Which of the following devices should be used to ensure the appropriate
amount of irrigation pressure during wound irrigation?
A. 10 mL syringe with a 19 gauge needle
B. 35 mL syringe with a 19 gauge needle
C. steady flow of fluid from a height of 12 inches above the wound
D. steady but gentle squirt of irrigant through a catheter irrigating system
- ANSWER B. 35 mL syringe with a 19 gauge needle
Which of the following are common sites for development of pressure
ulcers? (select all that apply)
A. sternum
B. heels
C. sacrum
D. ears
E. lateral malleoli
F. trochanters
G. tip of great toe - ANSWER B. heels
C. sacrum
D. ears
E. lateral maleoli
F. trochanters
When educating a patient about wound healing the nurse should include
what in the teaching?
A. inadequate nutrition delays wound healing and increases risk of
infection.
,B. chronic wounds heal better in a dry, open environment so leave them
open to air.
C. fat tissue heals more rapidly because there is less vascularization.
D. long term steroid use diminishes the inflammatory response and
speeds up wound healing - ANSWER A. inadequate nutrition delays
wound healing and increases risk of infection
What strategies should be included in pressure ulcer prevention (select
all that apply)
A. use moisture barrier ointment with incontinence
B. reposition immobile patients every 4 hours
C. when patient in side lying position ensure HOB <30 degrees
D. place patient on pressure reducing support surface
E. maintain bed at 45 degree angle
F. massage reddened bony prominences
G. oral nutrition supplement should be used when undernourished. -
ANSWER A. use moisture barrier ointment with incontinence
C. when patient in side lying position ensure HOB <30 degrees
D. place patient on pressure reducing support surface
G. oral nutrition supplement should be used when undernourished.
Why does a wound bed need to stay moist?
A. to support healing by enabling granulation tissue to grow.
B. to prevent excessive fluid loss from the body
C. to determine if the area has reactive hyperemia
D. to decrease patient discomfort - ANSWER A. to support healing by
enabling granulation tissue to grow.
What evaluation criteria are included in the Braden Risk assessment?
(select all that apply)
,A. sensory perception
B. medications
C. mobility
D. friction and shear
E. mental status
F. moisture - ANSWER A. sensory perception
C. mobility
D. friction and shear
F. moisture
What term refers to pale, red and watery drainage from a wound?
A. serous
B. sanguineous
C. serosanguineous
D. purulent - ANSWER C. serosanguineous
serous - clear, watery, plasma
sanguineous - bright red, active bleeding
purulent - thick, yellow, green, tan or brown (pus)
An 86 year old female patient is immobile and is in the right lateral
recumbent position. As the nurse you know that which sites below are at
most risk for pressure injury in this position?
A. Sacral
B. Patella
C. Ankle
D. Ear
E. Elbow
F. Hip
G. Heel
H. Shoulder - ANSWER B. Patella
C. Ankle
, D. Ear
F. Hip
H. Shoulder
The right lateral recumbent position is where the patient is positioned on
their right side. Therefore, the ankle, ear, hip, knee, and shoulders are
sites where a pressure injury can occur.
You're working on a medical surgical floor. You have the following
patients below. Select all the patients below that are at risk for a
pressure injury:
A. A 19 year old female who is a quadriplegic.
B. A 35 year old male with a BMI of 13.6 that is incontinent of stool and
has a right leg splint.
C. A 55 year old female who has controlled diabetes and is ambulating
three times a day.
D. A 76 year old male with an elevated ammonia level and is
excessively sweaty.
E. A 45 year old with a Braden Scale score of 7. - ANSWER A, B, D,
and E.
The only patient not at risk for a pressure injury is the patient in option B.
Remember altered sensory perception, any type of moisture issue
(incontinence, sweating etc.), immobility, poor nutrition, altered mental
status (high ammonia level can cause confusion and drowsiness),
Braden scale score less than 9 are all risk factors for a pressure injury.
The nurse is caring for clients on a medical unit. After the shift report,
which client should be assessed first?
1. the 34-year old client who is quadriplegic and cannot move his arms.
2. the elderly client diagnosed with a CVA who is weak on the right side.
amount of irrigation pressure during wound irrigation?
A. 10 mL syringe with a 19 gauge needle
B. 35 mL syringe with a 19 gauge needle
C. steady flow of fluid from a height of 12 inches above the wound
D. steady but gentle squirt of irrigant through a catheter irrigating system
- ANSWER B. 35 mL syringe with a 19 gauge needle
Which of the following are common sites for development of pressure
ulcers? (select all that apply)
A. sternum
B. heels
C. sacrum
D. ears
E. lateral malleoli
F. trochanters
G. tip of great toe - ANSWER B. heels
C. sacrum
D. ears
E. lateral maleoli
F. trochanters
When educating a patient about wound healing the nurse should include
what in the teaching?
A. inadequate nutrition delays wound healing and increases risk of
infection.
,B. chronic wounds heal better in a dry, open environment so leave them
open to air.
C. fat tissue heals more rapidly because there is less vascularization.
D. long term steroid use diminishes the inflammatory response and
speeds up wound healing - ANSWER A. inadequate nutrition delays
wound healing and increases risk of infection
What strategies should be included in pressure ulcer prevention (select
all that apply)
A. use moisture barrier ointment with incontinence
B. reposition immobile patients every 4 hours
C. when patient in side lying position ensure HOB <30 degrees
D. place patient on pressure reducing support surface
E. maintain bed at 45 degree angle
F. massage reddened bony prominences
G. oral nutrition supplement should be used when undernourished. -
ANSWER A. use moisture barrier ointment with incontinence
C. when patient in side lying position ensure HOB <30 degrees
D. place patient on pressure reducing support surface
G. oral nutrition supplement should be used when undernourished.
Why does a wound bed need to stay moist?
A. to support healing by enabling granulation tissue to grow.
B. to prevent excessive fluid loss from the body
C. to determine if the area has reactive hyperemia
D. to decrease patient discomfort - ANSWER A. to support healing by
enabling granulation tissue to grow.
What evaluation criteria are included in the Braden Risk assessment?
(select all that apply)
,A. sensory perception
B. medications
C. mobility
D. friction and shear
E. mental status
F. moisture - ANSWER A. sensory perception
C. mobility
D. friction and shear
F. moisture
What term refers to pale, red and watery drainage from a wound?
A. serous
B. sanguineous
C. serosanguineous
D. purulent - ANSWER C. serosanguineous
serous - clear, watery, plasma
sanguineous - bright red, active bleeding
purulent - thick, yellow, green, tan or brown (pus)
An 86 year old female patient is immobile and is in the right lateral
recumbent position. As the nurse you know that which sites below are at
most risk for pressure injury in this position?
A. Sacral
B. Patella
C. Ankle
D. Ear
E. Elbow
F. Hip
G. Heel
H. Shoulder - ANSWER B. Patella
C. Ankle
, D. Ear
F. Hip
H. Shoulder
The right lateral recumbent position is where the patient is positioned on
their right side. Therefore, the ankle, ear, hip, knee, and shoulders are
sites where a pressure injury can occur.
You're working on a medical surgical floor. You have the following
patients below. Select all the patients below that are at risk for a
pressure injury:
A. A 19 year old female who is a quadriplegic.
B. A 35 year old male with a BMI of 13.6 that is incontinent of stool and
has a right leg splint.
C. A 55 year old female who has controlled diabetes and is ambulating
three times a day.
D. A 76 year old male with an elevated ammonia level and is
excessively sweaty.
E. A 45 year old with a Braden Scale score of 7. - ANSWER A, B, D,
and E.
The only patient not at risk for a pressure injury is the patient in option B.
Remember altered sensory perception, any type of moisture issue
(incontinence, sweating etc.), immobility, poor nutrition, altered mental
status (high ammonia level can cause confusion and drowsiness),
Braden scale score less than 9 are all risk factors for a pressure injury.
The nurse is caring for clients on a medical unit. After the shift report,
which client should be assessed first?
1. the 34-year old client who is quadriplegic and cannot move his arms.
2. the elderly client diagnosed with a CVA who is weak on the right side.
