NURS 341 Exam 2 Questions With Complete Solutions

1. Which function does black polyurethane foam serve in wound healing? Select all that apply. One, some, or all responses may be correct. - ANSWER Contracts the wound Absorbs fluids from the wound 2. Which type of gauze should be used for dressing a wound on the palm? - ANSWER elastic net 3. Which equipment is used by the health care provider while applying moist dressing to a patient who has pressure ulcers? - ANSWER Montgomery ties 4. Which statement is true regarding hydrogel dressings? - ANSWER They enhance autolytic debridement 5. Which type of dressing is used for stage 1 pressure ulcers? - ANSWER Transparent film dressings 6. The nurse observes that a patient's ulcer is very slow to heal. Which action made by the nurse can help facilitate faster healing of the patient's wound? - ANSWER Assessing the ulcer during each dressing change 7. Which type of dressing is used for a stage 3 pressure ulcer? - ANSWER Calcium alginate 8. Which task can be delegated to assistive personnel (AP)? - ANSWER Securing the dressing using special tapes 9. Which condition does non blanchable erythema indicate about the skin tissue? - ANSWER damage 10. Which intervention can be performed by assistive personnel (AP) while caring for a patient who has a chronic wound? - ANSWER Reporting changes in skin integrity to the registered nurse immediately 11. The nurse administers an analgesic medication to a patient with a stage 4 pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic? - ANSWER 30 to 60 minutes after administration 12. Which type of dressing would be most appropriate for a patient with a partial-thickness, necrotic pressure ulcer with moderate drainage? - ANSWER Hydrocolloid dressing 13. Which fluids if exposed to the skin pose the highest risk of skin breakdown? - ANSWER Gastric secretions 14. Which type of dressing is preferred for dry wounds? - ANSWER hydrogel 15. Which function does black polyurethane foam serve in wound healing? Select all that apply. One, some, or all responses may be correct. - ANSWER Contracts the wound Absorbs fluids from the wound 16. A patient developed a pressure ulcer after knee surgery because of restriction to bed. Which irrigating fluid should the nurse use to clean the ulcer? - ANSWER normal saline 17. Which equipment would be required if wound drainage is present when applying an ace bandage? - ANSWER clean gloves 18. Which items would be required for wound irrigation? - ANSWER Gauze dressing supplies 19. Which statement is true regarding use of an abdominal binder after surgery? Select all that apply. One, some, or all responses may be correct. - ANSWER They protect incisions during movement. The binders are secured with Velcro strips They are effective in providing comfort during coughing 20. Which action would be inappropriate when applying an abdominal binder? - ANSWER Placing the patient in a prone position 21. Which item would be required for a wound irrigation delivery system? - ANSWER 19-gauge angiocath 22. Which body parts would be dressed in a figure-eight manner? - ANSWER joints 23. A patient reports pain in the ankle joint because of a sprain. Which nursing intervention would be beneficial to the patient? - ANSWER Placing an elastic bandage 24. Which responsibility can be delegated to an assistive personnel (AP) during wound care? Select all that apply. One, some, or all responses may be correct. - ANSWER Applying an elastic bandage Reporting any movement restrictions of the patient 25. For which reason would the nurse form a cuff on a waterproof bag and place it near the bed while performing wound irrigation? - ANSWER Holding the contaminated dressings to be discarded 26. Which patient may require a pulsatile high-pressure lavage for wound irrigation? - ANSWER The person who has a necrotic wound 27. Which color would be sanguineous drainage on a patient's dressing? - ANSWER Bright red 28. Which nursing action would be appropriate when the skin under the elastic bandage breaks? - ANSWER Reapply the bandage at a different area with less pressure. 29. Which size syringe is used for irrigating an open wound? Record your answer using whole number. _______ mL - ANSWER 35ml 30. Which amount of retinol equivalents for vitamin A per day would the nurse recommend a patient to consume to support proper wound healing? - ANSWER 1600 to 2000 retinol equivalents per day 31. The removal of devitalized tissue from a wound describes which process? - ANSWER Debridement 32. Which statement is true regarding sutures? - ANSWER Fine sutures cause minimal tissue injury 33. Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? - ANSWER Vitamin A 34. How many kilocalories per kilogram per day would the nurse suggest a patient consume to promote proper wound healing? - ANSWER 30-35 35. Which quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day - ANSWER The amount of vitamin C recommended for wound healing is 1000 mg/day to promote collagen synthesis, maintain capillary wall integrity, help fibroblast function, promote immunity, and provide antioxidant benefits. 36. Which image illustrates blanket continuous sutures? - ANSWER Correct3 37. A patient's wound drainage appears thick and yellow. Which type of drainage is this considered? - ANSWER Purulent 38. Which type of wound drainage is considered sanguineous? - ANSWER Bright red, active bleeding 39. A patient has come to the clinic after sustaining an abrasion. Which characteristic of this wound type would the nurse likely find upon assessment? Select all that apply. One, some, or all responses may be correct. - ANSWER Superficial Considered a partial-thickness wound Weepy 40. How much volume of drainage would equal 1 g of dressing? Record your answer using a whole number. ___ mL - ANSWER 1 ml 41. Which amount of zinc is recommended for wound healing? - ANSWER 15 to 30 mg 42. When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past how many years? Record your answer using whole number. ____ - ANSWER 10 years 43. Which amount of fluids per kilogram per day would the nurse encourage the patient to drink for proper wound healing? - ANSWER 30 to 35 ml 44. Which condition warrants the use of cold therapy? - ANSWER direct trauma 45. Which nursing action would be appropriate when providing care to a patient who exhibits no risk of skin breakdown? - ANSWER Using a standard surface 46. Which intervention is part of the Nursing Interventions Classification (NIC) for wound care? - ANSWER Irrigating the wound with a saline solution 2 times per day 47. Which dressing would be inappropriate for a patient with a clean stage 2 pressure injury? - ANSWER silver 48. Which size tape would the nurse use to stabilize a large dressing? - ANSWER 7.5 cm (3 inches) 49. Which dressing would the nurse use for a patient with a clean stage 3 pressure injury? - ANSWER Calcium alginate 50. Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure injury? - ANSWER Surgical consultation for debridement 51. How far beyond the wound edges would the nurse extend the sealant when framing the periwound area of a patient? - ANSWER 2.5 to 5 cm (1 to 2 inches) 52. The nurse is caring for a patient who is diagnosed with venous stasis pressure injuries. Which support surface would the nurse anticipate for this patient? - ANSWER Lateral rotation Which nursing action would be a teaching strategy for patients and families who will be working with a pressure-redistribution surface? Select all that apply. One, some, or all responses may be correct.s - ANSWER Explaining the reasons for the prescription Teaching common errors associated with the prescription Noting the minimum layers of linen to be used with the prescription Which nursing intervention is appropriate for a patient who is at risk of skin breakdown because of decreased sensory perception? - ANSWER Provide a pressure-redistribution surface. Which nursing intervention would be appropriate for a patient who is at risk of infection because of a surgical incision at the right hip? - ANSWER Obtaining a wound culture as needed After a surgical procedure, the patient experiences thrombocytopenia. For which condition would this postsurgical patient be at risk? - ANSWER Hemorrhage Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk of impaired skin integrity of the heels? - ANSWER Place a pillow under the calves Which nursing intervention would be appropriate for a patient who is at risk of skin breakdown because of moisture? - ANSWER Keep the skin dry and free of maceration