VSIM Josephine Morrow Pre-Sim & Post-Sim Answers

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? Prealbumin The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? -Have you noticed any swelling on your feet, ankles, or fingers? -Do some areas of your skin seem warmer or colder than others? -Have you used pads or special pants because you can't control your urine? -Do you have any sores on your body? The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history? -When did the edema start? -Can you describe the edema? -Do you have any recent history of surgery or illness? The nurse is conducting a skin assessment using the Braden scale. How would the nurse interpret a score of 12? High Risk The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? Dark discoloration of the skin surrounding the wound site The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound. The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? Purulent The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? Ask the patient to press the call bell to summon a co-worker to obtain another dressing. The nurse is completing an admission assessment on a patient for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition?