Question 1

A client is prescribed antiembolic stockings.How should the nurse assess the skin on the client's legs?

Accepted Answer

A)  Defer the assessment because the stockings are in place.
B)  Remove the stockings for this assessment.
C)  Review the morning assessment,but don't repeat it unless a problem occurs.
D)  Assess the skin when the client removes the stockings at bedtime.E) None of the above
F) A) and D)

Question 2

The nurse documents that a client's postoperative wound is purosanguinous.What did the nurse assess in this client's wound?

Accepted Answer

A)  Water and red blood cells
B)  Pus and red blood cells
C)  Watery drainage
D)  PusE) C) and D)
F) All of the above

Question 3

The nurse is assessing a client's pressure ulcer.To determine the depth of the ulcer,the nurse should take which action?

Accepted Answer

A)  Measure the width.
B)  Measure the length.
C)  Insert a sterile swab into the deepest part of the wound.
D)  Identify where on the face of a clock the ulcer is located.E) C) and D)
F) A) and B)

Question 4

The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg.In which order should the nurse prepare and apply this treatment?
A)Use tape or gauze ties to hold the pad in place.
B)Set the desired temperature according to the manufacturer's instructions.
C)Apply the pad to the body part.The treatment is usually continued for 30 minutes.
D)Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer.
E)Cover the pad and plug in the unit.Check for any leaks or malfunctions of the pad before use.

Accepted Answer

The answer of The nurse is preparing to apply a...

Question 5

The adult client is incontinent and wears incontinence briefs when using the wheelchair.An irritated rash has developed in the perianal area.What care should the nurse provide?

Accepted Answer

A)  Wash the area with soap and hot water at every brief change.
B)  Apply a petroleum-based cream to the area after cleaning.
C)  Wipe the skin with an alcohol-free barrier film agent after cleaning.
D)  Keep the client in bed on absorbent pads until the area clears.E) A) and C)
F) C) and D)

Question 6

The nurse has applied an aquathermia pad to a client's back.After 15 minutes of treatment,the client says that the pack no longer is warm and asks the nurse to increase the temperature.How should the nurse evaluate this request?

Accepted Answer

A)  Because this client's thermal tolerance is higher than normal,increasing the temperature is necessary.
B)  This client may be experiencing a rebound effect from the application of moist heat.
C)  Adaptation of the thermal receptors often results in the decreased sensation of warmth.
D)  The aquathermia pad should be replaced with a standard hot pack.E) All of the above
F) B) and C)

Question 7

A client sustained several wounds on the legs caused by a fall.On the day after the injuries,the wounds appear red and edematous.The nurse identifies the stage of healing of these wounds as being in which phase?

Accepted Answer

A)  Inflammatory
B)  Proliferative
C)  Maturation
D)  RemodelingE) None of the above
F) A) and C)

Question 8

A client has a wound that is going to heal through secondary intention.When instructing the client about this wound,the nurse would include which statements?
(Select all that apply)

Accepted Answer

A)  Minimal tissue loss.
B)  Closure of the wound will occur within 5 days.
C)  Healing time will be longer.
D)  Potential for scarring is greater.
E)  Susceptibility to infection is greater.F) B) and C)
G) C) and D)

Question 9

The UAP reports a small skin tear on the client's forearm that occurred during a routine turn.After assessing the wound the nurse should take which action?

Accepted Answer

A)  Obtain a transparent dressing for the UAP to place on the wound.
B)  Request a consult with the wound care nurse.
C)  Cleanse the wound and apply a dressing.
D)  Tell the UAP to reevaluate the wound in 20 minutes.E) A) and B)
F) B) and C)

Question 10

After completing a scheduled every-2-hour turn by turning the client to the left side,the nurse notices a reddened area over the coccyx.The area blanches when the nurse compresses it with thumb pressure.One hour later,the nurse reassesses the area and finds the redness has disappeared.How should the nurse document this area?

Accepted Answer

A)  Reactive hyperemia
B)  Stage I pressure ulcer
C)  Stage II pressure ulcer
D)  Stage III pressure ulcerE) None of the above
F) A) and D)

Question 11

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds.Which operative wound would be excluded from this study?

Accepted Answer

A)  Gastric resection
B)  Uncomplicated abdominal hysterectomy
C)  Breast biopsy
D)  Lung resectionE) A) and B)
F) C) and D)

Question 12

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention.What principles should the nurse use in choosing this dressing?

Accepted Answer

A)  Materials used in dressing this wound should keep the wound bed moist.
B)  The dressing should allow good air circulation through the wound.
C)  Dressings should be simple as they will be changed at least every 4 hours.
D)  Absorbent material to wick exudates away and support drying should be used.E) None of the above
F) All of the above

Question 13

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx.Which finding,discovered by the nurse during evaluation,might be implicated in the failure to achieve this outcome?

Accepted Answer

A)  The rubber doughnut pressure relief device was not delivered by central supply.
B)  The client's serum albumin increased over the last month.
C)  Nurses did not document disinfection of the wound with alcohol with each dressing change.
D)  Unlicensed assistive personnel (UAP) followed a right side-back-left side-back turning schedule.E) A) and D)
F) C) and D)

Question 14

A client has episodes of bowel and bladder incontinence.When planning care for this client,the nurse would identify which nursing diagnosis as being appropriate?

Accepted Answer

A)  Impaired Skin Integrity
B)  Risk for Impaired Skin Integrity
C)  Impaired Tissue Integrity
D)  Risk for InfectionE) All of the above
F) A) and C)

Exam 36: Skin Integrity and Wound Care

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx.Which finding,discovered by the nurse during evaluation,might be implicated in the failure to achieve this outcome?

Correct Answer
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Correct Answer
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Correct Answer
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The nurse documents that a client's postoperative wound is purosanguinous.What did the nurse assess in this client's wound?

Correct Answer
verified

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds.Which operative wound would be excluded from this study?

Correct Answer
verified

The nurse is assessing a client's pressure ulcer.To determine the depth of the ulcer,the nurse should take which action?

Correct Answer
verified

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention.What principles should the nurse use in choosing this dressing?

Correct Answer
verified

A client is prescribed antiembolic stockings.How should the nurse assess the skin on the client's legs?

Correct Answer
verified

The UAP reports a small skin tear on the client's forearm that occurred during a routine turn.After assessing the wound the nurse should take which action?

Correct Answer
verified

A client sustained several wounds on the legs caused by a fall.On the day after the injuries,the wounds appear red and edematous.The nurse identifies the stage of healing of these wounds as being in which phase?

Correct Answer
verified

The nurse has applied an aquathermia pad to a client's back.After 15 minutes of treatment,the client says that the pack no longer is warm and asks the nurse to increase the temperature.How should the nurse evaluate this request?

Correct Answer
verified

A client has episodes of bowel and bladder incontinence.When planning care for this client,the nurse would identify which nursing diagnosis as being appropriate?

Correct Answer
verified

The adult client is incontinent and wears incontinence briefs when using the wheelchair.An irritated rash has developed in the perianal area.What care should the nurse provide?

Correct Answer
verified

A client has a wound that is going to heal through secondary intention.When instructing the client about this wound,the nurse would include which statements? (Select all that apply)

Correct Answer
verified

Exam 36: Skin Integrity and Wound Care

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx.Which finding,discovered by the nurse during evaluation,might be implicated in the failure to achieve this outcome?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

The nurse documents that a client's postoperative wound is purosanguinous.What did the nurse assess in this client's wound?

Correct AnswerverifiedShow Answer

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds.Which operative wound would be excluded from this study?

Correct AnswerverifiedShow Answer

The nurse is assessing a client's pressure ulcer.To determine the depth of the ulcer,the nurse should take which action?

Correct AnswerverifiedShow Answer

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention.What principles should the nurse use in choosing this dressing?

Correct AnswerverifiedShow Answer

A client is prescribed antiembolic stockings.How should the nurse assess the skin on the client's legs?

Correct AnswerverifiedShow Answer

The UAP reports a small skin tear on the client's forearm that occurred during a routine turn.After assessing the wound the nurse should take which action?

Correct AnswerverifiedShow Answer

A client sustained several wounds on the legs caused by a fall.On the day after the injuries,the wounds appear red and edematous.The nurse identifies the stage of healing of these wounds as being in which phase?

Correct AnswerverifiedShow Answer

The nurse has applied an aquathermia pad to a client's back.After 15 minutes of treatment,the client says that the pack no longer is warm and asks the nurse to increase the temperature.How should the nurse evaluate this request?

Correct AnswerverifiedShow Answer

A client has episodes of bowel and bladder incontinence.When planning care for this client,the nurse would identify which nursing diagnosis as being appropriate?

Correct AnswerverifiedShow Answer

The adult client is incontinent and wears incontinence briefs when using the wheelchair.An irritated rash has developed in the perianal area.What care should the nurse provide?

Correct AnswerverifiedShow Answer

A client has a wound that is going to heal through secondary intention.When instructing the client about this wound,the nurse would include which statements? (Select all that apply)

Correct AnswerverifiedShow Answer

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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