MED-SURG EXAM 1 2025 WITH CORRECT ANSWERS

MED-SURG EXAM 1 2025 WITH
CORRECT ANSWERS




What are the ABCDE's to identify skin cancer? - correct answer A: Asymmetry of shape
e e e e e e e e e e e e e e




B: Border irregularity
e e




C: Color variation within one lesion
e e e e e




D: Diameter > 6mm
e e e




E: Evolving/changing features
e e




What are some psychosocial assessments for skin integrity? - correct answer Body Image
e e e e e e e e e e e e




Body Language e




Social Isolation e




The nurse is assessing a patient's skin. Which lesion finding requires further nursing intervention?
e e e e e e e e e e e e e




A- Symmetry
e




B- Consistent color
e e




C- Diameter of 8mm
e e e




D- Regular border - correct answer Answer is C
e e e e e e e e




Which of the following is not a safe and effective care environment?
e e e e e e e e e e e

,A- Assist patients to change positions at least every 2 hours; noting any areas of comprised tissue integrity
e e e e e e e e e e e e e e e e e




B Use lift sheets when moving pts with fragile skin to avoid sheering
e e e e e e e e e e e e e




C- Use standard precautions when providing care to pts who have skin integrity
e e e e e e e e e e e e e




D- Make sure to wash your hands after touching any areas of impaired skin integiry
e e e e e e e e e e e e e e




E- Position pts who are confined to bed to promote air circulation to skinfold areas to minimize pressure over
e e e e e e e e e e e e e e e e e e e




bony prominences - correct answer D- you should wash your hands BEFORE and AFTER
e e e e e e e e e e e e e




What is an important aspect of physiological integrity? - correct answer Ask any pt who has started taking a
e e e e e e e e e e e e e e e e e e e




new prescription or OTC drug whether he or she has noticed any skin changes that occurred since taking the
e e e e e e e e e e e e e e e e e e e




drug



What are some ways for a nurse to promote health and maintenance with adults to prevent damage and
e e e e e e e e e e e e e e e e e e




cancer development? - correct answer -Teach them to reduce sun exposure
e e e e e e e e e e




-To regularly use sunscreen
e e e




-To examine their skin on a monthly basis for new changes and lesions
e e e e e e e e e e e e




-Teach pts to bathe, shampoo hair, and keep fingernails clean and trimmed
e e e e e e e e e e e




What does red indicate for pressure mapping? What about blue? - correct answer Areas of greater heat
e e e e e e e e e e e e e e e e e




production and increased pressure loads. Blue indicates cooler areas under lower pressure e e e e e e e e e e e




What does a positive nitrogen balance require? - correct answer An intake of 30 to 35 calories per kg of body
e e e e e e e e e e e e e e e e e e e e e




weight with a protein intake of 1.25 to 1.5g/kg/day. Up to 2g/kg/day of protein may be needed when
e e e e e e e e e e e e e e e e e e




nutritional deficits are severe or protein loss is ongoing. e e e e e e e e e




So if a patient weighs 68kg they need at least 85g of protein daily.
e e e e e e e e e e e e e




What are 3 things that are important to remember with skin care? - correct answer 1. Do not massage bony
e e e e e e e e e e e e e e e e e e e e




prominences

2. Document and report any manifestations of skin infection
e e e e e e e e




3. Use moisturizers daily on dry skin and apply when skin is damp
e e e e e e e e e e e e




Explain a stage 1 pressure ulcer... - correct answer -The skin is intact
e e e e e e e e e e e e

, -Area usually over bony prominence, does not blanch (lighten/turn white) with external pressure which
e e e e e e e e e e e e e e




indicates absence of capillary blood flow e e e e e e




and early tissue damage
e e e




-Observable pressure-related alterations of intact skin e e e e e




Explain stage 2 pressure ulcer - correct answer -Skin is not intact
e e e e e e e e e e e




-Partial-thickness skin loss of epidermis or dermis e e e e e e




-Ulcer is superficial, may appear as abrasion, blister, or shallow crater
e e e e e e e e e e




-Bruising not present e e




Explain stage 3 pressure ulcer - correct answer -Full-thickness skin loss
e e e e e e e e e e




-Subcutaneous tissue and underlying fascia may be damaged or necrotic e e e e e e e e e




-Bone, tendon, muscle NOT exposed
e e e e




-May have undermining and tunneling
e e e e




Explain stage 4 pressure ulcer - correct answer -Full-thickness with exposed or palpable muscle, tendon, or
e e e e e e e e e e e e e e e e




bone e




-Undermining and tunneling common with sinus tracts possible e e e e e e e




-Slough and eschar often present (dead tissue)
e e e e e e




Nurses canNOT delegate this assessment to UAP because it is beyond their scope of practice - correct answer
e e e e e e e e e e e e e e e e e e




Nurses should also inspect the ENTIRE body for location, size, color, extent of tissue involvement and
e e e e e e e e e e e e e e e e




surrounding tissue, cell types in wound base and margins, exudate, and foreign bodies. Nurses should always
e e e e e e e e e e e e e e e e




clean before they assess is, then they can dress it. Document what you see, feel, and smell
e e e e e e e e e e e e e e e e




Explain sanguineous/bloody exudate - correct answer Bright red and thin in consistency
e e e e e e e e e e e




Explain serosanguineous exudate - correct answer Light red to pink and is thin in consistency
e e e e e e e e e e e e e e




Explain serous exudate - correct answer Clear or light in color and thin in consistency
e e e e e e e e e e e e e e