NUR 336 Exam 2 Questions With Complete Solutions
4 extrinsic factors that contribute to pressure ulcer formation
Correct Answers Pressure, friction, humidity, shearing force
A female patient placed in the dorsal recumbent position for the
insertion of an indwelling urinary catheter tells the nurse that she
"doesn't feel comfortable in this position" and that her "back
really hurts." What is the nurse's best response?
A. Reassure the patient that the procedure will take only a few
minutes.
B. Promise to reposition the patient as soon as the catheter has
been inserted.
C. Reposition the patient in a side-lying position, with her upper
leg flexed at the knee and hip.
D. Explain to the patient that the position will allow the catheter
insertion to be more efficient. Correct Answers C
A patient has a 4-day-old postoperative incision. Which would
be a normal finding when changing the dressing?
a. Small amount of serous drainage
b. Moderate amount of sanguineous drainage
c. Small amount of serosanguineous drainage
d. Small amount of purulent drainage Correct Answers A (A
small amount of serous drainage is normal postoperatively. A
moderate amount of sanguineous drainage would indicate
bleeding. Purulent drainage would indicate infection.)
,A patient states that she is unable to get her transparent dressing
to stay in place. What instruction should the nurse provide the
patient?
a. "If you are having difficulty with your dressing changes, we
can see if the doctor will give you a referral to a home care
facility."
b. "Make sure that you have a margin of 1 to 1.5 inches (2.5 to
3.75 cm) around the wound, and that the skin is thoroughly dry
before applying the dressing."
c. "This type of dressing requires frequent changing because
they do not stay in place."
d. "You probably are applying it incorrectly, or perhaps you are
just too anxious about having to perform the dressing change."
e. "There are many options on the market. Why don't you try to
use a non-adhesive-backed transparent dressing instead?"
Correct Answers B (If the transparent dressing does not stay in
place, the size of the dressing should be evaluated for adequate
(1 to 1.5 inches or 2.5 to 3.75 cm) margin, and the skin should
be dried thoroughly before reapplication. The patient requires
further instruction, not necessarily a referral, regarding
interventions to aid in dressing adherence. The dressing coming
off is an unexpected outcome. Blaming the patient is non-
therapeutic.)
Before administering an IV medication piggyback, what should
you check for with the IV? Correct Answers Aspirate for blood
return
, Before administering an IVPB, you should do what to check for
infiltration of the IV? Correct Answers Flush with 2-3 mL of
NS
Bright red: indicates active bleeding Correct Answers
Sangineous
Clear, watery plasma drainage Correct Answers Serous
During a sterile dressing change, when are the gloves changed?
a. After the old dressing is removed and before creating a sterile
field
b. After the old dressing is removed and before cleansing the
wound
c. After the old dressing is removed, after cleansing the wound,
and before applying a new dressing
d. It is unnecessary to change gloves for chronic wounds.
Correct Answers B (Gloves are discarded after removing the
old dressing. If required, a sterile field is then prepared, new
sterile gloves are applied, and the wound is cleansed. It is
unnecessary to change the gloves frequently unless they are
accidentally contaminated. Gloves are changed after removing
the old dressing and before cleaning the wound to reduce
transmission of cross-contamination microorganisms. The same
gloves may then be worn for applying a new dressing. Clean
gloves may be worn rather than sterile gloves with chronic
wounds (check facility policy).)
During the procedure of inserting an NG tube, it is important
that the patient:
4 extrinsic factors that contribute to pressure ulcer formation
Correct Answers Pressure, friction, humidity, shearing force
A female patient placed in the dorsal recumbent position for the
insertion of an indwelling urinary catheter tells the nurse that she
"doesn't feel comfortable in this position" and that her "back
really hurts." What is the nurse's best response?
A. Reassure the patient that the procedure will take only a few
minutes.
B. Promise to reposition the patient as soon as the catheter has
been inserted.
C. Reposition the patient in a side-lying position, with her upper
leg flexed at the knee and hip.
D. Explain to the patient that the position will allow the catheter
insertion to be more efficient. Correct Answers C
A patient has a 4-day-old postoperative incision. Which would
be a normal finding when changing the dressing?
a. Small amount of serous drainage
b. Moderate amount of sanguineous drainage
c. Small amount of serosanguineous drainage
d. Small amount of purulent drainage Correct Answers A (A
small amount of serous drainage is normal postoperatively. A
moderate amount of sanguineous drainage would indicate
bleeding. Purulent drainage would indicate infection.)
,A patient states that she is unable to get her transparent dressing
to stay in place. What instruction should the nurse provide the
patient?
a. "If you are having difficulty with your dressing changes, we
can see if the doctor will give you a referral to a home care
facility."
b. "Make sure that you have a margin of 1 to 1.5 inches (2.5 to
3.75 cm) around the wound, and that the skin is thoroughly dry
before applying the dressing."
c. "This type of dressing requires frequent changing because
they do not stay in place."
d. "You probably are applying it incorrectly, or perhaps you are
just too anxious about having to perform the dressing change."
e. "There are many options on the market. Why don't you try to
use a non-adhesive-backed transparent dressing instead?"
Correct Answers B (If the transparent dressing does not stay in
place, the size of the dressing should be evaluated for adequate
(1 to 1.5 inches or 2.5 to 3.75 cm) margin, and the skin should
be dried thoroughly before reapplication. The patient requires
further instruction, not necessarily a referral, regarding
interventions to aid in dressing adherence. The dressing coming
off is an unexpected outcome. Blaming the patient is non-
therapeutic.)
Before administering an IV medication piggyback, what should
you check for with the IV? Correct Answers Aspirate for blood
return
, Before administering an IVPB, you should do what to check for
infiltration of the IV? Correct Answers Flush with 2-3 mL of
NS
Bright red: indicates active bleeding Correct Answers
Sangineous
Clear, watery plasma drainage Correct Answers Serous
During a sterile dressing change, when are the gloves changed?
a. After the old dressing is removed and before creating a sterile
field
b. After the old dressing is removed and before cleansing the
wound
c. After the old dressing is removed, after cleansing the wound,
and before applying a new dressing
d. It is unnecessary to change gloves for chronic wounds.
Correct Answers B (Gloves are discarded after removing the
old dressing. If required, a sterile field is then prepared, new
sterile gloves are applied, and the wound is cleansed. It is
unnecessary to change the gloves frequently unless they are
accidentally contaminated. Gloves are changed after removing
the old dressing and before cleaning the wound to reduce
transmission of cross-contamination microorganisms. The same
gloves may then be worn for applying a new dressing. Clean
gloves may be worn rather than sterile gloves with chronic
wounds (check facility policy).)
During the procedure of inserting an NG tube, it is important
that the patient:
