Taylor NCLEX-RN Chapter 31
A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition? A. There is an unintentional separation of the wound. B. There is redness or inflammation of an area as a result of dilation. C. There is an accumulation of fluid in the interstitial tissue. D. The edges of the wound are lightly pulled together.
A
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure ulcer development? A. Braden scale B. FLACC scale C. Glascow scale D. Morse scale
A
A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? A. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. B. Do not attempt to remove the sutures because they need more time to heal. C. Pick the crusts off the sutures with the forceps before removing them. D. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them.
A
Which is not considered a skin appendage? A. Connective tissue B. Eccrine sweat glands C. Sebaceous gland D. Hair
A
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? A. stimulating the wound bed to promote the growth of granulation tissue B. removing dead or infected tissue to promote wound healing C. removing excess drainage and wet tissue to prevent maceration of surrounding skin D. removing purulent drainage from the wound bed in order to accurately assess it
B
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? A. a gauze dressing premedicated with antibiotics B. a transparent film C. a gauze dressing precut halfway to fit around the IV line D. a dressing with a nonadherent coating
B
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? A. The nurse swabs the wound with povidone-iodine to fight infection in the wound. B. The nurse works outward from the wound in lines parallel to it. C. The nurse uses friction when cleaning the wound to loosen dead cells. D. The nurse swabs the wound from the bottom to the top.
B
Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? A. Pull client up under the arms. B. Support the client from sliding in bed. C. Lubricate the area with skin oil. D. Improve the client's hydration.
B
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. An individual's skin changes little over the life span. B. A child's skin becomes less resistant to injury and infection as the child grows. C. An infant's skin and mucous membranes are easily injured and at risk for infection. D. In children younger than 2 years, the skin is thicker and stronger than in adults.
C
The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? A. Assess the client for claustrophobia. B. Assess for the use of antihypertensives. C. Assess the client's mental status. D. Assess the wound for active bleeding.
D