VSIM Josephine Morrow Pre-Sim & Post-Sim questions and answers

VSIM Josephine Morrow Pre-Sim & Post-Sim questions and answers The nurse is reviewing a pt's lab results. which lab test most accurately represent nutritional status? - CORRECT ANSWERS pre-albumin ( has a shorter half life and is a more sensitive measure of current nutritional status) the nurse is completing an admission assessment on a pt admitted for impaired skin integrity. which questions would be appropriate for the nurse to ask the patient? - CORRECT ANSWERS have you noticed any swelling on your feet, ankles or fingers?, do some area of your skin seem warmer or colder than others?, have you used pads or special pants because you cannot control your urine?, do you have any sores on your body? the nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history? - CORRECT ANSWERS when did the edema start?, can you describe the edema?, what were you doing before you noticed the edema?, do you have any recent hx of surgery or illness?, what are your usual ADL?, do you stand a lot?, what meds do you take?, do you have heart disease or blood vessel disease? the nurse is conducting a skin assessment using braden scale. how would the nurse interpret the score 12? - CORRECT ANSWERS high risk the nurse is assessing a pt admitted with a venous stasis ulcer on the right lower extremity. what should the nurse expect to find when assessing the leg? - CORRECT ANSWERS dark discoloration of the skin surrounding the wound site the nurse is preparing to irrigate a wound. which statement, if made by the nurse, indicates an understanding of the procedure? - CORRECT ANSWERS i will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound the nurse removes a dressing and assesses yellow foul smelling drainage. How would the nurse document this finding? - CORRECT ANSWERS purulent the nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? - CORRECT ANSWERS ask the pt to press the call bell to summon a co-worker to obtain another dressing the nurse is completing an admission assessment on a pt admitted for an infected non-healing factors in the pt history may contribute to this condition? - CORRECT ANSWERS poor hygiene, obesity, DM, poor circulation the nurse assesses a wound and documents it as stage 3. what did the nurse observe when the wound was assessed? - CORRECT ANSWERS full thickness tissue loss, possibly with visible subcutaneous fat.