Skills test 2 (Questions)

Which client will the nurse expect to be prescribed sitz baths? Select all that apply

1. Client after childbirth 2. Client who had surgery to the perineum 3. Client who had rectal surgery

Which clients will the nurse recognize are at an increased risk of thermal injury when using an external heating pad? Select all that apply.

1. Client who has a spinal cord injury 2. Client who has peripheral neuropathy 3. Client who is an older adult 4. Client who has diabetes.

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. Put on clean gloves. 2. Remove old dressing. 3. Assess the wound bed. 4. Open dressing materials. 5. Irrigate the wound bed. 6. Time and date the dressing.

The nurse is explaining the benefits of cold therapy to a client. What should the nurse include in the teaching plan? Select all that apply.

1. Reduces bleeding and hematoma formation 2. Reduces swelling and inflammation 3. Slows the transmission of pain stimuli

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, what temperature range will the nurse set the pad?

105°F to 109°F (40.5°C to 43°C)

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?

Replace the dressing with a larger one.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply.

1. Full-thickness tissue loss 2. No bone, tendon, or muscle visible. 3. Visible subcutaneous fat

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply.

1. Insert tubing into the infusion port of the sitz bath 2. Slowly unclamp the tubing and allow the sitz bath to fill 3. Fill the bowl of the sitz bath about halfway full with tepid to warm water 4. Ensure that the call bell is within reach

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

1. Press and rotate the swab several times over the wound surfaces. 2. Insert a swab into the wound. 3. Place the swab in the culture tube when done.

The nurse is preparing a sterile field using a pre-packaged kit. After performing hand hygiene, which action would the nurse take next?

Confirm the client's identity

When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which action would the nurse take first?

Unfold the top flap away from the body.

Which question by the nurse, to the client, will best help evaluate the outcome of having applied cold therapy?

"Do you feel your muscle spasms have decreased?"

After 30 minutes, the nurse comes to remove the warm compress from a client's wound site. The client requests to leave the warm compress on a little longer. What is the best response by the nurse?

"Leaving it on for more than 30 minutes can cause complications such as tissue injury."

A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long should the nurse have the client apply the bag before the nurse removes it?

20 minutes

Which client is a greatest risk of developing a pressure injury?

47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness

When adding sterile items to a sterile field, the nurse would drop the sterile items from which height?

6 in (15 cm)

Which client would be at greatest risk for developing a pressure injury?

Adult client who is comatose

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Apply apply a skin protectant to the skin around the incision skin protectant to the skin around the incision

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing. What action would be appropriate?

Call someone to bring in the necessary item to the client's room.

When preparing a sterile field, which action would be appropriate for the nurse to take first?

Check the packages for expiration date.

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?

Date and reuse leftover irrigation solution within 24 hours.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Discontinue the therapy and assess the client

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

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?

From the upper end of the wound to the lower end

After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain?

Fully compress the bulb and reapply the cap.

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure?

If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

What action does the nurse perform to remove gloves after performing a sterile procedure?

Invert the glove as it is removed.

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe?

Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound

When applying an external heating pad, which prescription from the health care provider would the nurse question?

Leave heating pad on for 40 to 45 minutes, then off for 2 hours.

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?

Obtain a sterile wound culture

A nurse is preparing a sterile field using a pre-packaged kit. The nurse opens the outside cover and removes the kit, placing it in the center of the work surface. The nurse places the kit so that the topmost flap is positioned in which direction?

On the far side of the package

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take?

Open the top and bottom folds completely.

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury?

Raise the bed to elbow height.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes.

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?

Reinforce the dressing and assess site frequently

What action will the nurse take to ensure a wound is ready for the sutures to be removed?

Remove every other suture and assess the wound edges.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next?

Remove gloves and perform hand hygiene.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?

Secure the drain to the client's gown with a safety pin below the level of the wound.

The nurse has created a sterile field with sterile dressings in preparation for a client's wound care. While getting ready to apply a dressing, the client moves his arm and touches the sterile field. Which action by the nurse would be most appropriate?

Set up an entirely new sterile field.

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?

Stage 1 pressure injury

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?

Sterile basin

When assessing the area of application of a warm compress, the nurse observes skin maceration of the surrounding area, and the client reports increased discomfort. What should the nurse do first?

Stop the heat application and completely remove the compress.

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time?

Teach the client ways to relieve the pressure on the heel.

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure?

The client's comfort and effectiveness of pain medication

The nurse is planning to use a pre-packaged kit to prepare a sterile field. Which would be of least importance in ensuring the sterility of the kit?

The outer wrapper is disposed in an appropriate receptacle.

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff?

Thumb and forefinger

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?

To promote moist wound healing and protect the wound from contamination and trauma

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client's large abdominal wound. The nurse uses the extra gloves for what purpose?

To use if the first pair of sterile gloves gets contaminated

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?

Use Montgomery straps instead of adhesive tape to hold the dressing in place.

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?

Use a gauze pad to clean the outlet.

Which action by the nurse is most appropriate when the sutures are difficult to remove because of crusted dried blood?

Use a sterile gauze and sterile saline to gently remove the crusted dried blood.

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?

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

When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect?

increased comfort of client

Place in order, from first to last, the actions the nurse will perform when applying a warmed moist compress. Use all options.

1. Assess the application site. 2. Remove the compress from the warmed solution. 3. Squeeze out any excess solution. 4. Gently mold the compress to the intended site. 5. Cover the site with a dry, clean bath towel.

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?

Assess for pain, shortness of breath, and abdominal pressure.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change?

Assessing the need for analgesia

How often will the nurse empty a Jackson-Pratt drain? Select all that apply.

At least every 4 hours and when the drain is one-half to two-thirds full

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure?

Clean 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?

Cleanse the wound with a nonantimicrobial cleanser.

In which client would the application of an external heating pad be contraindicated?

Client who has a wound that is bleeding

In which client would negative pressure wound therapy be contraindicated?

Client with a moderately bleeding wound

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis

During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the most likely rationale for this occasional effect from sitz bath therapy?

The warm water caused vasodilatation

When putting on the second sterile glove, the nurse places the gloved thumb at which location?

Outward away from the gloved hand

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure?

Pat the wound dry with a sterile gauze sponge.

The nurse has gathered several individually packaged dressings for a sterile dressing change. When adding these dressings to the sterile field, which action would the nurse take?

Peel the edges apart with both hands.

When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who:

Requires that the heat penetrate deeply into the tissues.

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?

Rolling motion

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated?

Sterile drape positioned with the moisture-proof side facing up

When opening a pre-packaged kit to prepare a sterile field, which would be important to keep in mind?

The inner surface of the outer wrapper is considered sterile.

The nurse is opening a package containing a sterile drape to establish a sterile field. Which occurrence would indicate that the nurse had contaminated the sterile drape?

The nurse allows the drape to touch his or her body.

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?

Turn and reposition the client every 2 hours.

Which client is most likely to require that the sutures be left in place for an extended period of time? A client who:

has a current history of alcoholism.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:

has black brown eschar covering the top.

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:

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

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.

1. Clean the incision using the wound cleanser and gauze. 2. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. 3. Using the scissors, cut one side of the suture below the knot, close to the skin. 4. Grasp the knot with the forceps and pull the cut suture through the skin. 5. Remove every other suture to be sure the wound edges are healed. 6. Apply adhesive closure strips.

To assess for circulatory compromise, what assessments will the nurse perform at the site of application before applying a warm compress? Select all that apply.

1. Distal pulses 2. Presence of sensation 3. Evidence of edema 4. Skin color

The nurse is teaching a client the purpose of using an external heating pad. What should the nurse include in the teaching plan? Select all that apply.

1. It reduces the discomfort of muscle tension and muscle spasms 2. It can be used to treat inflammation, chronic pain, and surgical wounds 3. It promotes healing by accelerating the body's natural inflammatory response 4. It helps to relieve pain from arthritis and joint stiffness.

The nurse is teaching a client the reasons for use of negative pressure wound therapy (NPWT). What should the nurse include in the teaching? Select all that apply

1. It stimulates cell growth and growth of new blood vessels. 2. It provides a moist wound healing environment. , It results in a reduction of bacteria in the wound. 3. It promotes wound healing and wound closure.

The nurse is caring for a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options.

1. Place the graduated collection container under the drain outlet. 2. Remove the cap from the bulb. 3. Empty the bulb's contents into the collection chamber. 4. Wipe the outlet of the bulb with a sterile gauze pad. 5. Fully compress the bulb. 6. Replace the cap on the bulb.

What should the nurse assess before application of sitz bath therapy? Select all that apply

1. client's ability to sit for 15 to 20 minutes 2. client's perineal/rectal area 3. client's ability to ambulate to the bathroom 4. client's need to void

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?

Deep tissue injury

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?

Dehiscence.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate?

Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.

The nurse has prepared a sterile field using a pre-packaged kit. Which would be important for the nurse to keep in mind?

The field is contaminated if it is out of the nurse's site.

The charge nurse is observing the new graduate nurse perform the dressing change for a client with negative pressure wound therapy. Which action by the graduate nurse will require the charge nurse to intervene?

The graduate nurse tightly stretches the transparent adhesive dressing and applies it to the wound.

The nurse is putting on sterile gloves. Which principle would be important to keep in mind?

The hands should remain above waist level at all times.

When removing soiled gloves, which action should the nurse take?

Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside.

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound?

When the solution from the wound flows out clear

How would the nurse secure a Jackson-Pratt drain after emptying it?

With a safety pin, secure the drain to the client's gown below the wound.