NS 660 Exam 2 – Questions With Verified Solutions
Which statement would indicate the need for further teaching?
A. If skin area gets red but red goas away after turning, I should report it to the
nurse
B. Putting foam pads under the heels or other bony prominences can help
decrease pressure
C. If a person cannot turn himself in bed, someone should help them change
position every 4 hours
D. Skin should be washed with only warm water (not hot) and lotion put on
wile it is still little whet Correct Answer - C. If a person cannot turn
himself in bed, someone should help them change position every 4 hours
Rationale:
This should happen every 2 hrs.
Wound draining thick yellow material. What type of drainage? Correct
Answer - Purulent
Client enters ED after motor cycle accident, resulting in skidding across
pavement. Client wearing shorts, so large areas skin ripped off. Best describe
this wound as:
A. Abrasion
B. Approximated
C. Laceration
D. Eschar Correct Answer - C. Laceration
Key word: Ripped
Laceration because large amounts of skin ripped off.
,Although abrasion is usually related to road rash, the large amount of skin
damaged is why it is considered a laceration
Nurse caring for patients with variety of wounds. Which wound will most
likely heal by primary intention?
A. Cut in skin from kitchen knife
B. Excoriated perineal area
C. Abrasion of the skin
D. Pressure ulcer Correct Answer - A. Cut in skin from kitchen knife
3 other options will heal by secondary intention
Nurse preparing to measure depth of client's tunneled wound. Which of the
following tools should nurse use to measure depth accurately?
A. Otic curette
B. Sterile tongue blade lubricated with water soluble gel
C. Sterile flexible applicator moistened with saline
D. Small ruler Correct Answer - C. Sterile flexible applicator moistened
with saline
Older patient is most likely to experience which of the following changes with
aging?
A. Thinning of epidermis
B. Thickening of epidermis
C. Oiliness of skin
D. Increased elasticity of skin Correct Answer - A. Thinning of epidermis
,Age causes thinning, decreased elasticity, and increased dryness.
Caring for client and notice a superficial ulcer on left hip that appears shallow
crater, red pink wound bed and no slough or eschar. Which stage would best
describe the break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable Correct Answer - B. Stage II
Stage I = no skin loss
Minimal skin loss/shallow depth = stage II
Caring for client at high risk for developing pressure ulcers. Which of the
following are intrinsic factors that increase risk of pressure ulcers? Select All
that Apply:
A. Friction
B. Impaired sensation d/t spinal cord injury
C. Poor nutrition
D. Shearing
E. Edema
F. Compression Correct Answer - B. impaired sensation d/t spinal cord
injury
C. Poor nutrition - specifically protein
E. Edema
, Friction, Shearing, and Compression are extrinsic factors associated with risk
of pressure injury.
Applying saline-moistened dressing to clients wound. Client asks, "Wouldn't it
be better to let wound dry out so scab can form?" Which is the most
appropriate response?
A. Wounds heal better when moist wound bed is maintained
B. you may be correct, I will check with your primary HCP
C. Allowing a scab to form would prevent from observing wound for signs of
infection
D. Wound too large for scab to form over it, so a moist dressing is the best
alternative Correct Answer - A. Wounds heal better when moist wound
bed is maintained
Which of the following factors contribute to impaired wound healing? Select
all that apply
A. Diabetes
B. Poor nutrition
C. Surgery requiring multiple incisions
D. Smoking
E. Obesity Correct Answer - A. Diabetes
B. Poor nutrition
D. Smoking
E. Obesity
Older adult client admitted to hospital with dehydration, and nurse has
inserted peripheral IV to forearm. Which type of dressing should be applied
over clients venous access site?
Which statement would indicate the need for further teaching?
A. If skin area gets red but red goas away after turning, I should report it to the
nurse
B. Putting foam pads under the heels or other bony prominences can help
decrease pressure
C. If a person cannot turn himself in bed, someone should help them change
position every 4 hours
D. Skin should be washed with only warm water (not hot) and lotion put on
wile it is still little whet Correct Answer - C. If a person cannot turn
himself in bed, someone should help them change position every 4 hours
Rationale:
This should happen every 2 hrs.
Wound draining thick yellow material. What type of drainage? Correct
Answer - Purulent
Client enters ED after motor cycle accident, resulting in skidding across
pavement. Client wearing shorts, so large areas skin ripped off. Best describe
this wound as:
A. Abrasion
B. Approximated
C. Laceration
D. Eschar Correct Answer - C. Laceration
Key word: Ripped
Laceration because large amounts of skin ripped off.
,Although abrasion is usually related to road rash, the large amount of skin
damaged is why it is considered a laceration
Nurse caring for patients with variety of wounds. Which wound will most
likely heal by primary intention?
A. Cut in skin from kitchen knife
B. Excoriated perineal area
C. Abrasion of the skin
D. Pressure ulcer Correct Answer - A. Cut in skin from kitchen knife
3 other options will heal by secondary intention
Nurse preparing to measure depth of client's tunneled wound. Which of the
following tools should nurse use to measure depth accurately?
A. Otic curette
B. Sterile tongue blade lubricated with water soluble gel
C. Sterile flexible applicator moistened with saline
D. Small ruler Correct Answer - C. Sterile flexible applicator moistened
with saline
Older patient is most likely to experience which of the following changes with
aging?
A. Thinning of epidermis
B. Thickening of epidermis
C. Oiliness of skin
D. Increased elasticity of skin Correct Answer - A. Thinning of epidermis
,Age causes thinning, decreased elasticity, and increased dryness.
Caring for client and notice a superficial ulcer on left hip that appears shallow
crater, red pink wound bed and no slough or eschar. Which stage would best
describe the break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable Correct Answer - B. Stage II
Stage I = no skin loss
Minimal skin loss/shallow depth = stage II
Caring for client at high risk for developing pressure ulcers. Which of the
following are intrinsic factors that increase risk of pressure ulcers? Select All
that Apply:
A. Friction
B. Impaired sensation d/t spinal cord injury
C. Poor nutrition
D. Shearing
E. Edema
F. Compression Correct Answer - B. impaired sensation d/t spinal cord
injury
C. Poor nutrition - specifically protein
E. Edema
, Friction, Shearing, and Compression are extrinsic factors associated with risk
of pressure injury.
Applying saline-moistened dressing to clients wound. Client asks, "Wouldn't it
be better to let wound dry out so scab can form?" Which is the most
appropriate response?
A. Wounds heal better when moist wound bed is maintained
B. you may be correct, I will check with your primary HCP
C. Allowing a scab to form would prevent from observing wound for signs of
infection
D. Wound too large for scab to form over it, so a moist dressing is the best
alternative Correct Answer - A. Wounds heal better when moist wound
bed is maintained
Which of the following factors contribute to impaired wound healing? Select
all that apply
A. Diabetes
B. Poor nutrition
C. Surgery requiring multiple incisions
D. Smoking
E. Obesity Correct Answer - A. Diabetes
B. Poor nutrition
D. Smoking
E. Obesity
Older adult client admitted to hospital with dehydration, and nurse has
inserted peripheral IV to forearm. Which type of dressing should be applied
over clients venous access site?
