Coursepoint Module 9 Quiz: Taylor's Clinical Nursing Skills

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options 1. remove old dressing 2. assess the wound bed 3. put on clean gloves 4. time and date the dressing 5. open dressing materials 6. irrigate the wound bed

Put on clean gloves. Remove old dressing. Assess the wound bed. Open dressing materials. Irrigate the wound bed. Time and date the dressing.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? a. clean the wound b. obtain the wound culture c. document the procedure d. dress the wound

a. clean the wound

The nurse has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction? a. fully compress the drain and reapply the cap b. recap the drain and keep tubing to gravity c. milk and then clamp the drain tubing d. turn the suction back on at the wall outlet

a. fully compress the drain and reapply the cap

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? a. remove gloves and perform hand hygiene b. identify the client using two client identifiers c. assess and clean the wound per orders d. twist and break the seal on the culture tube

a. remove gloves and perform hand hygiene

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? a. stage 1 pressure injury b. stage 2 pressure injury c. unstageable, skin intact d. deep tissue injury

a. stage 1 pressure injury

a. teach the client ways to relieve the pressure on the heel b. prescribe the client a high carb diet to promote healing c. remove the eschar by irrigating w sterile saline d. teach the client to reposition every 4 hrs

a. teach the client ways to relieve the pressure on the heel

the nurse is preparing to clean a clients surgical wound. what would the nurse assess before beginning the procedure? a. the clients comfort and effectiveness of pain medication b. color of drainage on the would dressings c. any physical limitation the client may have d. the clients temp and pulses

a. the clients comfort and effectiveness of pain medication

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? a. use montgomery straps instead of adhesive tape to hold the dressing in place b. cleanse the area w an antimicrobial wipe prior to applying the new dressing c. use a skin barrier on the wound itself prior to applying a dressing d. cleanse the ares with an alcohol wipe prior to applying the new dressing

a. use montgomery straps instead of adhesive tape to hold the dressing in place

Which client is a greatest risk of developing a pressure injury? a. a 84 yr old client diagnosed w a uti who frequently gets out of bed without calling for assistance b. 47 yr old client w severe alcoholism and tbi resulting in unconsciousness c. 17 yr old client postoperative for fracture of the upper extremity d. 25 yr old client on bed rest for 24 hours following a procedure

b. 47 yr old client w severe alcoholism and tbi resulting in unconsciousness

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. a. drainage is foul smelling and green in color b. full thickness tissue loss c. no bone, tendon, or muscle visible d. visible subcutaneous fat e. skin around injury is red and warm to touch

b. Full-thickness tissue loss c. No bone, tendon, or muscle visible. d. Visible subcutaneous fat

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: a. distal to proximal using a new gauze for each wipe b. side to side using a new gauze for each wipe c. outside to center using a new gauze for each wipe d. top to bottom using a new gauze for each wipe

d. top to bottom using a new gauze for each wipe

Which client would be at greatest risk for developing a pressure injury? a. older adult client who has COPD b. adult client who is comatose c. adolescent client w a cast on the left leg d. client who is delirious after taking pain meds

b. adult client who is comatose

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? a. place the client in a sitting position to reduce pressure on the abdomen b. assess for pain, sob, and abdominal pressure c. tell the client that this is a life-threatening situation and that the health care provider will be called d. leave the wound open and notify the health care provider

b. assess for pain, sob, and abdominal pressure

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? a. pour the chilled irrigating solution into the irrigation container b. date and reuse leftover irrigation solution within 24 hrs c. shake the bottle of irrigating solution before pouring d. discard any irrigation solution remaining in the bottle

b. date and reuse leftover irrigation solution within 24 hrs

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? a. undermining b. dehiscience c. sinus tract d. ecchymosis

b. dehiscience

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: a. has bright red granulation tissue in the wound bed b. has black brown eschar covering the top c. has exposed bone, tendon or muscle visible d. has redness w partial thickness loss of dermis

b. has black brown eschar covering the top

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? a. give ciprofloxacin 1 gram every 12 hrs b. obtain a sterile wound culture c. assist client up to chair three times daily d. consult dietician to assist client w meal choices

b. obtain a sterile wound culture

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? a. position the client b. raise the bed to elbow height c. gather all necessary equipment d. maintain the sterile field

b. raise the bed to elbow height

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? a. call a rapid response and stay with the client b. reinforce the dressing and assess site frequently c. notify the health care provider of the bleeding d. change the dressing using sterile technique

b. reinforce the dressing and assess site frequently

When collecting a culture from a client's wound, according to evidence- based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results? a. up and down motion b. rolling motion c. pushing motin d. back and forth motion

b. rolling motion

The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container? a. put clean gloves on b. use a gauze pad to clean the outlet c. replace the cap on the chamber d. fully compress the chamber

b. use a gauze pad to clean the outlet

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? a. when the solution from the wound flows a pink color b. when the solution from the wound flows out clear c. when the solution from the wound flows out a red color d. when all the irrigation solution is finished

b. when the solution from the wound flows out clear

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? a. from the right side of the would to the left side b. from the left side of the wound to the right side c. from the upper end of the wound to the lower end d. from the lower end of the wound to the upper end

c. from the upper end of the wound to the lower end

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? a. position the client to promote drainage of the solution b. allow the wound to air dry for 2 mins c. pat the wound dry w a sterile gauze sponge d. measure the length, depth, and width of the wound

c. pat the wound dry w a sterile gauze sponge

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? a. gauze b. used wound dressing c. sterile basin d. waterproof pad

c. sterile basin

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? a. to prevent the dressing from sticking to the wound b. to fill the wound w saline to dissolve wound secretions c. to promote moist wound healing and protect the wound from contamination and trauma d. to soften the dressing to prevent trauma to the wound bed

c. to promote moist wound healing and protect the wound from contamination and trauma

How would the nurse secure a Jackson-Pratt drain after emptying it? a. with a safety pin, secure the drain to the clients gown above the wound b. with tape, secure the drain to the clients gown above the wound c. with a safety pin, secure the drain to the clients gown below the wound d. with a safety pin, secure the drain to the side of the bedding

c. with a safety pin, secure the drain to the clients gown below the wound

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next? a. dry the wound bed using a sterile sponge b. assess the drainage for amount, type, color, and odor c. open the culture tube and apply the swab to the wound bed d. cleanse the wound with a nonantimicrobial cleanser

d. cleanse the wound with a nonantimicrobial cleanser

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? a. stage 2 pressure injury b. unstageable, skin intact c. stage 1 pressure injury d. deep tissue injury

d. deep tissue injury

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? a. directing the flow of irrigating solution from the top of the wound b. cleaning the tip of the syringe w an alcohol wipe after each use c. positioning the client to face away from the sterile supplies d. keeping the tip of the syringe at least 1 in above the wound

d. keeping the tip of the syringe at least 1 in above the wound

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? a. replace the dressing with a smaller one b. notify the hcp for further instruction c. allow the wound to air dry d. replace the dressing w a larger one

d. replace the dressing w a larger one

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development? a. pull the client up in the bed very gently b. gently massage any reddened areas for several mins c. keep the head of the bed elevated 35 degrees d. turn and reposition the client every 2 hrs

d. turn and reposition the client every 2 hrs

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? a. wipe the area w an alcohol wipe and pull the dressing from the skin b. wipe the area with an antimicrobial swab and pull the dressing from the skin c. soak the area w sterile water using gauze pads d. use small amounts of sterile saline to help loosen and remove the dressing

d. use small amounts of sterile saline to help loosen and remove the dressing