Foundations of Nursing Practice Exam 2
On initial assessment of a patient, the nurse notices an area of redness over
the right trochanter that, when pressed lightly, does not blanch. What does this
assessment finding indicate to the nurse?
a. The presence of an infection in the area
b. The presence of a stage I pressure ulcer
c. An allergic reaction to the sheets
d. The need to apply a cold compress to reduce inflammation: b. The presence
of a stage I pressure ulcer
Four days after abdominal surgery, the patient is getting out of bed and feels
something "pop" in his abdominal wound. An increase in amount of drainage
from the wound is seen, and further examination shows that the sutured
incision is now partially open, with tissue protruding from the wound. What is
the nurse's next action?
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze, and notify the physician.
c. Assure the patient that this is common, and document the findings.
d. Apply a binder to pull the wound edges together and provide support to the
edges.: b. Cover the wound with saline-moistened gauze, and notify the
physician
Which features are characteristic of a closed drainage system such as a
Jackson-Pratt (JP) drain? (Select all that apply.)
a. Works by gravity
b. Provides for early discharge
c. Usually is inserted in surgery
d. Reduces the amount of antibiotics required
e. Allows for accurate measurement of wound drainage
,f. Allows bacteria to migrate up the drain from the surrounding dressing: c,e c.
Usually is inserted in surgery
e. Allows for accurate measurement of wound drainage
Which intervention should be initiated by the nurse caring for a patient with
urinary or fecal incontinence?
a. Using a heat lamp to dry the skin
b. Changing the adult brief every 8 hours
c. Cleansing frequently with hot water and a strong soap
d. Using an incontinence cleanser and a moisture barrier ointment: d. Using an
incontinence cleanser and a moisture barrier ointment
Based on knowledge of areas at greatest risk for development of a pressure
ulcer in the bedridden patient, the nurse identifies which position to minimize
this risk?
a. 30-degree side-lying
b. Sitting with the head of the bed elevated 75 degrees
c. 90-degree side-lying
d. Lying supine with the bed flat at all times: a. 30-degree side-lying
A patient who has suffered a stroke is unable to maintain his position while
seated in a chair without sliding down. His physician has ordered him to be up
in a chair for part of the day. What does the nurse recognize as the patient's
greatest risk factor for development of pressure ulcers? a. Moisture from
incontinence
b. Nutritional deficiencies
c. Pressure and shear
d. Aging: c. Pressure and shear
, A patient has a stage III pressure ulcer on the coccyx. Which food will be most
beneficial in improving the healing process?
a. Food high in vitamin D
b. Whole-grain carbohydrates
c. High-calorie, high-protein drink
d. Food high in fat and water content: c. High-calorie, High-protein drink
Which technique is used to collect an aerobic culture specimen from a wound?
a. Collect the specimen immediately after removing the old dressing.
b. Apply sterile gloves, then open the culture tube.
c. Always be sure to culture any necrotic tissue.
d. Irrigate the wound before collecting the culture material.: d. Irrigate the
wound before collecting the culture material
Internal variables that influence health and beliefs: developmental,
intellectual background, perception of functioning, emotional factors
External variables that influence health and beliefs: family practices, culture,
socioeconomic factors
Passive strategies of health promotion: gaining the benefit from something
that's not been done
ex. getting vitamins from milk
Active strategies of health promotion: physically doing activities to promote
health
ex. exercising, taking multivitamins
On initial assessment of a patient, the nurse notices an area of redness over
the right trochanter that, when pressed lightly, does not blanch. What does this
assessment finding indicate to the nurse?
a. The presence of an infection in the area
b. The presence of a stage I pressure ulcer
c. An allergic reaction to the sheets
d. The need to apply a cold compress to reduce inflammation: b. The presence
of a stage I pressure ulcer
Four days after abdominal surgery, the patient is getting out of bed and feels
something "pop" in his abdominal wound. An increase in amount of drainage
from the wound is seen, and further examination shows that the sutured
incision is now partially open, with tissue protruding from the wound. What is
the nurse's next action?
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze, and notify the physician.
c. Assure the patient that this is common, and document the findings.
d. Apply a binder to pull the wound edges together and provide support to the
edges.: b. Cover the wound with saline-moistened gauze, and notify the
physician
Which features are characteristic of a closed drainage system such as a
Jackson-Pratt (JP) drain? (Select all that apply.)
a. Works by gravity
b. Provides for early discharge
c. Usually is inserted in surgery
d. Reduces the amount of antibiotics required
e. Allows for accurate measurement of wound drainage
,f. Allows bacteria to migrate up the drain from the surrounding dressing: c,e c.
Usually is inserted in surgery
e. Allows for accurate measurement of wound drainage
Which intervention should be initiated by the nurse caring for a patient with
urinary or fecal incontinence?
a. Using a heat lamp to dry the skin
b. Changing the adult brief every 8 hours
c. Cleansing frequently with hot water and a strong soap
d. Using an incontinence cleanser and a moisture barrier ointment: d. Using an
incontinence cleanser and a moisture barrier ointment
Based on knowledge of areas at greatest risk for development of a pressure
ulcer in the bedridden patient, the nurse identifies which position to minimize
this risk?
a. 30-degree side-lying
b. Sitting with the head of the bed elevated 75 degrees
c. 90-degree side-lying
d. Lying supine with the bed flat at all times: a. 30-degree side-lying
A patient who has suffered a stroke is unable to maintain his position while
seated in a chair without sliding down. His physician has ordered him to be up
in a chair for part of the day. What does the nurse recognize as the patient's
greatest risk factor for development of pressure ulcers? a. Moisture from
incontinence
b. Nutritional deficiencies
c. Pressure and shear
d. Aging: c. Pressure and shear
, A patient has a stage III pressure ulcer on the coccyx. Which food will be most
beneficial in improving the healing process?
a. Food high in vitamin D
b. Whole-grain carbohydrates
c. High-calorie, high-protein drink
d. Food high in fat and water content: c. High-calorie, High-protein drink
Which technique is used to collect an aerobic culture specimen from a wound?
a. Collect the specimen immediately after removing the old dressing.
b. Apply sterile gloves, then open the culture tube.
c. Always be sure to culture any necrotic tissue.
d. Irrigate the wound before collecting the culture material.: d. Irrigate the
wound before collecting the culture material
Internal variables that influence health and beliefs: developmental,
intellectual background, perception of functioning, emotional factors
External variables that influence health and beliefs: family practices, culture,
socioeconomic factors
Passive strategies of health promotion: gaining the benefit from something
that's not been done
ex. getting vitamins from milk
Active strategies of health promotion: physically doing activities to promote
health
ex. exercising, taking multivitamins
