Lewis - Med-Surg Nursing - Study Guide
- Ch. 11
A affected person had a complex vaginal hysterectomy. The student nurse furnished perineal
care after the patient had a bowel movement. The pupil nurse tells the nurse there was quite a
few light brown, smelly drainage seeping from the perianal vicinity. What must the nurse suspect
whilst assessing this affected person?
A. Dehiscence
b. Hemorrhage
c. Keloid formation
d. Fistula formation - ANS-d
A affected person had stomach surgical procedure three months in the past and calls the
hospital with complaints of excessive belly pain and cramping, vomiting, and bloating. What
should the nurse most likely suspect as the cause of the patient's trouble?
A. Infection
b. Adhesion
c. Contracture
d. Evisceration - ANS-b
A patient's documentation indicates he has a level III strain ulcer on his right hip. What need to
the nurse expect to locate on evaluation of the patient's right hip?
A. Exposed bone, tendon, or muscle
b. An abrasion, blister, or shallow crater
c. Deep crater via subcutaneous tissue to fascia
d. Persistent redness (or bluish coloration in darker skin tones) - ANS-c
Delegation Decision: Which nursing interventions for a patient with a Stage IV sacral strain ulcer
are mostappropriate to assign or delegate to a licensed realistic nurse (LPN) (pick all that
observe)?
A. Assess and record wound look.
B. Teach the patient strain ulcer hazard factors.
C. Choose the form of dressing to apply to the ulcer.
D. Measure the size (width, duration, intensity) of the ulcer.
E. Assist the patient to exchange positions at frequent intervals. - ANS-d, e
During the recovery phase of inflammation, which cells might be normally probable to
regenerate?
A. Skin
b. Neurons
c. Cardiac muscle
d. Skeletal muscle - ANS-a
- Ch. 11
A affected person had a complex vaginal hysterectomy. The student nurse furnished perineal
care after the patient had a bowel movement. The pupil nurse tells the nurse there was quite a
few light brown, smelly drainage seeping from the perianal vicinity. What must the nurse suspect
whilst assessing this affected person?
A. Dehiscence
b. Hemorrhage
c. Keloid formation
d. Fistula formation - ANS-d
A affected person had stomach surgical procedure three months in the past and calls the
hospital with complaints of excessive belly pain and cramping, vomiting, and bloating. What
should the nurse most likely suspect as the cause of the patient's trouble?
A. Infection
b. Adhesion
c. Contracture
d. Evisceration - ANS-b
A patient's documentation indicates he has a level III strain ulcer on his right hip. What need to
the nurse expect to locate on evaluation of the patient's right hip?
A. Exposed bone, tendon, or muscle
b. An abrasion, blister, or shallow crater
c. Deep crater via subcutaneous tissue to fascia
d. Persistent redness (or bluish coloration in darker skin tones) - ANS-c
Delegation Decision: Which nursing interventions for a patient with a Stage IV sacral strain ulcer
are mostappropriate to assign or delegate to a licensed realistic nurse (LPN) (pick all that
observe)?
A. Assess and record wound look.
B. Teach the patient strain ulcer hazard factors.
C. Choose the form of dressing to apply to the ulcer.
D. Measure the size (width, duration, intensity) of the ulcer.
E. Assist the patient to exchange positions at frequent intervals. - ANS-d, e
During the recovery phase of inflammation, which cells might be normally probable to
regenerate?
A. Skin
b. Neurons
c. Cardiac muscle
d. Skeletal muscle - ANS-a
