Fundamentals of Nursing 9th Ed Ch 36 QUESTIONS AND ANSWERS A+ RATED

Fundamentals of Nursing 9th Ed Ch 36 QUESTIONS AND ANSWERS A+ RATED The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection - ANS Correct Answer: 3 The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected - ANS Correct Answer: 2 A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this client's care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving. - ANS Correct Answer: 1 After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer - ANS Correct Answer: 1 The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top. - ANS Correct Answer: 3 The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should: 1. Obtain a transparent dressing for the UAP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the UAP to reevaluate the wound in 20 minutes. - ANS Correct Answer: 3