Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
The nurse assesses a patient's surgical wound on the first postoperative day and
notes redness and warmth around the incision. Which action by the nurse is
appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours. - CORRECT ANSWERS ANS: B
The incisional redness and warmth are indicators of the normal initial
(inflammatory) stage of wound healing by primary intention. The nurse should
document the wound appearance and continue to monitor the wound.
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL
and a band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
d. Redress the wound with wet-to-dry dressings. - CORRECT ANSWERS ANS:
A
The increase in WBC count with the increased bands (shift to the left) indicates that
the patient probably has a bacterial infection, and the nurse should obtain wound
cultures.
A patient with a systemic bacterial infection feels cold and has a shaking chill.
Which assessment finding will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure - CORRECT ANSWERS ANS: C
,Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
The patient's complaints of feeling cold and shivering indicate that the
hypothalamic set point for temperature has been increased and the temperature is
increasing.
A young adult patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which
action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - CORRECT ANSWERS
ANS: C
Mild to moderate temperature elevations (<103° F) do not harm young adult
patients and may benefit host defense mechanisms. The nurse should continue to
monitor the temperature.
A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse
apply to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing - CORRECT ANSWERS ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-
green slough. A hydrocolloid dressing such as DuoDerm would accomplish these
goals
The nurse notes that a patient's open abdominal wound widens as it extends deeper
into the abdomen. How would the nurse document this characteristic?
a. Eschar
,Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
b. Slough
c. Maceration
d. Undermining - CORRECT ANSWERS ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and
there is a narrower "lip" around the wound, which widens as the wound deepens.
Eschar is a crusted cover over a wound. Slough and maceration refer to loosening
friable tissue.
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - CORRECT ANSWERS ANS: D
The earliest manifestation of an infection may be "just not feeling well." Common
clinical manifestations of inflammation and infection are frequently not present
when patients receive immunosuppressive medications.
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas -
CORRECT ANSWERS ANS: D
Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-
thickness wound filled with eschar will require interventions such as surgical
debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on
approximated surgical incisions. Wet-to-dry dressings are not used on uninfected
granulating wounds because of the damage to the granulation tissue.
, Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
A patient from a long-term care facility is admitted to the hospital with a sacral
pressure ulcer. The base of the wound involves subcutaneous tissue. How should
the nurse classify this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV - CORRECT ANSWERS ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the
subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable
damage such as redness or a boggy feel. Stage II pressure ulcers have partial-
thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue
necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
A young male patient with paraplegia has a stage II sacral pressure ulcer and is
being cared for at home by his family. To prevent further tissue damage, what
instructions are most important for the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly. - CORRECT ANSWERS
ANS: C
The most important intervention is to avoid prolonged pressure on bony
prominences by frequent repositioning. The other interventions may also be
included in family teaching.
The nurse will perform which action when doing a wet-to-dry dressing change on a
patient's stage III sacral pressure ulcer?
a. Administer prescribed PRN hydrocodone 30 minutes before the change.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Apply antimicrobial ointment before repacking the wound with moist dressings.
Answers 2024/2025 RATED A+
The nurse assesses a patient's surgical wound on the first postoperative day and
notes redness and warmth around the incision. Which action by the nurse is
appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours. - CORRECT ANSWERS ANS: B
The incisional redness and warmth are indicators of the normal initial
(inflammatory) stage of wound healing by primary intention. The nurse should
document the wound appearance and continue to monitor the wound.
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL
and a band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
d. Redress the wound with wet-to-dry dressings. - CORRECT ANSWERS ANS:
A
The increase in WBC count with the increased bands (shift to the left) indicates that
the patient probably has a bacterial infection, and the nurse should obtain wound
cultures.
A patient with a systemic bacterial infection feels cold and has a shaking chill.
Which assessment finding will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure - CORRECT ANSWERS ANS: C
,Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
The patient's complaints of feeling cold and shivering indicate that the
hypothalamic set point for temperature has been increased and the temperature is
increasing.
A young adult patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which
action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - CORRECT ANSWERS
ANS: C
Mild to moderate temperature elevations (<103° F) do not harm young adult
patients and may benefit host defense mechanisms. The nurse should continue to
monitor the temperature.
A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse
apply to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing - CORRECT ANSWERS ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-
green slough. A hydrocolloid dressing such as DuoDerm would accomplish these
goals
The nurse notes that a patient's open abdominal wound widens as it extends deeper
into the abdomen. How would the nurse document this characteristic?
a. Eschar
,Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
b. Slough
c. Maceration
d. Undermining - CORRECT ANSWERS ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and
there is a narrower "lip" around the wound, which widens as the wound deepens.
Eschar is a crusted cover over a wound. Slough and maceration refer to loosening
friable tissue.
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - CORRECT ANSWERS ANS: D
The earliest manifestation of an infection may be "just not feeling well." Common
clinical manifestations of inflammation and infection are frequently not present
when patients receive immunosuppressive medications.
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas -
CORRECT ANSWERS ANS: D
Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-
thickness wound filled with eschar will require interventions such as surgical
debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on
approximated surgical incisions. Wet-to-dry dressings are not used on uninfected
granulating wounds because of the damage to the granulation tissue.
, Med-Surg Final Exam 223Questions and
Answers 2024/2025 RATED A+
A patient from a long-term care facility is admitted to the hospital with a sacral
pressure ulcer. The base of the wound involves subcutaneous tissue. How should
the nurse classify this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV - CORRECT ANSWERS ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the
subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable
damage such as redness or a boggy feel. Stage II pressure ulcers have partial-
thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue
necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
A young male patient with paraplegia has a stage II sacral pressure ulcer and is
being cared for at home by his family. To prevent further tissue damage, what
instructions are most important for the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly. - CORRECT ANSWERS
ANS: C
The most important intervention is to avoid prolonged pressure on bony
prominences by frequent repositioning. The other interventions may also be
included in family teaching.
The nurse will perform which action when doing a wet-to-dry dressing change on a
patient's stage III sacral pressure ulcer?
a. Administer prescribed PRN hydrocodone 30 minutes before the change.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Apply antimicrobial ointment before repacking the wound with moist dressings.
