NUR 305 EXAM 2 PRACTICE QUESTIONS & ANSWERS
Which amount of protein per kilogram of body weight a day would the nurse recommend
a patient consume to support wound healing?
A. 1.25 to 1.5 g
B. 2 to 3.5 g
C. 3.5 to 4.5 g
D. 5.15 to 6.5 g - Answer -1.25 to 1.5 g
The nurse should recommend that the patient consume 1.25 to 1.5 g of protein per
kilogram of body weight a day to support would healing. The amounts 2 to 3.5 g, 3.5 to
4.5 g, and 5.15 to 6.5 g are too much.
A nurse is performing mouth care for a patient who is unconscious. Which of the
following actions should the nurse take?
A. turn the patient's head to the side
B. place two fingers in the patient's mouth to open
C. brush the patient's teeth once per day
D. inject a mouth rise into the center of the patient's mouth - Answer -A. turn the
patient's head to the side
Which intervention would be MOST effective for compromised skin integrity?
A. preventing breakdown
B. administering medication
C. implementing wound care
D. monitoring would healing - Answer -A. preventing breakdown
The most effective intervention for compromised skin integrity & wound care is
prevention of skin breakdown. Whereas administering medication, implementing wound
care, and monitoring wound healing are all important nursing actions, prevention is the
first step.
The police arrive at the emergency department with a patient who has lacerated both
wrists. Which is the INITIAL nursing action?
A. administer an anti-anxiety agent
B. assess & treat wound sites
C. secure & record a detailed history
D. encourage the patient to ventilate feelings - Answer -B. assess & treat wound sites
The nurse is the first responder after a tornado has destroyed many homes in the
community. Which victim should the nurse attend to FIRST?
,A. a pregnant woman who exclaims, "My baby is not moving!"
B. a young child standing next to an adult family member who is screaming, "I want my
mommy!"
C. a woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall
off!"
D. an older victim who is next to her husband sobbing, "My husband is dead. My
husband is dead." - Answer -C. a woman who is complaining, "My leg is bleeding so
bad, I am afraid it is going to fall off!"
The staff nurse reviews the nursing documentation in a client's chart & notes that the
wound care nurse has documented that the client has a stage II pressure injury in the
sacral area. Which finding would the nurse expect to note on assessment of the client's
sacral area?
A. intact skin
B. full-thickness skin loss
C. exposed bone, tendon, or muscle
D. partial-thickness skin loss of the dermis - Answer -D. partial-thickness skin loss of
the dermis
A mother calls a neighbor who is a nurse & tells the nurse that her 3-year-old child has
just ingested liquid furniture polish. The nurse would direct the mother to take which
IMMEDIATE action?
A. bring the child to the emergency department
B. call poison control
C. induce vomiting
D. call an ambulance - Answer -B. call poison control
The home care nurse is performing an environmental assessment in the home of an
older patient. Which observation by the nurse requires intervention?
A. unsecured scatter rugs
B. clear exit pathways
C. an operable smoke detector
D. pre-filled medication box - Answer -A. unsecured scatter rugs
A patient on prolonged bed rest is at an increased risk to develop this common
complication of immobility if preventative measures are not taken:
A. myoclonus
B. pathological fractures
C. pressure ulcers
D. pruitis - Answer -C. pressure ulcers
,A patient has her call bell on & looks frightened when you enter the room. She has been
on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to
breath, and I can't catch my breath." Your first action is to:
A. call health care provider to report this change in condition
B. give the patient a paper bag to breathe into to decrease her anxiety
C. assess her vital signs, perform a respiratory assessment, and be prepared to start
oxygen
D. explain that this is normal after such trauma & administer the ordered pain
medication - Answer -C. assess her vital signs, perform a respiratory assessment, and
be prepared to start oxygen
A nurse is teaching a community group about ways to minimize the risk of developing
osteoporosis. Which of the following statements made by a woman in the audience
reflects a need for further education?
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I
need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not
taking another pill." - Answer -D. "I'll check the label of my multivitamin. If it has
calcium, I can save money by not taking another pill."
A nurse is caring for a patient who recently had a stroke & is going to be discharged at
the end of the week. The nurse notices that the patient is having difficulty with
attempting to eat his meal & is becoming tearful. The nurse includes which intervention
in the patient's plan of care?
A. teach the patient about special devices used to assist patients with eating meals
B. order the patient food that does not require utensils
C. place a consult for a home health nurse
D. obtain an order for antidepressant medications - Answer -A. teach the patient about
special devices used to assist patients with eating meals
The nurse is creating a plan of care for a patient with glaucoma. Which nursing
diagnosis addresses the complication of the sensory deficit that places the patient at the
greatest risk for injury?
A. risk for falls
B. body image disturbance
C. social isolation
D. fear - Answer -A. risk for falls
Which amount of zinc is recommended for wound healing?
, A. 15-30 mg
B. 30-50 mg
C. 25-60 mg
D. 50-70 mg - Answer -A. 15-30 mg
The amount of zinc recommended for wound healing is 15-30 mg. The amounts of 30-
50 mg, 25-60 mg, and 50-70 mg are more than necessary.
A long-term care facility encourages nurses to assess patients at risk of developing
pressure injuries based on six subscales: moisture, sensory perception, activity,
mobility, nutrition, and friction or shear force. Which tool is the long-term care facility
using for risk assessment of pressure injury development?
A. Gaskin's Nursing Assessment of Skin Color (SNASC) tool
B. Braden Scale
C. Bates-Jensen Wound Assessment Tool (BWAT)
D. Wound, Ostomy, and Continence Nurses Society (WOCN) scale - Answer -B.
Braden Scale
The Braden Scale is a widely used tool for risk assessment of pressure injury
development and is composed of six sub scales that are moisture, sensory perception,
activity, mobility, nutrition, and friction or shear force. The GNASC tool is used to assess
stage 1 pressure injuries in patients with dark skin tone. The BWAT is used to asses the
wound status. WOCN does not provide any measurement or assessment tools.
Which criteria does the Braden Scale evaluate?
A. skin integrity at bony prominences, including any wounds
B. risk factors that place the patient at risk of pressure injury
C. the amount of repositioning that the patient can tolerate
D. the factors that place the patient at risk of poor wound healing - Answer -B. risk
factors that place the patient at risk of pressure injury
The Braden Scale measures factors in six subscales that can predict the risk of
pressure injury development. It does not assess skin or wounds, repositioning, or
wound healing.
Which vitamin should be provided to a patient to promote wound healing? Select all that
apply. One, some, or all responses may be correct.
A. vitamin A
B. vitamin B
C. vitamin C
D. vitamin D
E vitamin E - Answer -A. vitamin A
C. vitamin C
Which amount of protein per kilogram of body weight a day would the nurse recommend
a patient consume to support wound healing?
A. 1.25 to 1.5 g
B. 2 to 3.5 g
C. 3.5 to 4.5 g
D. 5.15 to 6.5 g - Answer -1.25 to 1.5 g
The nurse should recommend that the patient consume 1.25 to 1.5 g of protein per
kilogram of body weight a day to support would healing. The amounts 2 to 3.5 g, 3.5 to
4.5 g, and 5.15 to 6.5 g are too much.
A nurse is performing mouth care for a patient who is unconscious. Which of the
following actions should the nurse take?
A. turn the patient's head to the side
B. place two fingers in the patient's mouth to open
C. brush the patient's teeth once per day
D. inject a mouth rise into the center of the patient's mouth - Answer -A. turn the
patient's head to the side
Which intervention would be MOST effective for compromised skin integrity?
A. preventing breakdown
B. administering medication
C. implementing wound care
D. monitoring would healing - Answer -A. preventing breakdown
The most effective intervention for compromised skin integrity & wound care is
prevention of skin breakdown. Whereas administering medication, implementing wound
care, and monitoring wound healing are all important nursing actions, prevention is the
first step.
The police arrive at the emergency department with a patient who has lacerated both
wrists. Which is the INITIAL nursing action?
A. administer an anti-anxiety agent
B. assess & treat wound sites
C. secure & record a detailed history
D. encourage the patient to ventilate feelings - Answer -B. assess & treat wound sites
The nurse is the first responder after a tornado has destroyed many homes in the
community. Which victim should the nurse attend to FIRST?
,A. a pregnant woman who exclaims, "My baby is not moving!"
B. a young child standing next to an adult family member who is screaming, "I want my
mommy!"
C. a woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall
off!"
D. an older victim who is next to her husband sobbing, "My husband is dead. My
husband is dead." - Answer -C. a woman who is complaining, "My leg is bleeding so
bad, I am afraid it is going to fall off!"
The staff nurse reviews the nursing documentation in a client's chart & notes that the
wound care nurse has documented that the client has a stage II pressure injury in the
sacral area. Which finding would the nurse expect to note on assessment of the client's
sacral area?
A. intact skin
B. full-thickness skin loss
C. exposed bone, tendon, or muscle
D. partial-thickness skin loss of the dermis - Answer -D. partial-thickness skin loss of
the dermis
A mother calls a neighbor who is a nurse & tells the nurse that her 3-year-old child has
just ingested liquid furniture polish. The nurse would direct the mother to take which
IMMEDIATE action?
A. bring the child to the emergency department
B. call poison control
C. induce vomiting
D. call an ambulance - Answer -B. call poison control
The home care nurse is performing an environmental assessment in the home of an
older patient. Which observation by the nurse requires intervention?
A. unsecured scatter rugs
B. clear exit pathways
C. an operable smoke detector
D. pre-filled medication box - Answer -A. unsecured scatter rugs
A patient on prolonged bed rest is at an increased risk to develop this common
complication of immobility if preventative measures are not taken:
A. myoclonus
B. pathological fractures
C. pressure ulcers
D. pruitis - Answer -C. pressure ulcers
,A patient has her call bell on & looks frightened when you enter the room. She has been
on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to
breath, and I can't catch my breath." Your first action is to:
A. call health care provider to report this change in condition
B. give the patient a paper bag to breathe into to decrease her anxiety
C. assess her vital signs, perform a respiratory assessment, and be prepared to start
oxygen
D. explain that this is normal after such trauma & administer the ordered pain
medication - Answer -C. assess her vital signs, perform a respiratory assessment, and
be prepared to start oxygen
A nurse is teaching a community group about ways to minimize the risk of developing
osteoporosis. Which of the following statements made by a woman in the audience
reflects a need for further education?
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I
need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not
taking another pill." - Answer -D. "I'll check the label of my multivitamin. If it has
calcium, I can save money by not taking another pill."
A nurse is caring for a patient who recently had a stroke & is going to be discharged at
the end of the week. The nurse notices that the patient is having difficulty with
attempting to eat his meal & is becoming tearful. The nurse includes which intervention
in the patient's plan of care?
A. teach the patient about special devices used to assist patients with eating meals
B. order the patient food that does not require utensils
C. place a consult for a home health nurse
D. obtain an order for antidepressant medications - Answer -A. teach the patient about
special devices used to assist patients with eating meals
The nurse is creating a plan of care for a patient with glaucoma. Which nursing
diagnosis addresses the complication of the sensory deficit that places the patient at the
greatest risk for injury?
A. risk for falls
B. body image disturbance
C. social isolation
D. fear - Answer -A. risk for falls
Which amount of zinc is recommended for wound healing?
, A. 15-30 mg
B. 30-50 mg
C. 25-60 mg
D. 50-70 mg - Answer -A. 15-30 mg
The amount of zinc recommended for wound healing is 15-30 mg. The amounts of 30-
50 mg, 25-60 mg, and 50-70 mg are more than necessary.
A long-term care facility encourages nurses to assess patients at risk of developing
pressure injuries based on six subscales: moisture, sensory perception, activity,
mobility, nutrition, and friction or shear force. Which tool is the long-term care facility
using for risk assessment of pressure injury development?
A. Gaskin's Nursing Assessment of Skin Color (SNASC) tool
B. Braden Scale
C. Bates-Jensen Wound Assessment Tool (BWAT)
D. Wound, Ostomy, and Continence Nurses Society (WOCN) scale - Answer -B.
Braden Scale
The Braden Scale is a widely used tool for risk assessment of pressure injury
development and is composed of six sub scales that are moisture, sensory perception,
activity, mobility, nutrition, and friction or shear force. The GNASC tool is used to assess
stage 1 pressure injuries in patients with dark skin tone. The BWAT is used to asses the
wound status. WOCN does not provide any measurement or assessment tools.
Which criteria does the Braden Scale evaluate?
A. skin integrity at bony prominences, including any wounds
B. risk factors that place the patient at risk of pressure injury
C. the amount of repositioning that the patient can tolerate
D. the factors that place the patient at risk of poor wound healing - Answer -B. risk
factors that place the patient at risk of pressure injury
The Braden Scale measures factors in six subscales that can predict the risk of
pressure injury development. It does not assess skin or wounds, repositioning, or
wound healing.
Which vitamin should be provided to a patient to promote wound healing? Select all that
apply. One, some, or all responses may be correct.
A. vitamin A
B. vitamin B
C. vitamin C
D. vitamin D
E vitamin E - Answer -A. vitamin A
C. vitamin C
