BSN 205 Skills ISB Quizzes - Questions, Answers and Rationales

BSN 205 Skills ISB Quizzes - Questions, Answers and Rationales When cleaning a wound during a dressing change, in what direction should the cleansing of the wound take place? Outward from the wound in a circular motion. Towards the wound in a circular motion. Clean around the wound edge only. Away from the wound in a linear pattern. What is a reason to use a wet to dry dressing? To keep the wound moist. To decrease healing time. To debride a wound. To keep the wound from becoming infected. Wet-to-dry gauze dressings are mainly intended for use in wound mechanical debridement and in this purpose they are conceptually distinct from wet-to-dry or wet-to-moist gauze as a primary dressing in non-infected wounds The wound vac dressing must be removed and replaced with a sterile dressing if the wound vac is turned off for more than how many hours? 4 1 2 3 If therapy is off for more than 2 hours, remove the old dressing and irrigate the wound. Apply an alternative dressing at the direction of the treating clinician. What is the most important dietary intake to promote pressure ulcer healing? Vitamin E Proteins Calcium Carbohydrates Increased protein levels have been linked to improved healing rates. The report of a culture sent on a client's leg wound states "contaminated specimen." Which nursing action most likely caused the outcome of this wound culture? Sample was collected from the wound base Swab included pooled exudate. Inner ampule at the bottom of the tube was crushed. Specimen tube cap was placed upside down on a firm dry surface. Pooled exudate is not cultured. These secretions contain a mixture on contaminants that are not the same as those causing the infection. The sample sound be collected from the base of the wound. A client wet-to-moist dressing for a leg wound. What technique should the nurse use when changing this dressing? Tape the entire surface of the dressing. Apply fluffed gauze to the wound bed and saturate with sterile normal saline. Press moistened fluffed gauze lightly into wound depressions. Apply a clean dry 4 x 8 pad over the wet fluffed gauze Moistened fluffed gauze should be pressed lightly into the depressions in the wound. A client has a hydrocolloid dressing over the right greater trochanter area. Which observation indicates to the nurse that the dressing needs to be changed? Silk tape applied to window frame the dressing Dressing located one third above the wound and two thirds below the wound Presence of a white blister under the dressing Dressing changed 1 day ago The dressing should be changed if a white blister appears under the dressing. The nurse is caring for a client with a wound V.A.C. with black foam on the left heel. For what should the nurse assess when changing the client's dressing? Amount of wound contraction Boundary of shallow chronic ulcer Healing of superficial wound Improvement in tunneling Black foam has larger pores and is used to stimulate granulation tissue and wound contraction, so this is what the nurse would assess. A newly admitted client has a 3 cm x 5 cm reddened area over the coccyx. What should the nurse do first for this client? Raise the head of the bed 45 degrees Massage the area. Position the client off this area Clean the area with hot water To prevent further skin damage, the client should be positioned off the reddened area. The nurse prepares to change a client's sterile wound dressing. Which approach should the nurse use if the old dressing is sticking to the site? Moisten the dressing with normal saline Gently pull on the old dressing away from the wound. Gently pull on the old dressing toward the wound. Pick the old dressing off with a pair of sterile forceps. If the older dressing adheres to the suture line, wet it with sterile normal saline. The nurse is measuring blood pressures as part of a community health fair. Which blood pressure reading would cause the nurse to refer the patient for follow-up regarding hypertension? 108/70 138/88 116/78 128/80 A reading of 138/88 mm Hg has both systolic and diastolic pressures that are considered high and classified as hypertension stage 1. This patient should be referred for additional readings. The other readings are within normal limits, although all patients should be considered for health promotion teaching regarding cardiac health, especially the patient with a blood pressure of 128/80 mm Hg, which is in the elevated category. The nurse is admitting a stable patient for a minor outpatient procedure. What site would the nurse most commonly use to assess pulse rate? Radial site Apical site Brachial site Carotid site The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature of 99.2° F (37.3° C) oral, pulse of 88 bpm and regular, respirations of 18 BPM and regular, blood pressure of 178/112 mm Hg, and oxygen saturation of 96%. Which vital sign should the nurse be most concerned about? Temperature Pulse Respirations Blood pressure The blood pressure is well above the expected normal of less than 120/80 mm Hg and requires immediate follow-up evaluation by the nurse. From the nurse's understanding, which statements regarding temperature and heat production in the body are accurate? (Select all that apply.)