NUR 3280 EXAM 2 REVIEW QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW
When repositioning an immobile 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 Ans✓✓✓ 4
After surgery the patient with a closed 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.
Ans✓✓✓ 1,4
,Place the steps when performing 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. Ans✓✓✓ 4,3,2,5,1
Which skin-care measures are used to 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 Ans✓✓✓ 1,4,5
Which of the following are measures 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.
Ans✓✓✓ 1,3,5
, Which of the following is an indication 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 Ans✓✓✓ 2,4
Medical adhesives, such as tape securing a wound dressing, cause
MARSI. Which of the following interventions reduce the risk for
MARSI?
1. Gently loosen the ends of the tape and gently pull the outer end
parallel with the skin surface toward the wound.
2. Change dressing only when saturated.
3. Apply adhesive remover.
4. Use Montgomery ties to secure the dressing.
5. Immobilize area of wound. Ans✓✓✓ 1,3,4
What is the removal of devitalized tissue from a wound called?
1. Debridement
2. Pressure distribution
3. Negative-pressure wound therapy
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW
When repositioning an immobile 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 Ans✓✓✓ 4
After surgery the patient with a closed 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.
Ans✓✓✓ 1,4
,Place the steps when performing 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. Ans✓✓✓ 4,3,2,5,1
Which skin-care measures are used to 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 Ans✓✓✓ 1,4,5
Which of the following are measures 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.
Ans✓✓✓ 1,3,5
, Which of the following is an indication 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 Ans✓✓✓ 2,4
Medical adhesives, such as tape securing a wound dressing, cause
MARSI. Which of the following interventions reduce the risk for
MARSI?
1. Gently loosen the ends of the tape and gently pull the outer end
parallel with the skin surface toward the wound.
2. Change dressing only when saturated.
3. Apply adhesive remover.
4. Use Montgomery ties to secure the dressing.
5. Immobilize area of wound. Ans✓✓✓ 1,3,4
What is the removal of devitalized tissue from a wound called?
1. Debridement
2. Pressure distribution
3. Negative-pressure wound therapy
