Fundamentals:Skills Wound Care Latest
Exam Questions All Answered Correct.
The nurse is caring for a young adult client admitted 3 days ago with pneumonia. The client has a history
of injury leading to paraplegia 5 years ago and has smoked tobacco for the past 8 years. The assessment
reveals that the client has lost 10 pounds in the last month and rarely uses the motorized wheelchair.
Which risk factors are most likely to lead to impaired tissue integrity? Select all that apply. - Answer
Poor nutritional statusTobacco smoking
Immobility
The nurse is caring for a client who begins to cry when the dressing from a leg wound is removed. The
client states, "It hurts so much with the slightest touch." The nurse notes an odor and purulent drainage
from the wound. Which is the most likely cause of these findings? - Answer Infection of the wound
The nurse is caring for a client who presents to the emergency department (ED) with dehydration and
fever. An assessment reveals a pressure injury on the left buttock covered with necrotic tissue that
measures 8 cm (length) x 5 cm (width) x 0.5 cm (depth). How should the nurse stage this pressure injury?
- Answer Unstageable
Select all the primary assessment findings that are causing impaired tissue integrity.
A nurse is caring for a client with diabetes mellitus who is scheduled for amputation of a necrotic left
great toe. The client's WBC count is 9,000, and they have coolness of the lower extremities. The client
weighs 75 lb more than their ideal body weight and smokes two packs of cigarettes a day. - Answer
Diabetes mellitus
coolness of the lower extremities
smokes two packs of cigarettes a day
The nurse is caring for a client with a stage 4 pressure injury on the heel of the right foot. Which actions
should the nurse take to protect the client's left heel from developing a pressure injury? Select all that
apply. - Answer Provide adequate nutrition and fluid intake.
Place a pillow under the client's feet.
Provide a trapeze bar to facilitate movement in bed.
Establish an individualized turning schedule.
Exam Questions All Answered Correct.
The nurse is caring for a young adult client admitted 3 days ago with pneumonia. The client has a history
of injury leading to paraplegia 5 years ago and has smoked tobacco for the past 8 years. The assessment
reveals that the client has lost 10 pounds in the last month and rarely uses the motorized wheelchair.
Which risk factors are most likely to lead to impaired tissue integrity? Select all that apply. - Answer
Poor nutritional statusTobacco smoking
Immobility
The nurse is caring for a client who begins to cry when the dressing from a leg wound is removed. The
client states, "It hurts so much with the slightest touch." The nurse notes an odor and purulent drainage
from the wound. Which is the most likely cause of these findings? - Answer Infection of the wound
The nurse is caring for a client who presents to the emergency department (ED) with dehydration and
fever. An assessment reveals a pressure injury on the left buttock covered with necrotic tissue that
measures 8 cm (length) x 5 cm (width) x 0.5 cm (depth). How should the nurse stage this pressure injury?
- Answer Unstageable
Select all the primary assessment findings that are causing impaired tissue integrity.
A nurse is caring for a client with diabetes mellitus who is scheduled for amputation of a necrotic left
great toe. The client's WBC count is 9,000, and they have coolness of the lower extremities. The client
weighs 75 lb more than their ideal body weight and smokes two packs of cigarettes a day. - Answer
Diabetes mellitus
coolness of the lower extremities
smokes two packs of cigarettes a day
The nurse is caring for a client with a stage 4 pressure injury on the heel of the right foot. Which actions
should the nurse take to protect the client's left heel from developing a pressure injury? Select all that
apply. - Answer Provide adequate nutrition and fluid intake.
Place a pillow under the client's feet.
Provide a trapeze bar to facilitate movement in bed.
Establish an individualized turning schedule.
