EXAM 3 PRACTICE Qs

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 injury development? Glasgow scale Braden scale FLACC scale Morse scale

Braden scale

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

Clean the wound from the top to the bottom and from the center to outside.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation Maceration Necrosis Evisceration

Desiccation

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy? Every 48 to 72 hours Every 8 to 12 hours Every 12 to 24 hours Every 25 to 36 hours

Every 48 to 72 hours

True or false: cutaneous refers to bones and joints.

Fale; cutaneous refers to skin

true or false: visceral refers to skin

False; visceral refers to organs

A patient comes into the wound care center with a wound that appears to have undermining and tunneling. this is known as... fistula herniation. dehiscence. evisceration.

Fistula

A nurse is documenting on a client who has had an appendectomy. During a dressing change at the surgical site, the nurse observed green, thick drainage on the dressing. Which drainage type should the nurse document? -purulent - serosanguineous - sanguineous - serous

Purulent

A nurse is documenting on a client who has had an appendectomy. During a dressing change at the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? -purulent - serosanguineous - sanguineous - serous

Serosanguineous

true or false: somatic refers to bones and joints

True

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

a client sitting in a chair who slides down

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence. evisceration.

dehiscence

Is a surgical incisions primary or secondary intention?

primary intention

A nurse is documenting on a client who has had an appendectomy. During a dressing change at the surgical site, the nurse observed fresh red drainage on the dressing. Which drainage type should the nurse document? -purulent - serosanguineous - sanguineous - serous

sanguineous

is a pressure ulcer a primary or secondary intention?

secondary intention

A nurse is documenting on a client who has had an appendectomy. During a dressing change at the surgical site, the nurse observed clear drainage on the dressing. Which drainage type should the nurse document? -purulent - serosanguineous - sanguineous - serous

serous

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage 1 stage 2 stage 3 stage 4

stage 4

True or false: excessive perspiration (sweating) during illness can cause skin break down.

true

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "Very little scar tissue will form." "This is a complex reparative process." "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time."

"Very little scar tissue will form."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "Do you experience incontinence?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"

"Do you experience incontinence?"

Which would be appropriate action(s) for the nurse to take when cleaning and dressing a pressure injury? Select all that apply. Clean the wound with each dressing change using aggressive motions to remove necrotic tissue. Use povidone-iodine or hydrogen peroxide to irrigate and clean the injury. Use whirlpool treatments, if prescribed, until the injury is considered clean. Keep the injury tissue moist and the surrounding skin dry. Use a dressing that absorbs exudate but maintains a moist healing environment. Pack wound cavities densely with dressing material to promote tissue healing.

Use whirlpool treatments, if prescribed, until the injury is considered clean. Keep the injury tissue moist and the surrounding skin dry. Use a dressing that absorbs exudate but maintains a moist healing environment.

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 to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? a transparent film a gauze dressing precut halfway to fit around the IV line a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics

a transparent film

Who can use the FLACC pain scale: children up to 7 years old teenagers older adults

children up to 7 years old *unless they can communicate

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Pasta salad Fish Banana Green beans

fish

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? elevate the head of the bed 90 degrees use pillows to maintain a side-lying position as needed provide incontinent care every 4 hours as needed place a foot board on the bed

use pillows to maintain a side-lying position as needed

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "This is normal tissue." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "Necrotic tissue is devitalized tissue that must be removed to promote healing."

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."

"That is necrotic tissue, which must be removed to promote healing."

A nurse is using cold therapy on a patient to...(select all that apply): constricts peripheral blood vessels reduce muscle stiffness/ tension reduce swelling and pain improves blood flow dilates peripheral blood vessels

constricts peripheral blood vessels reduces swelling and pain

A patient is brought into the hospital with his small and large intestines protruding through his abdomen wound. this is known as what? infection. herniation. dehiscence. evisceration.

evisceration

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spiral-reverse turn spica turn figure-of-eight turn

figure-of-eight turn

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation secondary intention tertiary intention

secondary intention