VSIM FUNDAMENTALS SCENARIO JOSEPHINE MORROW
CASE TEST SOLVED #12
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would
the nurse document this finding? - correct answer Purulent
The nurse is performing a sterile dressing change. After donning sterile gloves, the
nurse drops the dressing on the bed and does not have a replacement. What is the
appropriate action at this time? - correct answer Ask the patient to press the call bell to
summon a co-worker to obtain another dressing.
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure? - correct answer I will gently direct a
stream of fluid into the wound, keeping the syringe tip at least one inch from the upper
tip of the wound.
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower
extremity. What would the nurse expect to find when assessing the leg? - correct
answer Dark discoloration of the skin surrounding the wound site.
The nurse is reviewing the patient's laboratory results. Which lab test most accurately
represents current nutritional status? - correct answer Prealbumin
The nurse is completing an admission assessment on a patient admitted for impaired
skin integrity. Which questions would be appropriate for the nurse to ask the patient?
(Select all that apply.) - correct answer - Have you noticed any swelling on your feet,
ankles, or fingers?
- Do some areas of your skin seem warmer or colder than others?
- Have you used pads or special pants because you can't control your urine?
- Do you have any sores on your body?
The nurse is conducting a skin assessment using the Braden Scale. How would the
nurse interpret a score of 12? - correct answer High risk
The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is
the best dietary choice to promote wound healing? - correct answer Baked chicken
The nurse is irrigating a patient's wound when the patient complains of pain. What is the
appropriate action by the nurse? - correct answer Stop the procedure and administer
the ordered analgesic.
Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's
wound. What is the appropriate response by the nurse? - correct answer The procedure
helps remove drainage and debris from the wound.
CASE TEST SOLVED #12
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would
the nurse document this finding? - correct answer Purulent
The nurse is performing a sterile dressing change. After donning sterile gloves, the
nurse drops the dressing on the bed and does not have a replacement. What is the
appropriate action at this time? - correct answer Ask the patient to press the call bell to
summon a co-worker to obtain another dressing.
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse,
indicates an understanding of the procedure? - correct answer I will gently direct a
stream of fluid into the wound, keeping the syringe tip at least one inch from the upper
tip of the wound.
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower
extremity. What would the nurse expect to find when assessing the leg? - correct
answer Dark discoloration of the skin surrounding the wound site.
The nurse is reviewing the patient's laboratory results. Which lab test most accurately
represents current nutritional status? - correct answer Prealbumin
The nurse is completing an admission assessment on a patient admitted for impaired
skin integrity. Which questions would be appropriate for the nurse to ask the patient?
(Select all that apply.) - correct answer - Have you noticed any swelling on your feet,
ankles, or fingers?
- Do some areas of your skin seem warmer or colder than others?
- Have you used pads or special pants because you can't control your urine?
- Do you have any sores on your body?
The nurse is conducting a skin assessment using the Braden Scale. How would the
nurse interpret a score of 12? - correct answer High risk
The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is
the best dietary choice to promote wound healing? - correct answer Baked chicken
The nurse is irrigating a patient's wound when the patient complains of pain. What is the
appropriate action by the nurse? - correct answer Stop the procedure and administer
the ordered analgesic.
Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's
wound. What is the appropriate response by the nurse? - correct answer The procedure
helps remove drainage and debris from the wound.
