Exam 2 - Nur 100 Questions With complete
Solutions
What is the Braden Scale?
an evidence-based tool that looks at various
factors that put patients at risk for developing a
pressure ulcer. Includes:
sensory perception
moisture
activity
mobility
nutrition
friction
shear
The lowest the score (minimum 6) the greater the
risk. Maximum score is 23.
A nurse is caring for a client who has a dime sized
stg 1 pressure injury located on the sacrum. Which
of the following dressing types should the nurse
use?
- Hydrogel
- wet gauze
- transparent film
- alginate dressing
- Transparent Film
They have a reduced ability to absorb moisture,
,self-adhesive dressings are used for covering
superficial wounds that have minimal exudate.
A nurse is caring for a client who has sustained a
gunshot would to the abdomen and is 6hr post-op.
The nurse notices protrusion of the clients organs
form the incision site and calls for help. Which of
the following actions should the nurse take?
- ask the client to bear down and cough
- ask another nurse to bring icepacks to apply to
the wound
- cover the clients wound with a sterile saline
dressing
- place the client in high-fowlers position
- Cover the clients wound w a sterile saline
dressing
The nurse should place a sterile saline soaked
dressing over the clients wound to prevent the
dressing from adhering to the tissue and protect
the organs until the client is taken back to
suregery.
A nurse is in an outpatient clinic is assessing the
incision site of a client who is 7 days post-op.
Which of the following findings should the nurse
expect.
- a red incision site with a small amnt of exudate
- a bright pink incision site that is absent of
exudate
,- a pale pink incision with moderate amnt of
exudate
- a white to sliver incision site absent of exudate
- A bright pink incision that is absent of exudate
By the 7 post-op day, the incision should appear
bright, pink, and exudate should have subsided.
We have an expert-written solution to this
problem!
A nurse is teaching as ap abt the skin of older
adults, Which of the following statements by the ap
indicates an understanding of the teaching.
- skin changes cause the synthesis of vit b
decreases w age
- the layers of the skin become detached w age
- older adult clients have more moisture in the skin
placing them at risk for maceration
- the skin of older adults is thinner and has less
subq padding over bony prominences
- The skin of older adults is thinner and has less
subq padding over bony prominences
as an individual ages, expected changes occur in
the skin, including a decrease in elasticity and sub
q tissue. This increase the risk of injury for skin
tears in elderly.
, A nurse is assisting with the care of a client
following abdominal surgery. The nurse removes
the clients surgical dressing and notes a separation
of the wound edges. The nurse should identify that
the client is experiencing which of the following
complications?
- dehiscence
- evisceration
- hematoma
- fistula
- Dehiscence
Dehiscence is a separation of part or of all the
wound edges. This is a common complication after
abdominal surgery where the pt experiences a
ripping sensation at the wound site
A nurse in a dermatology clinic is developing a skin
anatomy poster to display for clients. Which of the
following information should the nurse plan to
include on the poster?
- The epidermis contains cells that assist in
systemic immune responses
- collage and elastin fibers increase w age
- the skin consists of 4 distinct layers
- the dermis contains blood vessels that help
nourish the epidermis
- the dermis contains blood vessels that help
nourish the skin
Solutions
What is the Braden Scale?
an evidence-based tool that looks at various
factors that put patients at risk for developing a
pressure ulcer. Includes:
sensory perception
moisture
activity
mobility
nutrition
friction
shear
The lowest the score (minimum 6) the greater the
risk. Maximum score is 23.
A nurse is caring for a client who has a dime sized
stg 1 pressure injury located on the sacrum. Which
of the following dressing types should the nurse
use?
- Hydrogel
- wet gauze
- transparent film
- alginate dressing
- Transparent Film
They have a reduced ability to absorb moisture,
,self-adhesive dressings are used for covering
superficial wounds that have minimal exudate.
A nurse is caring for a client who has sustained a
gunshot would to the abdomen and is 6hr post-op.
The nurse notices protrusion of the clients organs
form the incision site and calls for help. Which of
the following actions should the nurse take?
- ask the client to bear down and cough
- ask another nurse to bring icepacks to apply to
the wound
- cover the clients wound with a sterile saline
dressing
- place the client in high-fowlers position
- Cover the clients wound w a sterile saline
dressing
The nurse should place a sterile saline soaked
dressing over the clients wound to prevent the
dressing from adhering to the tissue and protect
the organs until the client is taken back to
suregery.
A nurse is in an outpatient clinic is assessing the
incision site of a client who is 7 days post-op.
Which of the following findings should the nurse
expect.
- a red incision site with a small amnt of exudate
- a bright pink incision site that is absent of
exudate
,- a pale pink incision with moderate amnt of
exudate
- a white to sliver incision site absent of exudate
- A bright pink incision that is absent of exudate
By the 7 post-op day, the incision should appear
bright, pink, and exudate should have subsided.
We have an expert-written solution to this
problem!
A nurse is teaching as ap abt the skin of older
adults, Which of the following statements by the ap
indicates an understanding of the teaching.
- skin changes cause the synthesis of vit b
decreases w age
- the layers of the skin become detached w age
- older adult clients have more moisture in the skin
placing them at risk for maceration
- the skin of older adults is thinner and has less
subq padding over bony prominences
- The skin of older adults is thinner and has less
subq padding over bony prominences
as an individual ages, expected changes occur in
the skin, including a decrease in elasticity and sub
q tissue. This increase the risk of injury for skin
tears in elderly.
, A nurse is assisting with the care of a client
following abdominal surgery. The nurse removes
the clients surgical dressing and notes a separation
of the wound edges. The nurse should identify that
the client is experiencing which of the following
complications?
- dehiscence
- evisceration
- hematoma
- fistula
- Dehiscence
Dehiscence is a separation of part or of all the
wound edges. This is a common complication after
abdominal surgery where the pt experiences a
ripping sensation at the wound site
A nurse in a dermatology clinic is developing a skin
anatomy poster to display for clients. Which of the
following information should the nurse plan to
include on the poster?
- The epidermis contains cells that assist in
systemic immune responses
- collage and elastin fibers increase w age
- the skin consists of 4 distinct layers
- the dermis contains blood vessels that help
nourish the epidermis
- the dermis contains blood vessels that help
nourish the skin
