Practice Questions
An 85 year old patient is assessed to have a score of 16 on the Braden scale. Based on this information, how should the nurse plan for this patient's care? A. Implement a q2hr turning schedule with a skin assessment B. Place DuoDerm on the patient's sacrum to prevent breakdown C. Elevate the head of the bed to 90 degrees when the patient is supine D. Continue with weekly skin assessments with no special precautions
A
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? A. Tertiary intention B. Secondary intention C. Regeneration of cells D. Remodeling of tissues
B
Which one of the orders should a nurse question in the plan of care for a patient with a stage III pressure ulcer? A. Pack the ulcer with foam dressing B. Turn and position the patient every 2 hours C. Clean the ulcer every shift with Dakin's solution D. Assess for pain and medicate before dressing changes
C
A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 x 10*6/uL, and he has coolness of the lower extremities, weighs 75 ibs more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? A. Imbalanced nutrition: more than body requirements r/t high-fat foods B. Impaired tissue integrity r/t decreased blood flow secondary to diabetes and smoking C. Ineffective peripheral tissue perfusion r/t narrowed blood vessels secondary to diabetes and smoking D. Ineffective individual coping r/t indifference and denial of the long-term effects of diabetes and smoking
B
A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5 degree F temperature, slight erythema at the incision margins, and 30 ml serosanguineous drainage in the Jackson-Pratt drain. Based on the assessment, what conclusion would the nurse make? A. The abdominal incision shows signs of an infection B. The patient is having a normal inflammatory response C. The abdominal incision shows signs of impending dehiscence D. The patient's physician needs to be notified about her condition
B
A patient is the unit has a 103.7 degree F temperature. Which intervention would be most effective in restoring normal body temperature? A. Use a cooling blanket while the patient is febrile B. Administer antipyretics on an around-the-clock schedule C. Provide increased fluids and have the UAP give sponge baths D. Give prescribed antibiotics and provide warm blankets for comfort
B
The nurse assessing a patient with a chronic leg wound finds local signs of erythema and pain at the would site. What would the name anticipate being ordered to assess the patient's systemic response? A. Serum protein analysis B. WBC count and differential C. Punch biopsy of center of wound D. Culture and sensitivity of the wound
B
A 65 year old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnosis is/are most appropriate (select all that apply)? A. Acute pain r/t tissue damage and inflammation B. Impaired skin integrity r/t immobility and decreased sensation C. Impaired tissue integrity r/t inadequate circulation secondary to pressure D. Risk for infection r/t loss of tissue integrity and under-nutrition secondary to stroke
B & C
An 82 year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 x 2 x 0.8 cm in depth and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? A. Stage I B. Stage II C. Stage III D. Stage IV
C