VSIM MORROW CASE TEST QUESTIONS AND ANSWERS #13
The nurse is caring for a patient admitted with bilateral lower extremity edema. What
questions should the nurse ask when completing a health history? - correct answer
When did the edema start?
Can you describe the edema?
What were you doing just before you noticed the edema?
Do you have any recent history of surgery or illness?
What are your usual daily activities?
Do you stand a lot?
What medications do you take?
Do you have a heart disease or blood vessel disease?
The nurse is conducting a skin assessment using the Braden Scale. How would the
nurse interpret a score of 12? - correct answer High risk
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower
extremity. What would the nurse expect to find when assessing the leg? - correct
answer Dark discoloration of the skin surrounding the wound site.
The nurse is preparing to irrigate a wound. Which statement, if made by a nurse,
indicates an understanding of the procedure? - correct answer I will gently direct a
stream of fluid into the wound, keeping the syringe tip at least one inch from the upper
tip of the wound.
The nurse removes a dressing and assess yellow, foul smelling drainage. How would
the nurse document the finding? - correct answer purulent
The nurse is performing a sterile dressing change. After donning sterile gloves, the
nurse drops the dressing on the bed and does not have a replacement. What is the
appropriate action at this time? - correct answer Ask the patient to press the call bell to
summon a co-worker to obtain another dressing.
The nurse is completing an admission assessment on a patient admitted for an infected,
non-healing wound. Which factors in the patient's history may contribute to this
condition? - correct answer Poor hygiene
Poor circulation
Obesity
Diabetes mellitus
The nurse assesses a wound and documents it as stage III. What did the nurse observe
when the wound was assessed? - correct answer Full thickness tissue loss, possibly
with visible subcutaneous fat.
The nurse is performing an assessment of Ms Morrow's wound. What should be
included in the documentation? - correct answer Tunneling
The nurse is caring for a patient admitted with bilateral lower extremity edema. What
questions should the nurse ask when completing a health history? - correct answer
When did the edema start?
Can you describe the edema?
What were you doing just before you noticed the edema?
Do you have any recent history of surgery or illness?
What are your usual daily activities?
Do you stand a lot?
What medications do you take?
Do you have a heart disease or blood vessel disease?
The nurse is conducting a skin assessment using the Braden Scale. How would the
nurse interpret a score of 12? - correct answer High risk
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower
extremity. What would the nurse expect to find when assessing the leg? - correct
answer Dark discoloration of the skin surrounding the wound site.
The nurse is preparing to irrigate a wound. Which statement, if made by a nurse,
indicates an understanding of the procedure? - correct answer I will gently direct a
stream of fluid into the wound, keeping the syringe tip at least one inch from the upper
tip of the wound.
The nurse removes a dressing and assess yellow, foul smelling drainage. How would
the nurse document the finding? - correct answer purulent
The nurse is performing a sterile dressing change. After donning sterile gloves, the
nurse drops the dressing on the bed and does not have a replacement. What is the
appropriate action at this time? - correct answer Ask the patient to press the call bell to
summon a co-worker to obtain another dressing.
The nurse is completing an admission assessment on a patient admitted for an infected,
non-healing wound. Which factors in the patient's history may contribute to this
condition? - correct answer Poor hygiene
Poor circulation
Obesity
Diabetes mellitus
The nurse assesses a wound and documents it as stage III. What did the nurse observe
when the wound was assessed? - correct answer Full thickness tissue loss, possibly
with visible subcutaneous fat.
The nurse is performing an assessment of Ms Morrow's wound. What should be
included in the documentation? - correct answer Tunneling
