NUR 108 NCLEX EXAM QUESTIONS WITH
CORRECT ANSWERS
Which of the following items are used to perform wound care
| | | | | | | | | | |
irrigation? Select all that apply.
| | | | |
| A. Clean gloves
| |
B. Sterile gloves
| | |
C. Refrigerated irrigating solution
| | |
D. 60-mL syringe - CORRECT ANSWER✔✔-A, B, D
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Which of the following are primary risk factors for pressure ulcers?
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Select all that apply.
| | | |
A. Low-protein diet
| | |
B. Insomnia
| |
C. Lengthy surgical procedures
| | | |
D. Fever
| |
E. Sleeping on a waterbed - CORRECT ANSWER✔✔-A, C, D
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An appropriate nursing diagnosis for a client with large areas of skin
| | | | | | | | | | | |
excoriation resulting from scratching an allergic rash is:
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A. Risk for Impaired Skin Integrity
| | | | |
,B. Impaired Skin Integrity
| | | |
C. Impaired Tissue Integrity
| | | |
D. Risk for Infection - CORRECT ANSWER✔✔-B
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Thirty minutes after application is initiated, the client requests that the
| | | | | | | | | | |
nurse leave the heating pad in place. The nurse explains to the client
| | | | | | | | | | | | |
that: |
A. Heat application for longer than thirty minutes can cause the
| | | | | | | | | | |
opposite effect (constriction) of the one desired (dilation)
| | | | | | | |
B. It will be acceptable to leave the pad in place for another thirty
| | | | | | | | | | | | | |
minutes - CORRECT ANSWER✔✔-A | | |
Which of the following actions would place a client at the greatest risk
| | | | | | | | | | | | |
for a shearing force injury to the skin?
| | | | | | | |
A. Walking without shoes
| | | |
B. Sitting in Fowler's position
| | | | |
C. Lying supine in bed
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D. Using a heating pad - CORRECT ANSWER✔✔-B
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A client's wound is draining thick yellow material. The nurse correctly
| | | | | | | | | | |
describes the drainage as: | | | |
A. Sanguineous
| |
B. Serous-sanguineous
| |
, C. Serous| |
D. Purulent - CORRECT ANSWER✔✔-D
| | | |
A nurse is caring for patients with a variety of wounds. Which would will
| | | | | | | | | | | | |
most likely heal by primary intention?
| | | | | | |
A. Cut in the skin from a kitchen knife
| | | | | | | | |
B. Excoriated perineal area
| | |
| C. Abrasion of the skin
| | | | |
D. Pressure ulcer - CORRECT ANSWER✔✔-A
| | | | |
A practitioner orders a wound to be packed with a wet-to-damp gauze
| | | | | | | | | | | |
dressing. What should the nurse explain to the client is the primary
| | | | | | | | | | | |
reason for this type of dressing? - CORRECT ANSWER✔✔-Packing the
| | | | | | | | | |
wound with wet-to-damp dressings allows epidermal cells to migrate
| | | | | | | | |
more rapidly across the bed of the wound surface than dry dressings,
| | | | | | | | | | | |
thereby facilitating healing. Wet-to-damp dressings will also wick
| | | | | | | |
exudate up and away from the base of the wound and help to increase
| | | | | | | | | | | | | |
resistance to a wound infection. | | | |
You are caring for an assigned client and notice a superficial ulcer on the
| | | | | | | | | | | | |
client's buttock that appears as a shallow crater involving the epidermis
| | | | | | | | | | | |
and the dermis. Which of the following stages would you say best
| | | | | | | | | | | |
describes this break in skin integrity? | | | | | |
A. Stage I
| | |
CORRECT ANSWERS
Which of the following items are used to perform wound care
| | | | | | | | | | |
irrigation? Select all that apply.
| | | | |
| A. Clean gloves
| |
B. Sterile gloves
| | |
C. Refrigerated irrigating solution
| | |
D. 60-mL syringe - CORRECT ANSWER✔✔-A, B, D
| | | | | | |
Which of the following are primary risk factors for pressure ulcers?
| | | | | | | | | | |
Select all that apply.
| | | |
A. Low-protein diet
| | |
B. Insomnia
| |
C. Lengthy surgical procedures
| | | |
D. Fever
| |
E. Sleeping on a waterbed - CORRECT ANSWER✔✔-A, C, D
| | | | | | | | |
An appropriate nursing diagnosis for a client with large areas of skin
| | | | | | | | | | | |
excoriation resulting from scratching an allergic rash is:
| | | | | | | |
A. Risk for Impaired Skin Integrity
| | | | |
,B. Impaired Skin Integrity
| | | |
C. Impaired Tissue Integrity
| | | |
D. Risk for Infection - CORRECT ANSWER✔✔-B
| | | | | |
Thirty minutes after application is initiated, the client requests that the
| | | | | | | | | | |
nurse leave the heating pad in place. The nurse explains to the client
| | | | | | | | | | | | |
that: |
A. Heat application for longer than thirty minutes can cause the
| | | | | | | | | | |
opposite effect (constriction) of the one desired (dilation)
| | | | | | | |
B. It will be acceptable to leave the pad in place for another thirty
| | | | | | | | | | | | | |
minutes - CORRECT ANSWER✔✔-A | | |
Which of the following actions would place a client at the greatest risk
| | | | | | | | | | | | |
for a shearing force injury to the skin?
| | | | | | | |
A. Walking without shoes
| | | |
B. Sitting in Fowler's position
| | | | |
C. Lying supine in bed
| | | | |
D. Using a heating pad - CORRECT ANSWER✔✔-B
| | | | | | |
A client's wound is draining thick yellow material. The nurse correctly
| | | | | | | | | | |
describes the drainage as: | | | |
A. Sanguineous
| |
B. Serous-sanguineous
| |
, C. Serous| |
D. Purulent - CORRECT ANSWER✔✔-D
| | | |
A nurse is caring for patients with a variety of wounds. Which would will
| | | | | | | | | | | | |
most likely heal by primary intention?
| | | | | | |
A. Cut in the skin from a kitchen knife
| | | | | | | | |
B. Excoriated perineal area
| | |
| C. Abrasion of the skin
| | | | |
D. Pressure ulcer - CORRECT ANSWER✔✔-A
| | | | |
A practitioner orders a wound to be packed with a wet-to-damp gauze
| | | | | | | | | | | |
dressing. What should the nurse explain to the client is the primary
| | | | | | | | | | | |
reason for this type of dressing? - CORRECT ANSWER✔✔-Packing the
| | | | | | | | | |
wound with wet-to-damp dressings allows epidermal cells to migrate
| | | | | | | | |
more rapidly across the bed of the wound surface than dry dressings,
| | | | | | | | | | | |
thereby facilitating healing. Wet-to-damp dressings will also wick
| | | | | | | |
exudate up and away from the base of the wound and help to increase
| | | | | | | | | | | | | |
resistance to a wound infection. | | | |
You are caring for an assigned client and notice a superficial ulcer on the
| | | | | | | | | | | | |
client's buttock that appears as a shallow crater involving the epidermis
| | | | | | | | | | | |
and the dermis. Which of the following stages would you say best
| | | | | | | | | | | |
describes this break in skin integrity? | | | | | |
A. Stage I
| | |
