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1. A client states that they have been having drainage from their wound. What
is the PRIORITY nursing action?
A) Send a culture of the drainage as ordered
B) Assess the drainage
C) Notify the provider
D) Tell the client that drainage is normal
Answer
Assess the drainage
2. What is a cause of a shearing injury?
A) Sitting in one position for 3 hours
B) Sitting in a wheelchair from breakfast to lunch
C) Continuously rubbing the heels against the bed sheets
D) Sitting in High Fowlers and sliding down in bed
Answer
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Sitting in High Fowlers and sliding down in bed
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,3. The nurse assesses an area of redness on a client that does not
blanch. What stage pressure ulcer is this?
A) Stage 1
B) Stage 2
C) Stage 3
D) Unstageable
Answer
Stage 1
4. How would the nurse document this drainage?
A) Serosanguineous
B) Serous
C) Purulent
D) Sanguineous
Answer
Sanguineous
5. What is NOT included in wound drainage assessment?
A) Color
B) Odor
C) Consistency
D) Temperature
Answer
Temperature
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,6. What is an age-related change for the elderly that may lead to skin integrity
impairment?
A) Thickening of the epidermis
B) Thinning of the epidermis
C) Hydration of the dermis
D) Increased elasticity of the dermis
Answer
Thinning of the epidermis
7. What is NOT a sign of infection?
A) Temperature of 102°F
B) Oxygen Saturation 95%
C) Purulent drainage
D) Pain rating of 8/10
Answer
Oxygen Saturation 95%
8. What is the BEST action by the nurse when caring for an immunocompro-
mised client to prevent infection?A) Wash hands before entering the room
B) Assess vital signs every 4 hours
C) Teach the client to get immunizations
D) Wear PPE
Answer
Wash hands before entering the room
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,9. A client has MRSA. What transmission-based precautions should be initi-
ated?
A) Airborne
B) Contact
C) Droplet
D) Protective
Answer
Contact
10. What is NOT appropriate client education for a client who is immunocom-
promised?
A) Choose foods high in protein
B) Drink at least 2L of fluids per day
C) Eat many fresh fruits and vegetables
D) Increase your calorie intake
Answer
Eat many fresh fruits and vegetables
11. What link in the chain of infection is broken by handwashing?
A) Portal of Entry
B) Reservoir
C) Mode of Transmission
D) All of the above
Answer
Jo
All of the above
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,12. What is the mechanism of action for medications that treat rheumatoid
arthritis?
A) Reduce inflammation
B) Kill the infection
C) Reduce pain
D) Increase the immune response
Answer
Reduce inflammation
13. What is the BEST way to utilize heat therapy for pain?
A) Use a warm, moist towel to the area of pain for 20 minutes
B) Heat a moist wash cloth up in the microwave and put it on the area of pain
C) Aim a blow dryer on a warm heat setting at the area of pain
D) Use an instant hot pack on the area for 45 minutes
Answer
Use a warm, moist towel to the area of pain for 20 minutes
14. What negatively affects wound healing?
A) Increased protein
B) Increased fluid intake
C) Poor nutrition
D) Good hygiene
Answer
Jo
Poor nutrition
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,15. What diagnosis has the hallmark sign of a butterfly rash across the bridge
of the nose?
A) SLE
B) Rheumatoid arthritis
C) HIV
D) Osteoarthritis
Answer
SLE
16. What is NOT a sign of inflammation?
A) Edema
B) Heat
C) Increased respiratory rate
D) Pain
Answer
Increased respiratory rate
17. If a client has HIV, they also have AIDS.
A) True
B) False
Answer
False
Jo
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,18. What is the BEST intervention to reduce swelling?
A) Apply heat therapy
B) Apply cold therapy
C) Use a topical cream
D) Ask the provider for Lasix
Answer
Apply cold therapy
19. How would the nurse document necrotic and black tissue around a wound?
A) Slough
B) Granulation tissue
C) Abnormal
D) Eschar
Answer
Eschar
20. What is NOT an appropriate nursing intervention if a client is experiencing
an oxygen saturation of 88%?A) Raise the head of the bed
B) Encourage coughing and deep breathing
C) Give oxygen as ordered
D) Tell the client you will be right back after you call the provider
Answer
Tell the client you will be right back after you call the provider
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,21. What is NOT a sign/symptom of Sjogren's syndrome?
A) Dry mouth
B) Dry eyes
C) Increased energy
D) Numbness
Answer
Increased energy
22. What is TRUE about glaucoma?
A) Once the tissue is damaged from high pressure, it doesn't regenerate
B) Permanent blindness always occurs due to the high pressure
C) Glaucoma
D) Bacteria causes tissue damage
Answer
Once the tissue is damaged from high
pressure, it doesn't regenerate
23. What test is used for Glaucoma?
A) Corneal staining
B) Snellen Eye Chart
C) Tonometry
D) Angiography
Answer
Tonometry
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,24. What is the PRIORITY nursing action for a fracture?A) Check for pulses
B) Assess pain
C) Educate on cast care
D) Assess medication history
Answer
Check for pulses
25. How can a client prevent Raynaud's syndrome?
A) Wear gloves when it is cold
B) Wear sunscreen
C) Stay home
D) Take hot baths
Answer
Wear gloves when it is cold
26. What innate immunity is the best protection from infection?
A) Inflammatory process
B) WBCs
C) Natural Killer Cells
D) Skin
Answer
Skin
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, 27. What is NOT a sign of cataracts?
A) Increased visual acuity
B) Cloudy vision
C) Difficulty with night vision
D) Halos
Answer
Increased visual acuity
28. What is an appropriate task to delegate to a UAP?
A) Assessing drainage of a wound
B) Evaluating pain
C) Bathing a client
D) Diagnosing difficulty breathing
Answer
Bathing a client
29. A nurse is caring for a terminally ill client whose death is imminent. What
is the most appropriate intervention?
A) Remain with the family but maintain silence
B) Make decisions for the family in difficult situations
C) Encourage family discussions of feelings
D) Tell the family to leave the client alone
Answer
Encourage family discussions of feelings
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