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1. A client states that they have been having drainage from their wound.What is the PRIORITY nursing action?
A) Send a culture of the drainage as ordered
B) Assess the drainage
C) Notify the provider
D) Tell the client that drainage is normal
Answer
Assess the drainage
2. What is a cause of a shearing injury?
A) Sitting in one position for 3 hours
B) Sitting in a wheelchair from breakfast to lunch
C) Continuously rubbing the heels against the bed sheets
D) Sitting in High Fowlers and sliding down in bed
Answer
Sitting in High Fowlers and sliding down in bed
,3. The nurse assesses an area of redness on a client that does not blanch. What stage pressure ulcer is this?
A) Stage 1
B) Stage 2
C) Stage 3
D) Unstageable
Answer
Stage 1
4. How would the nurse document this drainage?
A) Serosanguineous
B) Serous
C) Purulent
D) Sanguineous
Answer
Sanguineous
5. What is NOT included in wound drainage assessment?
A) Color
B) Odor
C) Consistency
D) Temperature
Answer
Temperature
6. What is an age-related change for the elderly that may lead to skin integrity
impairment?
A) Thickening of the epidermis
B) Thinning of the epidermis
,C) Hydration of the dermis
D) Increased elasticity of the dermis
Answer
Thinning of the epidermis
7. What is NOT a sign of infection?
A) Temperature of 102°F
B) Oxygen Saturation 95%
C) Purulent drainage
D) Pain rating of 8/10
Answer
Oxygen Saturation 95%
8. What is the BEST action by the nurse when caring for an immunocompro- mised client to prevent infection?A)
Wash hands before entering the room
B) Assess vital signs every 4 hours
C) Teach the client to get immunizations
D) Wear PPE
Answer
Wash hands before entering the room
9. A client has MRSA.What transmission-based precautions should be initi- ated?
A) Airborne
B) Contact
C) Droplet
D) Protective
Answer
Contact
, 10. What is NOT appropriate client education for a client who is immunocom- promised?
A) Choose foods high in protein
B) Drink at least 2L of fluids per day
C) Eat many fresh fruits and vegetables
D) Increase your calorie intake
Answer
Eat many fresh fruits and vegetables
11. What link in the chain of infection is broken by handwashing?
A) Portal of Entry
B) Reservoir
C) Mode of Transmission
D) All of the above
Answer
All of the above
12. What is the mechanism of action for medications that treat rheumatoid arthritis?
A) Reduce inflammation
B) Kill the infection
C) Reduce pain
D) Increase the immune response
Answer
Reduce inflammation
13. What is the BEST way to utilize heat therapy for pain?
A) Use a warm, moist towel to the area of pain for 20 minutes