MED-SURG EXAM , 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
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B: Border irregularity
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C: Color variation within one lesion
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D: Diameter > 6mm
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E: Evolving/changing features
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What are some psychosocial assessments for skin integrity? - correct answer Body Image
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Body Language e




Social Isolation e




The nurse is assessing a patient's skin. Which lesion finding requires further nursing intervention?
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A- Symmetry
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B- Consistent color
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C- Diameter of 8mm
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D- Regular border - correct answer Answer is C
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,Which of the following is not a safe and effective care environment?
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A- Assist patients to change positions at least every 2 hours; noting any areas of comprised tissue integrity
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B Use lift sheets when moving pts with fragile skin to avoid sheering
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C- Use standard precautions when providing care to pts who have skin integrity
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D- Make sure to wash your hands after touching any areas of impaired skin integiry
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E- Position pts who are confined to bed to promote air circulation to skinfold areas to minimize pressure over
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bony prominences - correct answer D- you should wash your hands BEFORE and AFTER
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What is an important aspect of physiological integrity? - correct answer Ask any pt who has started taking a
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new prescription or OTC drug whether he or she has noticed any skin changes that occurred since taking the
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drug



What are some ways for a nurse to promote health and maintenance with adults to prevent damage and
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cancer development? - correct answer -Teach them to reduce sun exposure
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-To regularly use sunscreen
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-To examine their skin on a monthly basis for new changes and lesions
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-Teach pts to bathe, shampoo hair, and keep fingernails clean and trimmed
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What does red indicate for pressure mapping? What about blue? - correct answer Areas of greater heat
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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
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weight with a protein intake of 1.25 to 1.5g/kg/day. Up to 2g/kg/day of protein may be needed when
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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.
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What are 3 things that are important to remember with skin care? - correct answer 1. Do not massage bony
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prominences

2. Document and report any manifestations of skin infection
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3. Use moisturizers daily on dry skin and apply when skin is damp
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, Explain a stage 1 pressure ulcer... - correct answer -The skin is intact
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-Area usually over bony prominence, does not blanch (lighten/turn white) with external pressure which
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indicates absence of capillary blood flow e e e e e e




and early tissue damage
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-Observable pressure-related alterations of intact skin e e e e e




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




Explain stage 3 pressure ulcer - correct answer -Full-thickness skin loss
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-Subcutaneous tissue and underlying fascia may be damaged or necrotic e e e e e e e e e




-Bone, tendon, muscle NOT exposed
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-May have undermining and tunneling
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Explain stage 4 pressure ulcer - correct answer -Full-thickness with exposed or palpable muscle, tendon, or
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bone e




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




-Slough and eschar often present (dead tissue)
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Nurses canNOT delegate this assessment to UAP because it is beyond their scope of practice - correct answer
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Nurses should also inspect the ENTIRE body for location, size, color, extent of tissue involvement and
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surrounding tissue, cell types in wound base and margins, exudate, and foreign bodies. Nurses should always
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clean before they assess is, then they can dress it. Document what you see, feel, and smell
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Explain sanguineous/bloody exudate - correct answer Bright red and thin in consistency
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Explain serosanguineous exudate - correct answer Light red to pink and is thin in consistency
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