NUR 201 Exam 1
Terms in this set (155)
The nurse assesses a ANS: B
patient's surgical wound on The incisional redness and warmth are indicators of the
the first postoperative day normal initial (inflammatory) stage of wound healing by
and notes redness and primary intention. The nurse should document the
warmth around the incision. wound appearance and continue to monitor the
Which action by the nurse wound. Notification of the health care
is provider, assessment every 2 hours, and obtaining
appropriate? wound cultures are not indicated because the healing
a. Obtain wound cultures.
is progressing normally.
b. Document the assessment.
c. Notify the health care
provider.
d. Assess the wound every 2
hours.
A patient with an open leg ANS: A
lesion has a The increase in WBC count with the increased bands
white blood cell (WBC) count (shift to the left) indicates that the patient probably has
of 13,500/µL and a band a bacterial infection, and the nurse should obtain wound
count of 11%. What cultures. Antibiotic therapy and/or dressing changes
prescribed action should may be started, but cultures
the nurse take first? should be done first. The nurse will continue to monitor
a. Obtain cultures of the
wound. the wound, but additional actions are needed as well.
b. Begin antibiotic
administration.
c. Continue to monitor
the wound for
drainage.
d. Redress the wound with
wet-to-dry
dressings.
,A patient with a systemic ANS: C
bacterial infection feels cold The patient's report of feeling cold and shivering
and has a shaking chill. indicate that the hypothalamic set point for temperature
Which has increased and the temperature will be increasing.
assessment finding will the Because associated peripheral vasoconstriction and
nurse expect
next? sympathetic nervous system stimulation will occur,
a. Skin flushing skin flushing and hypotension are not expected.
b. Muscle cramps Muscle cramps are not expected with chills and
c. Rising body temperature shivering or with a rising temperature.
d. Decreasing blood pressure
A young adult patient ANS: C
receiving antibiotics for an Mild to moderate temperature elevations (less than 103°
infected leg wound has a F) do not harm young adult patients and may benefit
temperature of 101.8° F (38.7° host defense mechanisms. Continue to monitor the
C). The
temperature. Antipyretics are not indicated unless the patient
patient denies any has fever-related
discomfort. Which action by symptoms, and the patient does not require analgesics
the nurse is appropriate? if not reporting discomfort. There is no need to notify
a. Apply a cooling blanket. the patient's health care provider of a fever in a patient
b. Notify the health care
who is already being treated for the infection or to
provider.
use a cooling blanket for a moderate temperature
c. Check the patient's
elevation.
temperature again in 4
hours.
d. Give acetaminophen
prescribed as- needed
for pain.
A patient's 4 ⋅ 3-cm leg ANS: C
wound has a 0.4- cm black The wound requires debridement of the necrotic areas and
absorption of the
area in the center of the
yellow-green slough. A hydrocolloid dressing, such as
wound surrounded by
DuoDerm, would accomplish these goals. Transparent
yellow-green semiliquid
film dressings are used for clean wounds or
material. Which dressing
approximated surgical incisions. Dry dressings will
should the nurse apply to
not debride the necrotic areas. Nonadherent
the wound?
dressings will not absorb wound drainage or debride the wound.
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing
,The nurse notes that a ANS: D
patient's open Undermining is evident when a cotton-tipped applicator
abdominal wound widens as it is placed in the wound and there is a narrower "lip"
extends
around the wound, which widens as the wound deepens.
deeper into the abdomen.
Eschar is a crusted cover over a wound. Slough and
How would the nurse
maceration refer to loosening friable tissue.
document this
characteristic?
a. Eschar
b. Slough
c. Maceration
d. Undermining
A patient with rheumatoid ANS: D
arthritis has been taking oral The earliest manifestation of an infection may be "just not feeling
corticosteroids for 2 years. well." Common
clinical manifestations of inflammation and infection are
Which nursing action is
frequently not present when patients receive
most likely to detect early
immunosuppressive medications.
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.
, The nurse should plan to use ANS: D
a wet-to-dry dressing for Wet-to-dry dressings are used when there is minimal
which patient? eschar to be removed. A full- thickness wound filled with
a. A patient who has a eschar will require interventions such as surgical
pressure injury with pink debridement to remove the necrotic tissue. Wet-to-dry
granulation tissue. dressings are not needed on approximated surgical
b. A patient who has a incisions. Wet-to-dry dressings are not used on
surgical incision with pink, uninfected
approximated edges. granulating wounds because of the damage to the granulation
tissue.
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
A patient from a long-term ANS: C
care facility is admitted to A stage 3 pressure injury has full-thickness skin damage and
the hospital with a sacral extends into the
subcutaneous tissue. A stage 1 pressure injury has intact
pressure injury. The base
skin with some observable damage such as redness or a
of the wound involves
boggy feel. Stage 2 pressure injuries have partial-
subcutaneous tissue. How
thickness skin loss. Stage 4 pressure injuries have full-
should the nurse classify
thickness damage with tissue necrosis, extensive
this pressure injury?
a. Stage 1 damage, or damage to bone, muscle, or supporting
b. Stage 2 tissues.
c. Stage 3
d. Stage 4
A young male patient with ANS: C
paraplegia who has a stage 2 The most important intervention is to avoid prolonged pressure
on bony
sacral pressure injury is being
prominences by frequent repositioning. The other
cared for at home by his
interventions may also be included in family
family. To prevent further
teaching.
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
Terms in this set (155)
The nurse assesses a ANS: B
patient's surgical wound on The incisional redness and warmth are indicators of the
the first postoperative day normal initial (inflammatory) stage of wound healing by
and notes redness and primary intention. The nurse should document the
warmth around the incision. wound appearance and continue to monitor the
Which action by the nurse wound. Notification of the health care
is provider, assessment every 2 hours, and obtaining
appropriate? wound cultures are not indicated because the healing
a. Obtain wound cultures.
is progressing normally.
b. Document the assessment.
c. Notify the health care
provider.
d. Assess the wound every 2
hours.
A patient with an open leg ANS: A
lesion has a The increase in WBC count with the increased bands
white blood cell (WBC) count (shift to the left) indicates that the patient probably has
of 13,500/µL and a band a bacterial infection, and the nurse should obtain wound
count of 11%. What cultures. Antibiotic therapy and/or dressing changes
prescribed action should may be started, but cultures
the nurse take first? should be done first. The nurse will continue to monitor
a. Obtain cultures of the
wound. the wound, but additional actions are needed as well.
b. Begin antibiotic
administration.
c. Continue to monitor
the wound for
drainage.
d. Redress the wound with
wet-to-dry
dressings.
,A patient with a systemic ANS: C
bacterial infection feels cold The patient's report of feeling cold and shivering
and has a shaking chill. indicate that the hypothalamic set point for temperature
Which has increased and the temperature will be increasing.
assessment finding will the Because associated peripheral vasoconstriction and
nurse expect
next? sympathetic nervous system stimulation will occur,
a. Skin flushing skin flushing and hypotension are not expected.
b. Muscle cramps Muscle cramps are not expected with chills and
c. Rising body temperature shivering or with a rising temperature.
d. Decreasing blood pressure
A young adult patient ANS: C
receiving antibiotics for an Mild to moderate temperature elevations (less than 103°
infected leg wound has a F) do not harm young adult patients and may benefit
temperature of 101.8° F (38.7° host defense mechanisms. Continue to monitor the
C). The
temperature. Antipyretics are not indicated unless the patient
patient denies any has fever-related
discomfort. Which action by symptoms, and the patient does not require analgesics
the nurse is appropriate? if not reporting discomfort. There is no need to notify
a. Apply a cooling blanket. the patient's health care provider of a fever in a patient
b. Notify the health care
who is already being treated for the infection or to
provider.
use a cooling blanket for a moderate temperature
c. Check the patient's
elevation.
temperature again in 4
hours.
d. Give acetaminophen
prescribed as- needed
for pain.
A patient's 4 ⋅ 3-cm leg ANS: C
wound has a 0.4- cm black The wound requires debridement of the necrotic areas and
absorption of the
area in the center of the
yellow-green slough. A hydrocolloid dressing, such as
wound surrounded by
DuoDerm, would accomplish these goals. Transparent
yellow-green semiliquid
film dressings are used for clean wounds or
material. Which dressing
approximated surgical incisions. Dry dressings will
should the nurse apply to
not debride the necrotic areas. Nonadherent
the wound?
dressings will not absorb wound drainage or debride the wound.
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing
,The nurse notes that a ANS: D
patient's open Undermining is evident when a cotton-tipped applicator
abdominal wound widens as it is placed in the wound and there is a narrower "lip"
extends
around the wound, which widens as the wound deepens.
deeper into the abdomen.
Eschar is a crusted cover over a wound. Slough and
How would the nurse
maceration refer to loosening friable tissue.
document this
characteristic?
a. Eschar
b. Slough
c. Maceration
d. Undermining
A patient with rheumatoid ANS: D
arthritis has been taking oral The earliest manifestation of an infection may be "just not feeling
corticosteroids for 2 years. well." Common
clinical manifestations of inflammation and infection are
Which nursing action is
frequently not present when patients receive
most likely to detect early
immunosuppressive medications.
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.
, The nurse should plan to use ANS: D
a wet-to-dry dressing for Wet-to-dry dressings are used when there is minimal
which patient? eschar to be removed. A full- thickness wound filled with
a. A patient who has a eschar will require interventions such as surgical
pressure injury with pink debridement to remove the necrotic tissue. Wet-to-dry
granulation tissue. dressings are not needed on approximated surgical
b. A patient who has a incisions. Wet-to-dry dressings are not used on
surgical incision with pink, uninfected
approximated edges. granulating wounds because of the damage to the granulation
tissue.
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
A patient from a long-term ANS: C
care facility is admitted to A stage 3 pressure injury has full-thickness skin damage and
the hospital with a sacral extends into the
subcutaneous tissue. A stage 1 pressure injury has intact
pressure injury. The base
skin with some observable damage such as redness or a
of the wound involves
boggy feel. Stage 2 pressure injuries have partial-
subcutaneous tissue. How
thickness skin loss. Stage 4 pressure injuries have full-
should the nurse classify
thickness damage with tissue necrosis, extensive
this pressure injury?
a. Stage 1 damage, or damage to bone, muscle, or supporting
b. Stage 2 tissues.
c. Stage 3
d. Stage 4
A young male patient with ANS: C
paraplegia who has a stage 2 The most important intervention is to avoid prolonged pressure
on bony
sacral pressure injury is being
prominences by frequent repositioning. The other
cared for at home by his
interventions may also be included in family
family. To prevent further
teaching.
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
