therapeutics exam 2 practice q's--wound care

B

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. a. false b. true

C

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a. stage III b. stage I c. stage II d. stage IV

D

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. removing excess drainage and wet tissue to prevent maceration of surrounding skin b. removing purulent drainage from the wound bed in order to accurately assess it c. removing purulent drainage from the wound bed in order to accurately assess it d. removing dead or infected tissue to promote wound healing

B

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. removing purulent drainage from the wound bed in order to accurately assess it b. removing dead or infected tissue to promote wound healing c. stimulating the would bed to promote the growth of granulation tissue d. removing excess drainage and wet tissue to prevent maceration of surrounding skin

A

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: a. primary intention. b. secondary intention. c. tertiary intention. d. dehiscence.

D

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? a. stage I b. stage II c. stage IV d. stage III

D

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? a. primary intention b. tertiary intention c. desiccation d. secondary intention

B

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider? a. hydrogel b. alginate c. hydrocolloid d. transparent

D

A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-blue (RYB) Wound Classification System, which of the following classifications should the nurse document? a. red classification b. unstageable c. yellow classification d. black classification

A

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a. Clean the wound from the top to the bottom, and center to outside. b. Once the wound is cleaned, dry the area with an absorbent cloth. c. use clean technique to clean the wound. d. Clean the wound from the bottom to the top, and outside to center.

D

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. Pick the crusts off the sutures with the forceps before removing them. b. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c. Do not attempt to remove the sutures because they need more time to heal. d. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

B

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a. In children younger than 2 years, the skin is thicker and stronger than in adults. b. An infant's skin and mucous membranes are easily injured and at risk for infection. c. A child's skin becomes less resistant to injury and infection as the child grows. d. An individual's skin changes little over the life span.

A

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? a. local capillary pressure must be lower than external pressure b. The volume of circulating blood must be sufficient. c. The heart must be able to pump adequately. d. Arteries and veins must be patent and functioning well.

D

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 halfway to fit around the IV line b. a gaze dressing premedicated with antibiotics c. a dressing with a nonadherent coating d. a transparent film

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 wound for active bleeding. d. assess the client's mental status.

C

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? a. a client who must remain on his back for long periods of time b. a client who lies on wrinkled sheets c. a client sitting in a chair who slides down d. a client who lifts himself up on hsi elbows

C

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? a. The nurse uses a safety pin to attach the pad to the bedding. b. The nurse covers the heating pad with a heavy blanket. c. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. d. The nurse places the heating pad under the client's neck.

B

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? a. The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain. b. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. c. The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. d. The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain.

D

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing? a. pasta salad b. green beans c. banana d. fish

B

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority? a. knowledge deficit b. impaired tissue integrity c. disturbed body image d. acute pain

C

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate? a. "Dehiscence is not anything that you need to worry about." b. "Dehiscence is the softening of tissue due to excessive moisture." c. "Dehiscence is when a wound has partial or total separation of the wound layers." d. "Dehiscence is a total separation of the wound with protrusion of the viscera through it."

C

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a. a client whose breast reconstruction surgery required numerous incisions b. a client who is npo following bowel surgery c. an obese woman with a history of type 1 diabetes d. a man with sedentary lifestyle and a long history of cigarette smoking

C

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? a. improve the client's hydration b. lubricate the area with skin oil. c. support the client from sliding in bed d. pull client up under the arms.

ABD

Which education points would the nurse use to explain the development of pressure ulcers to clients and how to prevent them? SELECT ALL THAT APPLY a. "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation." b. "The skin can tolerate considerable pressure without cell death, but for short periods only." c. "Most pressure ulcers occur over the trochanter and calcaneus." d. "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." e. "Generally, a pressure ulcer will not appear within the first 2 days in a person who has not moved for an extended period of time." f. "The major predisposing factor for a pressure ulcer is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues."

B

Which is not considered a skin appendage? a. eccrine sweat glands b. connective tissue c. hair d. sebaceous gland