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Unitek College - VN 100
A nurse is assisting with the care of a client following abdominal surgery.
The nurse removes the client's surgical dressing and notes a separation
of the wound edges. The nurse should identify that the client is
experiencing which of the following complications?
ANSWERS: Dehiscence
A nurse is assisting with the care of a client who has a portable wound
bulb suction device and notes that the drainage bulb is three-fourths
full. Which of the following actions should the nurse take?
ANSWERS: Empty and measure the drainage.
A nurse in a dermatology clinic is assisting with the development of a
skin anatomy poster to display for clients. Which of the following
information should the nurse plan to include on the poster?
ANSWERS: The dermis contains blood vessels that help nourish the
epidermis.
,A nurse is reinforcing teaching with a group of nurses about
documentation of pressure injuries. Which of the following statements
by one of the group members indicates an understanding of the
teaching
ANSWERS: "Pressure injury documentation includes the location,
stage, measurements, condition of the wound bed and any drainage
present."
A nurse is reinforcing teaching with an assistive personnel (AP) about
the skin of older adults. Which of the following statements by the AP
indicates an understanding of the teaching?
ANSWERS: "The skin of older adults is thinner and has less
subcutaneous padding over bony prominences."
,A nurse is assisting with the care of a group of clients. Which of the
following clients should the nurse identify as having the highest risk for
developing alterations in tissue integrity?
ANSWERS: A client who is incontinent and is taking a prescribed diuretic.
A nurse is reviewing strategies to reduce the risk of wound dehiscence
with a client following abdominal surgery. Which of the following
responses by the client indicates an understanding of the information?
ANSWERS: "I should report pain at my wound site
A nurse is monitoring a client following a cholecystectomy. Which of the
following findings should the nurse identify as a potential manifestation
of sepsis?
ANSWERS: Increased blood glucose
A nurse is assisting with the care of a client who has a deep foot wound
with minimal exudate and necrotized tissue. Which of the following
dressing types should the nurse anticipate a prescription for to cover
the wound?
ANSWERS: Hydrogel
, A nurse is reinforcing teaching with a newly licensed nurse about wound
healing by secondary intention. Which of the following statements by
the newly licensed nurse indicates an understanding of healing by
secondary intention?
ANSWERS: "This type of healing begins in the wound bed with the
generation of granulation tissue."
A nurse in an outpatient clinic is collecting data from a client who is 7
days postoperative. Which of the following findings should the nurse
expect to find at the client's incision site?
ANSWERS: A bright pink incision site that is absent of exudate
A nurse is observing an assistive personnel (AP) care for a client. Which
of the following actions by the AP places the client at risk for alterations
in skin integrity?
ANSWERS: The AP places the client in high-Fowler's position.