Josephine Morrow vSim
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?
A) Dark discoloration of the skin surrounding the wound site. Shiny skin on lower extremities with hair loss over legs, feet, and toes would be indicative of peripheral arterial disease. Pale, white toes and decreased sensation are descriptive of Reynaud's disease. Scaly rash between the toes with itchiness can be found with athlete's foot.
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)
A) have you used pads or special pants because you can't control your urine? B) have you notice any swelling on your feet, ankles, or fingers? D) do you have any sores on your body? E) do some areas of your skin seem warmer or colder than other?
The nurse is preparing to irrigate a wound. Which statement, if made but the nurse, indicates an understanding of the procedure?
D) 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 reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status?
D) Prealbumin Although albumin and prealbumin are both indicators of the protein nutritional status, prealbumin has a shorter half-life and is a more sensitive measurement of current nutritional status. Both calcium and iron are incorrect and do not represent a patients nutritional status.
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?
B) ask the patient to press the call bell to summon a co-worker to obtain another dressing.
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding?
C) Purulent Serous drainage is clear and watery Sanguineous is bright red and looks like blood Serosanguineous is light pink to blood tinged
The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12?
High Risk: 10-12 - score is a high risk Moderate Risk: 13-14 Low Risk: 15-18 Not a Risk: 19-23
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? What were you doing just before you noticed the edema? Do you have a recent history of surgery or illness? What are your usual daily activities? Do you stand a lot? What medications do you take? Do you have a heart disease or blood vessel disease?
