2310 Exam 2 Questions And Correct A
A patient's 4 × 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by
c c c c c c c c c c c c c c c c c c c
material. Which dressing should the nurse apply to the wound?
c c c c c c c c c c
Dry gauze dressing
c c
Nonadherent dressing c
Transparent film dressing c c
Hydrocolloid dressing - CORRECT ANS✔✔Hydrocolloid dressing
c c c c c
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough.
c c c c c c c c c c c c c c
as DuoDerm, would accomplish these goals. Transparent film dressings are used for clean wound
c c c c c c c c c c c c c c
incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb
c c c c c c c c c c c c c c
wound.
c
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdo
c c c c c c c c c c c c c c c c
document this characteristic?
c c c
Eschar
Undermining
Maceration
Slough - CORRECT ANS✔✔Correct! Undermining
c c c c
Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narro
c c c c c c c c c c c c c c c c
which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and macera
c c c c c c c c c c c c c c c c c
tissue.
c
A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The
c c c c c c c c c c c c c c c c c
subcutaneous tissue. How should the nurse classify this pressure injury?
c c c c c c c c c c
Stage 1 c
Stage 4 c
Stage 3 c
Stage 2 - CORRECT ANS✔✔Correct! Stage 3
c c c c c c
A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue
c c c c c c c c c c c c c c
intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injur
c c c c c c c c c c c c c c c c c
loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage
c c c c c c c c c c c c c
supporting tissues.
c c
c c c c c c c c c c c c c c c c c c
, c
although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's
c c c c c c c c c c c c c c
c
pain does not directly affect wound healing.
c c c c c c
A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. W
c c c c c c c c c c c c c c c
interventions to promote wound healing, what is the nurse's highest priority?
c c c c c c c c c c c
Giving antipyretics to keep the temperature less than 102° F (38.9° C
c c c c c c c c c c c
Maintaining the patient's blood glucose within a normal range c c c c c c c c c
Ensuring that the patient has an adequate dietary protein intake
c c c c c c c c c
Redressing the surgical incision with a dry, sterile dressing twice daily - CORRECT ANS✔✔Correc
c c c c c c c c c c c c c
blood glucose within a normal range Elevated blood glucose will impair wound healing in multiple
c c c c c c c c c c c c c c c c
nutrition is important for the postoperative patient, but a higher priority is blood glucose control. A t
c c c c c c c c c c c c c c c c c
impact wound healing. Application of a dry, sterile dressing daily may be ordered, but frequent dre
c c c c c c c c c c c c c c c c
healing by primary intention is not necessary to promote wound healing.
c c c c c c c c c c c
After the home health nurse teaches a patient's family member about how to care for a sacral pres
c c c c c c c c c c c c c c c c c
indicates that additional teaching is needed?
c c c c c c
The family member uses clean tap water to clean the wound.
c c c c c c c c c c
The family member dries the wound using a hair dryer on a low setting.
c c c c c c c c c c c c c
The family member uses a lift sheet to reposition the patient.
c c c c c c c c c c
The family member places contaminated dressings in a plastic grocery bag. - CORRECT ANS✔✔C
c c c c c c c c c c c c c
dries the wound using a hair dryer on a low setting. Pressure injuries need to be moist to facilitate
c c c c c c c c c c c c c c c c c c c
actions indicate a good understanding of pressure ulcer care. The use of lift sheets prevents shea
c c c c c c c c c c c c c c c c
acceptable for home use on chronic pressure wounds. Proper disposal of contaminated dressings
c c c c c c c c c c c c c
infection.
c
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing a
c c c c c c c c c c c c c c c
early signs of infection in this patient?
c c c c c c c
Monitor white blood cell counts c c c c
Ask about feelings of fatigue or malaise
c c c c c c c
Check the skin for areas of redness
c c c c c c
Measure the temperature every 2 hours - CORRECT ANS✔✔Correct! Ask about feelings of fatigue
c c c c c c c c c c c c c
manifestation of an infection may be "just not feeling well." Common clinical manifestations of infla
c c c c c c c c c c c c c c c
frequently not present when patients receive immunosuppressive medications.
c c c c c c c c
A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated m
c c c c c c c c c c c c c c c c
that the patient understands the reason for this teaching when he states which of the following?
c c c c c c c c c c c c c c c c
"Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my int
c c c c c c c c c c c c c c c c
c
absorbed by my inflamed tissue." c c c c
"The coating on these medications is irritating to my intestines."
c c c c c c c c c
"I need a more immediate response from my medications than can be obtained from enteric coated
c c c c c c c c c c c c c c c
"I don't need to use these medications because they cause diarrhea, and I have had enough troub
c c c c c c c c c c c c c c c c
c
bleeding over the past weeks." - CORRECT ANS✔✔Correct! "Enteric coated medications are abs
c c c c c c c c c c c c
c
tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." Enteri
c c c c c c c c c c c c c c c
c
designed to prevent breakdown and absorption of the medication until lower in the digestive tract,
c c c c c c c c c c c c c c c
c
irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with
c c c c c c c c c c c c c c c c c
c
lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, ente
c c c c c c c c c c c c c
c
be avoided. The coating is not irritating, but the medication can be. The response time of the med
c c c c c c c c c c c c c c c c c
c
instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.
c c c c c c c c c c c c c
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal
c c c c c c c c c c c c c
stools a day. What should the nurse include in the plan of care?
c c c c c c c c c c c c c
Discontinue the patient's oral food intake. c c c c c
Administer cobalamin (vitamin B12) injections. c c c c
c c c c c c
A patient's 4 × 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by
c c c c c c c c c c c c c c c c c c c
material. Which dressing should the nurse apply to the wound?
c c c c c c c c c c
Dry gauze dressing
c c
Nonadherent dressing c
Transparent film dressing c c
Hydrocolloid dressing - CORRECT ANS✔✔Hydrocolloid dressing
c c c c c
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough.
c c c c c c c c c c c c c c
as DuoDerm, would accomplish these goals. Transparent film dressings are used for clean wound
c c c c c c c c c c c c c c
incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb
c c c c c c c c c c c c c c
wound.
c
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdo
c c c c c c c c c c c c c c c c
document this characteristic?
c c c
Eschar
Undermining
Maceration
Slough - CORRECT ANS✔✔Correct! Undermining
c c c c
Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narro
c c c c c c c c c c c c c c c c
which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and macera
c c c c c c c c c c c c c c c c c
tissue.
c
A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The
c c c c c c c c c c c c c c c c c
subcutaneous tissue. How should the nurse classify this pressure injury?
c c c c c c c c c c
Stage 1 c
Stage 4 c
Stage 3 c
Stage 2 - CORRECT ANS✔✔Correct! Stage 3
c c c c c c
A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue
c c c c c c c c c c c c c c
intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injur
c c c c c c c c c c c c c c c c c
loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage
c c c c c c c c c c c c c
supporting tissues.
c c
c c c c c c c c c c c c c c c c c c
, c
although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's
c c c c c c c c c c c c c c
c
pain does not directly affect wound healing.
c c c c c c
A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. W
c c c c c c c c c c c c c c c
interventions to promote wound healing, what is the nurse's highest priority?
c c c c c c c c c c c
Giving antipyretics to keep the temperature less than 102° F (38.9° C
c c c c c c c c c c c
Maintaining the patient's blood glucose within a normal range c c c c c c c c c
Ensuring that the patient has an adequate dietary protein intake
c c c c c c c c c
Redressing the surgical incision with a dry, sterile dressing twice daily - CORRECT ANS✔✔Correc
c c c c c c c c c c c c c
blood glucose within a normal range Elevated blood glucose will impair wound healing in multiple
c c c c c c c c c c c c c c c c
nutrition is important for the postoperative patient, but a higher priority is blood glucose control. A t
c c c c c c c c c c c c c c c c c
impact wound healing. Application of a dry, sterile dressing daily may be ordered, but frequent dre
c c c c c c c c c c c c c c c c
healing by primary intention is not necessary to promote wound healing.
c c c c c c c c c c c
After the home health nurse teaches a patient's family member about how to care for a sacral pres
c c c c c c c c c c c c c c c c c
indicates that additional teaching is needed?
c c c c c c
The family member uses clean tap water to clean the wound.
c c c c c c c c c c
The family member dries the wound using a hair dryer on a low setting.
c c c c c c c c c c c c c
The family member uses a lift sheet to reposition the patient.
c c c c c c c c c c
The family member places contaminated dressings in a plastic grocery bag. - CORRECT ANS✔✔C
c c c c c c c c c c c c c
dries the wound using a hair dryer on a low setting. Pressure injuries need to be moist to facilitate
c c c c c c c c c c c c c c c c c c c
actions indicate a good understanding of pressure ulcer care. The use of lift sheets prevents shea
c c c c c c c c c c c c c c c c
acceptable for home use on chronic pressure wounds. Proper disposal of contaminated dressings
c c c c c c c c c c c c c
infection.
c
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing a
c c c c c c c c c c c c c c c
early signs of infection in this patient?
c c c c c c c
Monitor white blood cell counts c c c c
Ask about feelings of fatigue or malaise
c c c c c c c
Check the skin for areas of redness
c c c c c c
Measure the temperature every 2 hours - CORRECT ANS✔✔Correct! Ask about feelings of fatigue
c c c c c c c c c c c c c
manifestation of an infection may be "just not feeling well." Common clinical manifestations of infla
c c c c c c c c c c c c c c c
frequently not present when patients receive immunosuppressive medications.
c c c c c c c c
A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated m
c c c c c c c c c c c c c c c c
that the patient understands the reason for this teaching when he states which of the following?
c c c c c c c c c c c c c c c c
"Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my int
c c c c c c c c c c c c c c c c
c
absorbed by my inflamed tissue." c c c c
"The coating on these medications is irritating to my intestines."
c c c c c c c c c
"I need a more immediate response from my medications than can be obtained from enteric coated
c c c c c c c c c c c c c c c
"I don't need to use these medications because they cause diarrhea, and I have had enough troub
c c c c c c c c c c c c c c c c
c
bleeding over the past weeks." - CORRECT ANS✔✔Correct! "Enteric coated medications are abs
c c c c c c c c c c c c
c
tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." Enteri
c c c c c c c c c c c c c c c
c
designed to prevent breakdown and absorption of the medication until lower in the digestive tract,
c c c c c c c c c c c c c c c
c
irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with
c c c c c c c c c c c c c c c c c
c
lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, ente
c c c c c c c c c c c c c
c
be avoided. The coating is not irritating, but the medication can be. The response time of the med
c c c c c c c c c c c c c c c c c
c
instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.
c c c c c c c c c c c c c
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal
c c c c c c c c c c c c c
stools a day. What should the nurse include in the plan of care?
c c c c c c c c c c c c c
Discontinue the patient's oral food intake. c c c c c
Administer cobalamin (vitamin B12) injections. c c c c
c c c c c c
