Josephine Morrow Vsim Pre/Post quiz

The nurse knows __________ will help to promote ___________, leading to improvements in Josephine Morrow's wound healing.

applying compression stocking venous return

When performing wound irrigation, the nurse understands to include which of the following during implementation of the procedure? (Select all that apply.) a. Assess the client's pain level during irrigation. b. Irrigate from most to least contaminated area. c. Apply gown, gloves, and mask with goggles. d. Dry intact skin prior to applying dressing. e. Assess wound bed for appearance. f. Keep tip of syringe less than 1 inch from wound.

b, c, d, e

Which of the following sign(s) and symptom(s) would the nurse expect in a patient with chronic venous insufficiency? (Select all that apply.) a. Rounded smooth borders b. Wound exudate c. Thick toenails d. Lower extremity edema

b, d

The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? a. "I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound bed." b. "I will make sure the tip of the syringe touches the wound bed while performing the irrigation." c. "In order to debride the wound, I will use a moderate amount of force to instill the solution." d. "I will gently direct a stream of fluid into the wound, keeping the syringe tip at least 1 inch from the upper tip of the wound."

d

The home health nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which question(s) would be appropriate for the nurse to ask the patient? (Select all that apply.) a. "Have you used pads or special pants because you can't control your urine?" b. "What kind of activities cause you to be fatigued?" c. "Do you have any sores on your body?" d. "Do some areas of your skin seem warmer or colder than others?" e. "Have you noticed any swelling on your feet, ankles, or fingers?"

a, c, d, e

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12? a. High risk b. Low risk c. Not at risk d. Moderate risk

a

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? a. Remove gloves and go to the supply room to obtain more supplies. b. Ask the patient to press the call bell to summon a co-worker to obtain another dressing. c. Pick up the dressing and use the side that did not touch the bed. d. Reapply the original dressing until a new one can be obtained.

b

The nurse is reviewing Josephine Morrow's medical records before initiating her plan of care. Which of the following factor(s) contributed to the development of her venous stasis ulcer? (Select all that apply.) a. Diabetes b. Poor circulation c. Hypertension d. Obesity e. Poor hygiene f. Poor nutrition

b , d, e, f

The nurse is reviewing a patient's laboratory results to determine the current nutritional status. Which of the following will negatively affect wound healing? (Select all that apply.) a. Iron deficiency b. Calcium excess c. Protein deficiency d. Vitamin B excess

c, d

The nurse removes a dressing and assesses yellow, foul-smelling drainage. How would the nurse document this finding? a. Serous b. Serosanguineous c. Sanguineous d. Purulent

d

Following the review of Josephine Morrow's medical record, the nurse recognizes which of the following assessment(s) are part of her focused assessment? (Select all that apply.) a. Vital signs assessment b. Pain assessment c. Peripheral pulse assessment d. Bowel assessment e. Home safety assessment f. Wound assessment

a, b, c, f

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. When assessing the wound, the nurse will include which of the following? (Select all that apply.) a. Presence of undermining or tunneling b. Condition of surrounding skin c. Hair loss on the legs d. Length, width, and depth in centimeters

a, c, d

The nurse is preparing to irrigate Josephine Morrow's wound. Upon wound assessment, the nurse will most likely consider that which of the following indicate poor wound healing? (Select all that apply.) a. Creamy, yellow, purulent drainage b. Red/pink granulated wound bed c. Presence of new epithelization d. Persistent tunneling e. A 2 mm increase in wound length f. Black, avascular tissue

a, d, e, f