NSG300 Exam 2 Foundations of Nursing
GCU Questions and Answers
1. Which irrigation technique with normal saline is best for a wound?
A. Pour saline directly onto wound from the bottle
B. Moisten a sterile gauze pad and pat over the wound
C. Irrigate as gently as possible using a 60mL bulb syringe
D. Apply steady pressure using a 35mL syringe and 19 gauge
needle
ANS: D.
Rationale:
Using a 35mL syringe and 19 gauge needle provides adequate pressure to ensure effective irrigation
2. What is the purpose of a wet-to-dry wound dressing?
A. To mechanically debride the tissue
B. Facilitate tissue healing
C. Decrease risk of infection
D. Preserve granulation tissue
ANS: A. Rationale:
-B is incorrect because this dressing impedes healing due to tissue cooling
-C is incorrect because this dressing increases the risk of infection due to frequency of dressing change
-D is incorrect because this dressing may destroy granulation tissue
,3. A wound is infected with MRSA. Which type of precautions should
the nurse and staff use when caring for this client?
A. Standard
B. Droplet
C. Airborne
D. Contact
ANS: D.
Rationale:
Contact precautions are needed because MRSA's mode of transmission includes direct contact and contact
with infected surfaces
4. What type of equipment is used to assess the length of the
tract in wound tunneling?
A. Sterile gloves and lubricant
B. Sterile tape measure
C. Sterile cotton-tipped applicator
D. Sterile irrigation tray with
syringe
ANS: C.
Rationale:
Tunneling is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the
location and length of the tunneling
,5. A nurse observes a reddish area that is round and directly over
the client's sacrum. The skin is intact. What assessment measures
should the nurse per- form? (SELECT ALL THAT APPLY)
A. Apply light pressure to the area with the fingertips
B. Measure the diameter of the redness
C. Obtain a wound culture
D. Gently lift a fold of skin
E. Observe for wound approximation
ANS: A. B.
Rationale:
-A. The nurse should apply light pressure to assess for blanching
-B. The area of redness should be measured to evaluate progression or healing
-C. The nurse does not need to obtain a wound culture if the skin is intact with no drainage
-D. This would be to assess turgor for hydration status, not for assessing wounds
-E. Since the skin is intact, there are no wound edges to be approximated
6. To provide pressure relief at night, the nurse should teach a
wound care patient to sleep in which position?
A. Supine with the head of the bed elevated
B. Supine with a foam wedge between the knees
C. Thirty-degree lateral inclined position
D. Full side-lying position supported with
pillows
, ANS: C.
Rationale:
This position (AKA semi Fowlers) best reduces pressure on bony prominences where pressure ulcers
frequently develop. Pillows and foam wedges may be used for support and protection in this position
7. A patient arrives to the ED with a sacral ulcer that is crater-like in
appearance, and is draining a thick yellow-tan fluid with an
unpleasant odor. Which best describes the drainage of the wound?
A. Infectious
B. Purulent
C. Serous
D. Sanguineous
ANS: B.
Rationale:
Purulent refers to something that contains or produces pus. Pus is an indication that infection is likely
-A. Infectious is not the best terminology to describe the appearance of the drainage
-C. Serous describes a thin, watery substance
-D. Sanguineous describes a bright red substance
8. Which intervention is important to reduce the effect of
diarrhea on the skin when a sacral ulcer is present?
A. Apply a moisture-repellent ointment to intact skin areas
B. Rinse ulcerated areas with an alcohol-based irrigating solution
GCU Questions and Answers
1. Which irrigation technique with normal saline is best for a wound?
A. Pour saline directly onto wound from the bottle
B. Moisten a sterile gauze pad and pat over the wound
C. Irrigate as gently as possible using a 60mL bulb syringe
D. Apply steady pressure using a 35mL syringe and 19 gauge
needle
ANS: D.
Rationale:
Using a 35mL syringe and 19 gauge needle provides adequate pressure to ensure effective irrigation
2. What is the purpose of a wet-to-dry wound dressing?
A. To mechanically debride the tissue
B. Facilitate tissue healing
C. Decrease risk of infection
D. Preserve granulation tissue
ANS: A. Rationale:
-B is incorrect because this dressing impedes healing due to tissue cooling
-C is incorrect because this dressing increases the risk of infection due to frequency of dressing change
-D is incorrect because this dressing may destroy granulation tissue
,3. A wound is infected with MRSA. Which type of precautions should
the nurse and staff use when caring for this client?
A. Standard
B. Droplet
C. Airborne
D. Contact
ANS: D.
Rationale:
Contact precautions are needed because MRSA's mode of transmission includes direct contact and contact
with infected surfaces
4. What type of equipment is used to assess the length of the
tract in wound tunneling?
A. Sterile gloves and lubricant
B. Sterile tape measure
C. Sterile cotton-tipped applicator
D. Sterile irrigation tray with
syringe
ANS: C.
Rationale:
Tunneling is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the
location and length of the tunneling
,5. A nurse observes a reddish area that is round and directly over
the client's sacrum. The skin is intact. What assessment measures
should the nurse per- form? (SELECT ALL THAT APPLY)
A. Apply light pressure to the area with the fingertips
B. Measure the diameter of the redness
C. Obtain a wound culture
D. Gently lift a fold of skin
E. Observe for wound approximation
ANS: A. B.
Rationale:
-A. The nurse should apply light pressure to assess for blanching
-B. The area of redness should be measured to evaluate progression or healing
-C. The nurse does not need to obtain a wound culture if the skin is intact with no drainage
-D. This would be to assess turgor for hydration status, not for assessing wounds
-E. Since the skin is intact, there are no wound edges to be approximated
6. To provide pressure relief at night, the nurse should teach a
wound care patient to sleep in which position?
A. Supine with the head of the bed elevated
B. Supine with a foam wedge between the knees
C. Thirty-degree lateral inclined position
D. Full side-lying position supported with
pillows
, ANS: C.
Rationale:
This position (AKA semi Fowlers) best reduces pressure on bony prominences where pressure ulcers
frequently develop. Pillows and foam wedges may be used for support and protection in this position
7. A patient arrives to the ED with a sacral ulcer that is crater-like in
appearance, and is draining a thick yellow-tan fluid with an
unpleasant odor. Which best describes the drainage of the wound?
A. Infectious
B. Purulent
C. Serous
D. Sanguineous
ANS: B.
Rationale:
Purulent refers to something that contains or produces pus. Pus is an indication that infection is likely
-A. Infectious is not the best terminology to describe the appearance of the drainage
-C. Serous describes a thin, watery substance
-D. Sanguineous describes a bright red substance
8. Which intervention is important to reduce the effect of
diarrhea on the skin when a sacral ulcer is present?
A. Apply a moisture-repellent ointment to intact skin areas
B. Rinse ulcerated areas with an alcohol-based irrigating solution
