After surgery the patient with a closed 1,4
abdominal wound reports a sudden
"pop" after coughing. When the nurse
examines the surgical wound site, the
sutures are open, and small bowel
sections are observed at the bottom
of the now-opened wound. Which are
the priority nursing interventions?
(Select all that apply.)
1. Notify the health care provider.
2. Allow the area to be exposed to air
until all drainage has stopped.
3. Place several cold packs over the
area, protecting the skin around the
wound.
4. Cover the area with sterile, saline-
soaked towels immediately.
5. Cover the area with sterile gauze
and apply an abdominal binder.
Place the steps when performing 4,3,2,5,1
wound irrigation of a large open
wound in the correct sequence.
1. Use slow, continuous pressure to
irrigate wound.
2. Attach 19-gauge angiocatheter to
syringe.
3. Fill syringe with irrigation fluid.
4. Place biohazard bag near bed.
5. Position angiocatheter over wound.
, Which skin-care measures are used to 1,4,5
manage a patient who is experiencing
fecal and/or urinary incontinence?
(Select all that apply.)
1. Frequent position changes
2. Keeping the buttocks exposed to
air at all times
3. Using a large absorbent diaper,
changing when saturated
4. Using an incontinence cleaner
5. Applying a moisture barrier
ointment
Which of the following are measures 1,3,5
to reduce tissue damage from shear?
(Select all that apply.)
1. Use a transfer device (e.g., transfer
board).
2. Have head of bed elevated when
transferring patient.
3. Have head of bed flat when
repositioning patient.
4. Raise head of bed 60 degrees when
patient is positioned supine.
5. Raise head of bed 30 degrees when
patient is positioned supine.
Which of the following is an indication 2,4
for a binder to be placed around a
surgical patient with a new abdominal
wound? (Select all that apply.)
1. Collection of wound drainage
2. Provision of support to abdominal
tissues when coughing or walking
3. Reduction of abdominal swelling
4. Reduction of stress on the
abdominal incision
5. Stimulation of peristalsis (return of
bowel function) from direct pressure
Solutions
Save Groups
Terms in this set (47)
When repositioning an immobile 4
patient, the nurse notices redness
over the hip bone. What is indicated
when a reddened area blanches on
fingertip touch?
1. A local skin infection requiring
antibiotics
2. Sensitive skin that requires special
bed linen
3. A Stage 3 pressure injury needing
the appropriate dressing
4. Blanching hyperemia, indicating the
attempt by the body to overcome the
ischemic episode
,After surgery the patient with a closed 1,4
abdominal wound reports a sudden
"pop" after coughing. When the nurse
examines the surgical wound site, the
sutures are open, and small bowel
sections are observed at the bottom
of the now-opened wound. Which are
the priority nursing interventions?
(Select all that apply.)
1. Notify the health care provider.
2. Allow the area to be exposed to air
until all drainage has stopped.
3. Place several cold packs over the
area, protecting the skin around the
wound.
4. Cover the area with sterile, saline-
soaked towels immediately.
5. Cover the area with sterile gauze
and apply an abdominal binder.
Place the steps when performing 4,3,2,5,1
wound irrigation of a large open
wound in the correct sequence.
1. Use slow, continuous pressure to
irrigate wound.
2. Attach 19-gauge angiocatheter to
syringe.
3. Fill syringe with irrigation fluid.
4. Place biohazard bag near bed.
5. Position angiocatheter over wound.
, Which skin-care measures are used to 1,4,5
manage a patient who is experiencing
fecal and/or urinary incontinence?
(Select all that apply.)
1. Frequent position changes
2. Keeping the buttocks exposed to
air at all times
3. Using a large absorbent diaper,
changing when saturated
4. Using an incontinence cleaner
5. Applying a moisture barrier
ointment
Which of the following are measures 1,3,5
to reduce tissue damage from shear?
(Select all that apply.)
1. Use a transfer device (e.g., transfer
board).
2. Have head of bed elevated when
transferring patient.
3. Have head of bed flat when
repositioning patient.
4. Raise head of bed 60 degrees when
patient is positioned supine.
5. Raise head of bed 30 degrees when
patient is positioned supine.
Which of the following is an indication 2,4
for a binder to be placed around a
surgical patient with a new abdominal
wound? (Select all that apply.)
1. Collection of wound drainage
2. Provision of support to abdominal
tissues when coughing or walking
3. Reduction of abdominal swelling
4. Reduction of stress on the
abdominal incision
5. Stimulation of peristalsis (return of
bowel function) from direct pressure
