NUR 222 Exam on Skin & Wounds Integrity
A nurse is preparing a diet plan for a client admitted to a wound care unit. After the nurse explains the
diet plan to the client, the client asks the reason for an increase in intake of citrus fruits. What should
the nurse explain to the client: - Correct Answer-They have antioxidant properties, they help in collagen
synthesis, they provide fuel for cell energy
The nurse is attending to a client who is immobilized due to stroke. What measures should the nurse
take to prevent development of pressure ulcers in the client: - Correct Answer-Keep the client well
hydrated, reposition the client every 1-2 hours, place client in a 30-degree lateral position ad avoid
pulling on the patient when moving them
A nurse is caring for older adult clients in a nursing home. The nurse understands that older adults are
susceptible to development of pressure ulcers and other wounds. What makes older adults more
vulnerable to developing pressure ulcers: - Correct Answer-diminished inflammatory response, loss of
collagen and thinning of muscles
When obtaining a wound culture to determine the presence of a wound infection, from where should
the specimen be taken: - Correct Answer-Wound after it has first been cleaned with sterile saline
The edges of a client's appendectomy incision are approximated, and no drainage is noted. Which type
of healing should be applied: - Correct Answer-Primary Intention
While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is
on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse
violated: - Correct Answer-A sterile field becomes contaminated by prolonged exposure to air
A nurse is managing wound care for a client with a stage III pressure ulcer on the elbow. The nurse
cleans the area and removes all the dead, nonviable tissue from the wound. What term is used to
describe this process: - Correct Answer-Debridement
client who has an intravenous line has pain at the access site associated with erythema, edema, red
streaks, and a palpable vein. What grade does the nurse assign while entering the phlebitis grade in the
client's record: - Correct Answer-Grade 3
Which of the following is an indication for a binder to be placed around a surgical client with a new
abdominal wound: - Correct Answer-Reduction of stress on the abdominal incision
A client in a rehabilitation clinic is recovering from the loss of a limb in a motor vehicle accident. In
addition to wound care and physical therapy, what factors should the nurse assess to help the client
recover: - Correct Answer-Family support, behaviors indicating a grief response, the client's point of
view of the loss
A nurse is preparing a diet plan for a client admitted to a wound care unit. After the nurse explains the
diet plan to the client, the client asks the reason for an increase in intake of citrus fruits. What should
the nurse explain to the client: - Correct Answer-They have antioxidant properties, they help in collagen
synthesis, they provide fuel for cell energy
The nurse is attending to a client who is immobilized due to stroke. What measures should the nurse
take to prevent development of pressure ulcers in the client: - Correct Answer-Keep the client well
hydrated, reposition the client every 1-2 hours, place client in a 30-degree lateral position ad avoid
pulling on the patient when moving them
A nurse is caring for older adult clients in a nursing home. The nurse understands that older adults are
susceptible to development of pressure ulcers and other wounds. What makes older adults more
vulnerable to developing pressure ulcers: - Correct Answer-diminished inflammatory response, loss of
collagen and thinning of muscles
When obtaining a wound culture to determine the presence of a wound infection, from where should
the specimen be taken: - Correct Answer-Wound after it has first been cleaned with sterile saline
The edges of a client's appendectomy incision are approximated, and no drainage is noted. Which type
of healing should be applied: - Correct Answer-Primary Intention
While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is
on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse
violated: - Correct Answer-A sterile field becomes contaminated by prolonged exposure to air
A nurse is managing wound care for a client with a stage III pressure ulcer on the elbow. The nurse
cleans the area and removes all the dead, nonviable tissue from the wound. What term is used to
describe this process: - Correct Answer-Debridement
client who has an intravenous line has pain at the access site associated with erythema, edema, red
streaks, and a palpable vein. What grade does the nurse assign while entering the phlebitis grade in the
client's record: - Correct Answer-Grade 3
Which of the following is an indication for a binder to be placed around a surgical client with a new
abdominal wound: - Correct Answer-Reduction of stress on the abdominal incision
A client in a rehabilitation clinic is recovering from the loss of a limb in a motor vehicle accident. In
addition to wound care and physical therapy, what factors should the nurse assess to help the client
recover: - Correct Answer-Family support, behaviors indicating a grief response, the client's point of
view of the loss
