VSIM Josephine Morrow Pre-Sim & Post-Sim Answers
The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?
-When did the edema start? -Can you describe the edema? -Do you have any recent history of surgery or illness?
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?
Ask the patient to press the call bell to summon a co-worker to obtain another dressing.
The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears to be healing and the wound bed is beefy red. Which solution should the nurse select for this procedure?
Normal Saline
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding?
Purulent
Then nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient?
-Monitor patient for signs of skin breakdown -Perform neurovascular checks to look for changes -Assist with range of motion exercises to lower extremities -Provide meticulous skin care
The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status?
Prealbumin
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?
The procedure helps remove drainage and debris from the wound.
The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation?
-Location -Tunneling -Drainage -Odor
The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing?
Baked chicken
The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse?
Stop the procedure and administer the ordered analgesic
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?
-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?
High Risk
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure?
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?
Dark discoloration of the skin surrounding the wound site
The nurse is completing an admission assessment on a patient for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition?
-Diabetes Mellitus -Obesity -Poor Hygiene -Poor Circulation
The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed?
Full-thickness tissue loss, possibly with subcutaneous fat.
The nurse is providing education to Ms. Morrow and her daughter on management of venous stasis on the lower extremities. What would be appropriate for the nurse to include in the teaching session?
Put on anti-embolism stockings as soon as you get up in the morning and wear them all day
The nurse has received an order to apply a hydro colloid dressing to Ms.Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education?
This dressing will need to be held in place by surgical tape