NUR 111 Final Exam Questions and Answers with Complete Solutions Graded A 2023

A nurse is caring for a patient who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the patient that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement. B When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? A) friction B) necrosis of tissue C) ischemia D) shearing force D What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings? A) Change position at least once each shift. B) Implement a turning schedule every 2 hours. C) Use ring cushions for heels and elbows. D) Do not turn, use pressure-relieving support surface. B A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) full-thickness skin loss B) skin pallor C) blister formation D) eschar formationA During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers .C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery. D A nurse assessing a patients wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) clear, watery blood B) large numbers of red blood cells C) mixture of serum and red blood cells D) white blood cells, debris, bacteria D A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A) Oh, for gosh sakes it doesnt look that bad! B) I understand, but you are going to have to look someday. C) I respect your wish not to look at it right now. D) You wont be able to go home until you look at it. C Of the many topics that may be taught to patients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) taking medications as prescribed B) proper intake of food and fluids C) thorough hand hygiene D) adequate sleep and rest C A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?A. The therapy is used to collect excess blood loss and prevent the formation of a scab. B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. C. The therapy provides a moist environment and stimulates blood flow to the wound. D. The therapy irrigates the wound to keep it free from debris and excess wound fluid. C What would a nurse expect to administer for a Heparin overdose? A) Urokinase B) Pentoxifylline C) Thrombin D) Protamine sulfate D The nurse is monitoring a pt's Heparin infusion. What potential nursing diagnosis should the nurse prioritize when planning assessments? A) Deficient Knowledge regarding drug therapy B) Ineffective Tissue Perfusion (Total Body) related to blood loss C) Risk for Imbalanced Fluid Volume related to third-spacing D) Risk for Infection related to bone marrow suppression B