Chapter 26 and 27

Question 1

The nurse is caring for a dark-skinned patient. The nurse suspects the patient has a stage 1 pressure injury. Which finding will help confirm the nurse’s conclusion?

Red area
Purple area
Darkened area
Maroon area

Answer 1

Darkened area

Question 2

Which term would the nurse use in report to describe a patient’s bruise?

Open wound
Abrasion
Contusion
Laceration

Answer 2

Contusion

Question 3

The nurse is explaining to a coworker how a pressure injury occurs. The nurse should describe the process in which order?

Reduced blood flow to the area occurs.

Tissues receive inadequate oxygen and nutrients.

External pressure is prolonged.

Cells eventually necrose.

Tissues and capillaries are compressed.

Answer 3

1. External pressure is prolonged
2. Tissues and capillaries are compressed
3. Reduced blood flow to the area occurs
   4.Tissues receive inadequate oxygen
   5.Cells eventually necrose

Question 4

The nurse is collecting data about a patient’s wound. Which findings indicate the wound is infected? Select all that apply.

Erythemic wound edges and surrounding area

Thick yellowish drainage
No odor from wound or drainage

Warmer skin temperature around wound

Edema 2 inches around wound

Answer 4

-Erythmic wound edges and surrounding area
-Thick yellowish drainage
-Warmer skin temperature around wound
- Edema 2 inches around wound

Question 5

The nurse needs to obtain a wound culture from a patient’s draining wound. Which action should the nurse take?

Swab the outer edges of the wound.
Swab the dark black area of the wound.
Swab the area of drainage in the wound.
Swab the pinkish, red area of the wound.

Answer 5

Swab the pinkish red area of the wound

Question 6

The nurse is reviewing the instructions for a negative pressure wound therapy dressing for a patient’s infected wound. Which statement by the nurse indicates a correct understanding of the instructions?

“I will use clean technique for this procedure.”
“I will remove the old transparent dressing by pulling it away from the wound.”
“I will make sure the dressing collapses after the pump is turned on.”
“I will cut the foam dressing to attach the suction device.”

Answer 6

I will make sure the dressing collapses after the pump is turned on

Question 7

The nurse is describing the inflammatory process. In which order should the nurse explain the process?

There is increased blood flow to the site.
Capillaries dilate.
Pain occurs.
Injury occurs.
Damaged cells release histamine.
Edema develops.

Answer 7

1. Injury occurs
2. Damaged cells release histamine
3. Capillaries dilate
4. There is increased blood flow to the site
5. Edema develops
6. Pain occurs

Question 8

The nurse is observing an unlicensed assistive personnel (UAP) move a patient in bed. Which action by the UAP would the nurse praise?

Slides the patient across the bed
Pulls the patient across the bed
Drags the patient across the bed
Lifts the patient across the bed

Answer 8

Lifts the patient across the bed

Question 9

While observing the skin of a patient, the nurse discovers a pressure injury that extends into the subcutaneous tissue with undermining and tunneling. The nurse would report the patient has which stage of pressure injury?

Stage 1
Stage 2
Stage 3
Stage 4

Answer 9

Stage 3

Question 10

The nurse provides care for a postoperative patient who states, “Something just popped.” The nurse assesses the wound and finds abdominal organs exposed. Which action would the nurse implement? Select all that apply.

Cover the area with sterile dressing soaked in normal saline.
Take the patient’s vital signs at least every 15 minutes.
Place the patient in a supine position.
Offer the patient cool water to drink.
Gently replace the organs with gloved hands.

Answer 10

• Cover the area with a sterile dressing
• take the patients vitals every

Question 11

The medical nurse provides care for a 76-year-old patient following right knee surgery. The patient’s mobility will be limited this shift until physical therapy consultation in the morning. Which action should the nurse implement to decrease the risk for impaired skin integrity? Select all that apply.

Apply hot packs to the knee incision as needed.
Use a trapeze bar for positioning assistance.
Use pillows to elevate heels off the bed.
Complete a new Braden Scale after surgery.
Change the wound dressing.

Answer 11

• Uses trapeze bar
• Uses pillow to elevate the hall bed
  -Complete a new brandon scale after surgery

Question 12

The nurse is collecting data about a patient’s wound and notices that the wound is getting smaller and filling with deep pink to light red tissue. The nurse determines the patient’s wound is in which phase of healing?

Maturation
Reconstruction
Remodeling
Inflammatory

Answer 12

Reconstruction

Question 13

The nurse is collecting data on a patient’s wound drainage. The drainage is reddish in color. How would the nurse document this finding?

Sanguineous drainage present.
Serosanguineous drainage present.
Serous drainage present.
Purulent drainage present.

Answer 13

Sanguineous

Question 14

The nurse is caring for a patient who has a drain that works by suction. The nurse is caring for which type of drain?

T-tube
Jackson-Pratt
Penrose drain
Montgomery strap

Answer 14

Jackson-Pratt

Question 15

The nurse is reviewing a patient’s plan of care. Which goal would the nurse most likely observe for a wet-to-damp dressing?

To blanch the wound surfaces
To prevent evisceration of the wound
To debride dead tissue in the wound
To reduce formation of wound keloids

Answer 15

To debride dead tissue in the wound

Question 16

Which actions should the nurse take when changing a wet-to-damp dressing? Select all that apply.

Use dripping 4 × 4s to pack wound.
Fluff the 4 × 4s before placing in wound.
Loosely pack the 4 × 4s into the wound
Cover the filled wound with damp, unfluffed 4 × 4s.
Let the packed 4 × 4s touch skin outside the wound .

Answer 16

-Fluff the 4x4s before placing in the wound
-Loosely pack the 4x4s into the wound
-Cover the filed wound with damp, unfluffed 4x4s

Question 17

The nurse is helping a coworker turn a patient. Which action by the coworker would cause the nurse to intervene?

Gently rubs a red area on the hip bone
Places a pillow behind the patient’s back
Positions a pillow between the patient’s knees
Puts heel protectors on the patient

Answer 17

Gently rubs a red area on the hip bone

Question 18

The nurse reinforces home care with a patient about wound care. Which statement by the patient indicates a correct understanding of the teaching?

“I will take the antibiotic until I feel better.”
“There will be increased warmth around the wound.”
“My temperature should run around 100.1°F (37.8°C).”
“Increasing pain around the wound is not normal.”

Answer 18

Increasing pain around the wound is not normal

Question 19

The nurse is caring for a patient with a pressure injury. Which technique should the nurse use to measure the pressure injury?

Touch the ruler to the skin to measure the length of the wound
Measure the wound in inches
Use a sterile cotton-tipped swab to measure depth
Estimate the length of a sinus tract

Answer 19

Use a sterile cotton tipped swab to measure depth

Question 20

A patient is having internal hemorrhage from gastrointestinal surgery. Which findings will the nurse observe? Select all that apply.

Large amount of bright red blood
Elevated, thready pulse
Low blood pressure
Pale, sweaty skin
Distended, rigid abdomen

Answer 20

-Elevated, thread pulse
- Low blood pressure
-Pale, sweaty skin
-Distended, rigid abdomen

Question 21

The nurse is using normal saline (NS) to clean a wound. Which intervention would the nurse perform when using NS?

“Lips” the previously opened (12 hours ago) normal saline bottle before using

After opening a new bottle of normal saline, dates and times the bottle

Checks the label two times before using

Places the cap with the open rim pointing upward on the sterile field

Answer 21

Lips the previously opened (12 hours ago) normal saline bottle before using

-If within 24 hours, pour some out of the bottle to release microorganisms

Question 22

The nurse is collecting data from a patient who has gas gangrene. Which finding would be consistent with gas gangrene?

The culture identifies Staphylococcus aureus as the microorganism.
Upon palpation of the affected area, a crackling sensation is felt.
The area is jaundiced and produces a foul odor.
Laboratory results indicate it is an aerobe.

Answer 22

Upon palpation of the affected area, a crackling sensation is felt

Question 23

The nurse is removing staples from a patient’s leg incision. Which technique should the nurse use?

Remove staples in succession
Gently pull the handles apart
Slide hooked jaw under the staple
Place staple remover near the knot

Answer 23

Slide hooked jaw under the staple

Question 24

A patient is admitted with a stasis ulcer. In which area would the nurse most likely find the stasis ulcer?

Fingertips
Sacrum
Lower legs
Chest

Answer 24

Lower legs

Question 25

Which statements by the nurse indicates a correct understanding of irrigating a patient's gaping wound? Select all that apply. "I will touch the Angiocath sheath to attach the syringe." "I will put 60 mL of irrigating solution into the syringe." "I will hold the syringe about 1 inch (2.5 cm) above the wound." "I will spray using a back-and-forth motion." "I will start at the superior edge of the wound and work down to the inferior end."

Answer 25

-I will hold the syringe about 1 inch above the wound -I will spray using a back and forth motion -I will start at the superior edge of the wound and work down to the inferior end

Question 26

The nurse is cleaning a patient's abdominal incision and Jackson-Pratt drain. Which action should the nurse take? Clean the drain in a circular motion starting outward and moving inward. Clean the incision from top to bottom. Clean the drain by going back over areas that have already been cleaned. Clean the entire left side of the incision, then clean the right side of the incision.

Answer 26

Clean the incision from top to bottom

Question 27

The nurse is contributing to a staff education program about the different types of dressings. Which information should the nurse recommend including? Alginate absorbs up to 10 times its own weight. An example of a foam dressing is Mepilex. Honey-impregnated dressings are used for stage 4 pressure injuries. Silicone dressings, like Comfitel, absorb exudate.

Answer 27

An example of a foam dressing is a Mepilex

Question 28

The clinic nurse is cleaning a child's skinned elbow from falling on the playground. The nurse is cleaning which type of wound? Puncture wound Abrasion Penetrating wound Closed wound

Answer 28

Abrasion

Question 29

The nurse is caring for several patients who have wound care. Which actions should the nurse take for each patient? Select all that apply. Uses a bottle of normal saline for a wet-to-damp dressing change that was opened 48 hours ago After irrigating a wound, avoids touching the interior of the wound when drying Reactivates a patient's Hemovac after emptying the contents Medicates a patient 30 minutes before a wet-to-damp dressing change Places a patient's wound culture in the refrigerator

Answer 29

-After irrigating a wound, avoids touching the interior of the wound when drying -Reactivates a patients hemovac after emptying its contents -Medicates a patient 30 minutes before a wet to damp dressing change

Question 30

The nurse is collecting data on a wound that is healing by second intention. Which patient finding will the nurse most likely observe? An abdominal incision closed with staples A gaping wound being packed with moist gauze A wound that was open for several days and then sutured An approximated incision closed with sutures

Answer 30

A gapping wound being packed with moist gauze

Question 31

The nurse is using the Braden Scale to determine pressure injury risk. Which parameters would the nurse assess? Select all that apply. Sensory perception Moisture Nutrition Age Presence of chronic illnesses

Answer 31

-Sensory perception -Moisture -Nutrition

Question 32

The nurse is reinforcing teaching with a mother of a child who has a sprained ankle. Which statements by the mother would indicate a correct understanding of the teaching? Select all that apply. "I should let the child rest." "I will place ice on the ankle." "I will make sure the bandage stays in place." "I will put pillows under my child's ankle." "I can take my child back to soccer practice this week."

Question 33

The nurse is contributing to the plan of care for a patient with a continuous passive motion (CPM) machine after left knee surgery. Which intervention should the nurse recommend including in the patient's plan of care? Take the patient to physical therapy for CPM treatments. Inform the patient that pain medication is rarely needed. Position the break in the platform beneath the patient's popliteal area. Check the patient's body alignment by standing on the left side of the bed.

Question 34

The nurse is contributing to the plan of care for a patient with a continuous passive motion (CPM) machine after left knee surgery. Which intervention should the nurse recommend including in the patient's plan of care? Take the patient to physical therapy for CPM treatments. Inform the patient that pain medication is rarely needed. Position the break in the platform beneath the patient's popliteal area. Check the patient's body alignment by standing on the left side of the bed.

Question 35

A patient has returned from surgery after a right knee replacement. Which pulse is priority for the nurse to monitor for impaired circulation? Radial pulse Apical pulse Right pedal pulse Right femoral pulse

Question 36

The nurse is caring for a patient with crutches from a broken right leg. Which instruction should the nurse reinforce? When standing, bend the knee and hold the right leg behind the crutches. Make sure there is 1 fingerbreadth between the crutch pad and the axilla. Bear weight on the underarms when standing with crutches. When walking up the stairs, place the left leg first, then the crutches and the right leg

Question 37

The nurse is caring for a patient in a plaster cast that is drying. Which action should the nurse take? Lay the cast flat on the bed. Use fingers to lift the cast. Turn the spica cast with abductor bar. Use palms to position the cast.

Question 38

The nurse is caring for a patient in traction. Which action should the nurse take? Allow the patient's foot to touch the end of the bed. Let the weight rest on the floor. Keep the ropes straight on the pulleys Make sure there is enough slack to prevent crossing of lines.

Question 39

The nurse is caring for a patient who has an Ilizarov frame. The nurse is most likely caring for which patient? One whose left leg is shorter than the right after a vehicle accident One whose spine is severely curved since birth One who has osteoarthritis from wear and tear on the body One who has an amputation from a limb that developed gangrene

Question 40

The nurse is caring for a patient with a lateral approach left hip arthroplasty. Which action should the nurse take? Remove the abductor pillow when turning the patient. Turn the patient to the left side q2h. Do not let the patient bend forward when getting out of bed. Place the left leg over the right leg at intervals.

Question 41

The nurse and the assistive personnel are caring for a patient after a direct anterior approach for a hip replacement. Which action by the assistive personnel would cause the nurse to intervene? Assisting the patient to turn Placing an abduction pillow between the patient's legs Assisting the patient with the use of a bedpan Allowing the patient to cross legs for comfort

Question 42

A patient with a weak left leg is using a walker. Which patient finding would the nurse praise? The patient's elbows are bent at a 20° angle. The patient's walker is at waist level. The patient moves the left leg with the walker, then the right. The patient stands behind the walker's back legs with the right leg.

Question 43

The nurse at an outpatient orthopedic practice evaluates a patient who suffered a wrist fracture yesterday. The patient asks, “Is this cast too tight?” Which assessment would the nurse perform to evaluate the area? Select all that apply. Ask the patient, “Are you experiencing numbness or tingling in your arm or hand?” Assess for edema in the upper arm. Compare temperature of the left and right hands. Check patient’s orientation to place and self. State to the patient, “Rate your pain on a scale of 1 to 10.” Test capillary refill in the fingernails.

Question 44

The nurse is observing a patient with a weak left leg walk with a cane. Which patient action indicates a correct understanding of using a cane? Places the cane by the left leg Leans over the cane while walking Moves the left leg and cane together, then the right leg Has the height of the cane to the top of the hip bone

Question 45

The nurse is assisting the registered nurse (RN) in developing a plan of care for a patient with impaired mobility from hip replacement surgery. Place in order the necessary steps. Plan outcome to reduce pain to at least a 4 on a 0–10 scale Observe patient after surgery moaning and saying that pain is at a level 8 on a 0–10 scale Ask the patient to rate pain level after interventions Encourage pain medication and deep breathing Contribute data to the development of acute pain nursing diagnosis