Ramont2e Rev TIF Ch24

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 24Question 1

Type: MCSA

The nurse admits a 65-year-old client diagnosed with asthma receiving steroids every six hours. A priority nursin

concern for this client is which of the following

1. !dema in the feet and legs

2. "rinary function

. S#in integrity

4. Mental status

Corre!t "ns#er: $

Rationa$e 1% The 65-year-old client ta#ing steroids increases the ris# of alteration of s#in integrity &ecause

steroids cause thinning of the s#in. The nurse plans s#in assessments and appropriate s#in care as a priority for

this client. The other options are not primary concerns for this client.

Rationa$e 2% The 65-year-old client ta#ing steroids increases the ris# of alteration of s#in integrity &ecausesteroids cause thinning of the s#in. The nurse plans s#in assessments and appropriate s#in care as a priority for


Rationa$e % The 65-year-old client ta#ing steroids increases the ris# of alteration of s#in integrity &ecause

steroids cause thinning of the s#in. The nurse plans s#in assessments and appropriate s#in care as a priority forthis client. The other options are not primary concerns for this client.

Rationa$e 4% The 65-year-old client ta#ing steroids increases the ris# of alteration of s#in integrity &ecause

steroids cause thinning of the s#in. The nurse plans s#in assessments and appropriate s#in care as a priority for


%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analy'ingC$ient Need: (hysiological )ntegrity

C$ient Need )u&:

Nursing*+ntegrated Con!epts: *ursing (rocess% (lanning

(earning ut!ome: *ame factors that affect s#in integrity.

Question 2

Type: MCSA

+amont, *iedringhous, Comprehensive Nursing Care nd !dition "pdate Test an#

Copyright /0 &y (earson !ducation, )nc.



1hen caring for a young child with a deep cut to the #nee and an elderly client with a &urn, the nurse anticipates

which of the following related to s#in healing

1. oth clients will heal at the same rate &ecause the child2s wound is deep.

2. The young client2s wound will heal more slowly due to increased ris# of infection.

. The child2s wound will heal faster due to rapid cell division.

4. The wounds will heal at the same rate &ecause &oth clients have similar ris# factors.

Corre!t "ns#er: $

Rationa$e 1% The child2s wound will heal faster &ecause of the rapid cell division and growth in children. The

elderly client2s wound should show signs of healing, &ut will ta#e longer, as cell division is not as rapid in theelderly.

Rationa$e 2% The child2s wound will heal faster &ecause of the rapid cell division and growth in children. The

elderly client2s wound should show signs of healing, &ut will ta#e longer, as cell division is not as rapid in theelderly.

Rationa$e % The child2s wound will heal faster &ecause of the rapid cell division and growth in children. The

elderly client2s wound should show signs of healing, &ut will ta#e longer, as cell division is not as rapid in the

elderly.

Rationa$e 4% The child2s wound will heal faster &ecause of the rapid cell division and growth in children. Theelderly client2s wound should show signs of healing, &ut will ta#e longer, as cell division is not as rapid in the

elderly.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Applying

C$ient Need: (hysiological )ntegrity

C$ient Need )u&:

Nursing*+ntegrated Con!epts: *ursing (rocess% Assessment

(earning ut!ome: *ame factors that affect s#in integrity.

Question

Type: MCSA

The nurse is caring for a client in the !mergency 3epartment who was in a motor vehicle accident. The client has

deep, 4agged cuts on &oth legs with a great deal of road de&ris in the wounds. The nurse is preparing to document

the assessment of the wounds, and descri&es which of the following

1. arge, contaminated lacerations on &oth legs

2. Clean, closed puncture wounds to &oth legs





. )ntentional, dirty a&rasions on &oth legs

4. pen lacerations on &oth legs

Corre!t "ns#er: 0

Rationa$e 1% 3eep, 4agged tears of the s#in are lacerations. )n this case, there is de&ris in the wounds, which

classifies them as contaminated. The wounds descri&ed are not puncture wounds, and the de&ris in the woundwould exclude them from &eing clean wounds.

Rationa$e 2% 3eep, 4agged tears of the s#in are lacerations. )n this case, there is de&ris in the wounds, whichclassifies them as contaminated. The wounds descri&ed are not puncture wounds, and the de&ris in the wound

would exclude them from &eing clean wounds.

Rationa$e % 3eep, 4agged tears of the s#in are lacerations. )n this case, there is de&ris in the wounds, which

classifies them as contaminated. The wounds descri&ed are not puncture wounds, and the de&ris in the woundwould exclude them from &eing clean wounds.

Rationa$e 4% 3eep, 4agged tears of the s#in are lacerations. )n this case, there is de&ris in the wounds, whichclassifies them as contaminated. The wounds descri&ed are not puncture wounds, and the de&ris in the wound

would exclude them from &eing clean wounds.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: 3efine terms used to descri&e or to classify wounds.

Question 4

Type: MCSA

A client with an infected four-day-old postoperative wound has &een readmitted to the unit for wound

de&ridement and anti&iotic therapy. The wound is sutured with a sca& that is pulling away from the edges of the

s#in, is draining pus and serosanguinous fluid, and is swollen and reddened. The nurse classifies the wound at

what stage of healing

1. Secondary intention healing

2. (roliferative phase

. Maturation phase

4. )nflammatory phase

Corre!t "ns#er: 7





Rationa$e 1% The wound was sutured and therefore intended to heal as primary intention. The wound is red andinflamed with serosanguinous drainage, and is four days old, which is the inflammatory phase. )n the proliferative

phase, the s#in is still reddened &ut is no longer greatly inflamed. The maturation phase is characteri'ed &y a scar

that continues to grow stronger with tissue growth. Secondary intention healing occurs when the wound is leftopen to heal rather than &eing sutured or approximated.

Rationa$e 2% The wound was sutured and therefore intended to heal as primary intention. The wound is red and

inflamed with serosanguinous drainage, and is four days old, which is the inflammatory phase. )n the proliferative phase, the s#in is still reddened &ut is no longer greatly inflamed. The maturation phase is characteri'ed &y a scarthat continues to grow stronger with tissue growth. Secondary intention healing occurs when the wound is left

open to heal rather than &eing sutured or approximated.

Rationa$e % The wound was sutured and therefore intended to heal as primary intention. The wound is red and

inflamed with serosanguinous drainage, and is four days old, which is the inflammatory phase. )n the proliferative phase, the s#in is still reddened &ut is no longer greatly inflamed. The maturation phase is characteri'ed &y a scar

that continues to grow stronger with tissue growth. Secondary intention healing occurs when the wound is left

open to heal rather than &eing sutured or approximated.

Rationa$e 4% The wound was sutured and therefore intended to heal as primary intention. The wound is red andinflamed with serosanguinous drainage, and is four days old, which is the inflammatory phase. )n the proliferative

phase, the s#in is still reddened &ut is no longer greatly inflamed. The maturation phase is characteri'ed &y a scar

that continues to grow stronger with tissue growth. Secondary intention healing occurs when the wound is leftopen to heal rather than &eing sutured or approximated.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: )dentify how wounds heal, the phases of wound healing, and types of wound drainage.

Question -

Type: MCSA

A 85-year-old woman has &een on the unit with a &urn to the left el&ow caused &y a &athro&e that caught fire

while the client was coo#ing. The &urn is on the inner aspect of the el&ow, and is descri&ed as a full-thic#ness

&urn, which is now in the third stage of healing. 1hen planning care for this client, the nurse focuses on which of

the following as a priority of care

1. Monitoring the client for wound hemorrhage

2. Monitoring for signs of infection

. (reventing contractures and immo&ility

4. (reventing dehiscence





Corre!t "ns#er: $

Rationa$e 1% The elderly client has scar tissue that is less elastic and less flexi&le, placing the client at ris# for acontracture of the el&ow. The wound is in the third stage of healing, and is no longer at ris# for infection or

hemorrhage. urn wounds are not sutured, so there is no ris# of dehiscence.

Rationa$e 2% The elderly client has scar tissue that is less elastic and less flexi&le, placing the client at ris# for a

contracture of the el&ow. The wound is in the third stage of healing, and is no longer at ris# for infection orhemorrhage. urn wounds are not sutured, so there is no ris# of dehiscence.

Rationa$e % The elderly client has scar tissue that is less elastic and less flexi&le, placing the client at ris# for a

contracture of the el&ow. The wound is in the third stage of healing, and is no longer at ris# for infection or


Rationa$e 4% The elderly client has scar tissue that is less elastic and less flexi&le, placing the client at ris# for a

contracture of the el&ow. The wound is in the third stage of healing, and is no longer at ris# for infection or


%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analy'ing


C$ient Need )u&:

Nursing*+ntegrated Con!epts: *ursing (rocess% (lanning

(earning ut!ome: 3escri&e factors that affect wound healing and complications that can occur.

Question

Type: MCSA

A client with rheumatoid arthritis is recovering from an appendectomy. The client ta#es aspirin for 4oint pain. The

nurse monitors the wound closely for complications, anticipating which of the following

1. 3elayed healing from the use of aspirin

2. )ncreased pain levels due to the arthritis

. (neumonia due to immo&ility

4. 9oint contractures due to immo&ility

Corre!t "ns#er: 0

Rationa$e 1% Aspirin delays the healing process, so the nurse monitors healing and assesses for complications.

(neumonia and 4oint contractures are not part of wound monitoring. (ain at the wound site is not increased due to

arthritis.





Rationa$e 2% Aspirin delays the healing process, so the nurse monitors healing and assesses for complications.(neumonia and 4oint contractures are not part of wound monitoring. (ain at the wound site is not increased due to

arthritis.

Rationa$e % Aspirin delays the healing process, so the nurse monitors healing and assesses for complications.

(neumonia and 4oint contractures are not part of wound monitoring. (ain at the wound site is not increased due toarthritis.

Rationa$e 4% Aspirin delays the healing process, so the nurse monitors healing and assesses for complications.

(neumonia and 4oint contractures are not part of wound monitoring. (ain at the wound site is not increased due toarthritis.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: 3escri&e factors that affect wound healing and complications that can occur.

Question /

Type: MCSA

A client with a perineal car&uncle and an a&scess is &eing given morning care &y a newly hired nurse who is &ein

mentored &y another staff nurse. The client had an incision and drainage of the wound three days ago. Current

orders include &edrest: diet and fluids as desired: warm, moist compresses every four hours: and topical and

systemic anti&iotics. 1hich o&servation of the newly hired nurse giving care should &e interrupted and clarified

&y the mentoring nurse

1. The nurse cleanses the area with warm water &efore applying the compress.

2. The nurse encourages the client to do active range of motion to all extremities.

. The nurse uses sterile gloves and gau'e to change the compresses.

4. The nurse places a &ed cradle on the &ed.

Corre!t "ns#er:

Rationa$e 1% Active +M of the legs can irritate the perineal wound, cause tears in the wound, or cause

hemorrhaging. Cleansing the area with warm water using sterile gloves and gau'e is a correct action. (lacing a &ed cradle on the &ed to #eep sheets and &lan#ets from irritating the wound is also an accepta&le action &y the

nurse.


hemorrhaging. Cleansing the area with warm water using sterile gloves and gau'e is a correct action. (lacing a





&ed cradle on the &ed to #eep sheets and &lan#ets from irritating the wound is also an accepta&le action &y thenurse.

Rationa$e % Active +M of the legs can irritate the perineal wound, cause tears in the wound, or cause

hemorrhaging. Cleansing the area with warm water using sterile gloves and gau'e is a correct action. (lacing a

&ed cradle on the &ed to #eep sheets and &lan#ets from irritating the wound is also an accepta&le action &y thenurse.


hemorrhaging. Cleansing the area with warm water using sterile gloves and gau'e is a correct action. (lacing a &ed cradle on the &ed to #eep sheets and &lan#ets from irritating the wound is also an accepta&le action &y the

nurse.

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: ;*(<)ntervention

(earning ut!ome: ist and discuss aspects of caring for wounds.

Question 0

Type: MCSA

A client is in the hospital recovering from extensive wounds from an automo&ile accident. The nurse is reviewing

the la&oratory results from the previous day, and notices that the client2s total protein levels are low. The nurse

plans nutritional teaching with the client and concludes that the client has understood when the client ma#es

which of the following selections for dinner

1. =ried chic#en, spinach salad, whole mil#, fruit

2. a#ed chic#en, red &eans, &rown rice, s#im mil#, fresh fruit

. >eal chops, tossed salad, s?uash casserole, whole mil#, peach co&&ler

4. a#ed chic#en, cole slaw, mixed vegeta&les, diet soda, apple

Corre!t "ns#er:

Rationa$e 1% A high-protein, high-car&ohydrate diet supplies the nutrients needed for wound healing. a#edchic#en with red &eans and rice provides ?uality protein and complex car&ohydrates for healing. =ried chic#en

and whole mil# have too much fat, and there are no complex car&ohydrates in this selection. >eal chops contain

whole mil#, which should &e avoided due to high fat content, and this selection also contains no complexcar&ohydrate choices for energy production. The &a#ed chic#en, slaw, and vegeta&les are a healthy choice, &ut do

not contain enough protein or car&ohydrates.





Rationa$e 2% A high-protein, high-car&ohydrate diet supplies the nutrients needed for wound healing. a#edchic#en with red &eans and rice provides ?uality protein and complex car&ohydrates for healing. =ried chic#en

and whole mil# have too much fat, and there are no complex car&ohydrates in this selection. >eal chops contain

whole mil#, which should &e avoided due to high fat content, and this selection also contains no complexcar&ohydrate choices for energy production. The &a#ed chic#en, slaw, and vegeta&les are a healthy choice, &ut do

not contain enough protein or car&ohydrates.

Rationa$e % A high-protein, high-car&ohydrate diet supplies the nutrients needed for wound healing. a#edchic#en with red &eans and rice provides ?uality protein and complex car&ohydrates for healing. =ried chic#enand whole mil# have too much fat, and there are no complex car&ohydrates in this selection. >eal chops contain

whole mil#, which should &e avoided due to high fat content, and this selection also contains no complex

car&ohydrate choices for energy production. The &a#ed chic#en, slaw, and vegeta&les are a healthy choice, &ut donot contain enough protein or car&ohydrates.

Rationa$e 4% A high-protein, high-car&ohydrate diet supplies the nutrients needed for wound healing. a#ed

chic#en with red &eans and rice provides ?uality protein and complex car&ohydrates for healing. =ried chic#en

and whole mil# have too much fat, and there are no complex car&ohydrates in this selection. >eal chops containwhole mil#, which should &e avoided due to high fat content, and this selection also contains no complex

car&ohydrate choices for energy production. The &a#ed chic#en, slaw, and vegeta&les are a healthy choice, &ut donot contain enough protein or car&ohydrates.

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: *ursing (rocess% !valuation

(earning ut!ome: ist and discuss aspects of caring for wounds.

Question

Type: MCMA

The nurse applies a hydrocolloidal dressing to the client2s pressure ulcer, and explains the &enefits of this type of

dressing as &eing which of the following Select all that apply.

)tandard Tet: Select all that apply.

1. )ncreases client comfort.

2. 3ecreases anero&ic &acterial growth.

. Can &e used on all wound types.

4. Can &e molded to uneven &ody surfaces.

-. )s water-resistant.





Corre!t "ns#er: 0,7,5

Rationa$e 1% The hydrocolloid dressing is plia&le, can &e molded to uneven surfaces, reduces pain, and is water-resistant. Some disadvantages are that it increases the ris# of anero&ic &acterial growth and cannot &e used on

wounds that are infected.

Rationa$e 2% The hydrocolloid dressing is plia&le, can &e molded to uneven surfaces, reduces pain, and is water-

resistant. Some disadvantages are that it increases the ris# of anero&ic &acterial growth and cannot &e used onwounds that are infected.

Rationa$e % The hydrocolloid dressing is plia&le, can &e molded to uneven surfaces, reduces pain, and is water-

resistant. Some disadvantages are that it increases the ris# of anero&ic &acterial growth and cannot &e used on


Rationa$e 4% The hydrocolloid dressing is plia&le, can &e molded to uneven surfaces, reduces pain, and is water-

resistant. Some disadvantages are that it increases the ris# of anero&ic &acterial growth and cannot &e used on


Rationa$e -% The hydrocolloid dressing is plia&le, can &e molded to uneven surfaces, reduces pain, and is water-resistant. Some disadvantages are that it increases the ris# of anero&ic &acterial growth and cannot &e used on


%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: *ursing (rocess% )mplementation

(earning ut!ome: Compare different types of dressings used in wound care and methods of application.

Question 13

Type: MCSA

A dia&etic client is &eing treated for a foot ulcer with warm compresses to the wound twice a day. The priority

nursing action when applying the dressing is which of the following

1. !levate the foot to prevent edema.

2. Monitor the wound for &leeding.

. Monitor the wound for exudate.

4. Monitor the client2s response to prevent a &urn.

Corre!t "ns#er: 7





Rationa$e 1% The dia&etic has decreased perfusion to the wound and neurosensory impairment, which will reduce perception of heat. The nurse measures the temperature of the compress @/-0/5B=, and monitors the site

fre?uently for signs of &urn. !levating the extremity will counteract the purpose of the compress and decrease

&lood flow to the wound. A compress is not li#ely to cause excess &leeding or exudate.

Rationa$e 2% The dia&etic has decreased perfusion to the wound and neurosensory impairment, which will reduce perception of heat. The nurse measures the temperature of the compress @/-0/5B=, and monitors the site

fre?uently for signs of &urn. !levating the extremity will counteract the purpose of the compress and decrease &lood flow to the wound. A compress is not li#ely to cause excess &leeding or exudate.

Rationa$e % The dia&etic has decreased perfusion to the wound and neurosensory impairment, which will reduce

perception of heat. The nurse measures the temperature of the compress @/-0/5B=, and monitors the site



Rationa$e 4% The dia&etic has decreased perfusion to the wound and neurosensory impairment, which will reduce

perception of heat. The nurse measures the temperature of the compress @/-0/5B=, and monitors the site



%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: 3iscuss methods of applying dry and moist heat and cold to aid wound healing.

Question 11

Type: MCSA

A client with a muscle in4ury has 4ust returned to the unit from the (hysical Therapy department. The client

complains to the nurse that the muscles of the shoulder are sore after the exercise in physical therapy. The nurse

suggests that the client apply an ordered cold pac# for / minutes to the shoulder muscles for which of the

following reasons

1. Cooling the muscles will help them to relax and feel less sore.

2. Cold will reduce &lood flow and inflammation created &y the exercise.

. Cold pac#s will &ring healing &lood to the in4ured muscle.

4. Cold therapy reduces the ris# of infection.

Corre!t "ns#er:





Rationa$e 1% 1hen in4ured muscles are exercised, inflammation occurs immediately following the exercise. Cold pac#s help reduce the inflammation. Deat is then applied after the cold to promote relaxation and perfusion to the

muscle. Since sore muscles are not an open wound, infection is not a consideration.

Rationa$e 2% 1hen in4ured muscles are exercised, inflammation occurs immediately following the exercise. Cold

pac#s help reduce the inflammation. Deat is then applied after the cold to promote relaxation and perfusion to themuscle. Since sore muscles are not an open wound, infection is not a consideration.

Rationa$e % 1hen in4ured muscles are exercised, inflammation occurs immediately following the exercise. Cold

pac#s help reduce the inflammation. Deat is then applied after the cold to promote relaxation and perfusion to themuscle. Since sore muscles are not an open wound, infection is not a consideration.

Rationa$e 4% 1hen in4ured muscles are exercised, inflammation occurs immediately following the exercise. Cold

pac#s help reduce the inflammation. Deat is then applied after the cold to promote relaxation and perfusion to the

muscle. Since sore muscles are not an open wound, infection is not a consideration.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need: (hysiological )ntegrity

C$ient Need )u&:


(earning ut!ome: 3iscuss methods of applying dry and moist heat and cold to aid wound healing.

Question 12

Type: MCSA

An unconscious $E-year-old client is &rought to the !mergency 3epartment after a motorcycle accident. The

nurse is assessing the client, and notes several lacerations that contain dirt, pe&&les, and glass. The nurseanticipates that care for this client will include cleaning and dressing the wounds and which of the following

1. Applying cold pac#s to the wounds

2. Administering a tetanus &ooster

. Completing the nursing history

4. Assessment of treated wounds

Corre!t "ns#er:

Rationa$e 1% The client is unconscious, and has road de&ris in his wounds. The nurse would anticipate giving atetanus &ooster to this client, &ecause he would &e una&le to report when he had his last &ooster shot. Cold pac#s

would not &e applied to the wounds until they are treated. Since the client is unconscious, the nurse will not

anticipate completing the nursing history. Assessment of treated wounds will occur on the unit after admissionrather than in the !mergency 3epartment.





Rationa$e 2% The client is unconscious, and has road de&ris in his wounds. The nurse would anticipate giving atetanus &ooster to this client, &ecause he would &e una&le to report when he had his last &ooster shot. Cold pac#s

would not &e applied to the wounds until they are treated. Since the client is unconscious, the nurse will not

anticipate completing the nursing history. Assessment of treated wounds will

Rationa$e % The client is unconscious, and has road de&ris in his wounds. The nurse would anticipate giving atetanus &ooster to this client, &ecause he would &e una&le to report when he had his last &ooster shot. Cold pac#s

would not &e applied to the wounds until they are treated. Since the client is unconscious, the nurse will notanticipate completing the nursing history. Assessment of treated wounds will occur on the unit after admissionrather than in the !mergency 3epartment.

Rationa$e 4% The client is unconscious, and has road de&ris in his wounds. The nurse would anticipate giving a

tetanus &ooster to this client, &ecause he would &e una&le to report when he had his last &ooster shot. Cold pac#s

would not &e applied to the wounds until they are treated. Since the client is unconscious, the nurse will notanticipate completing the nursing history. Assessment of treated wounds will occur on the unit after admission

rather than in the !mergency 3epartment.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: )dentify interventions for nursing care of clients with wounds.

Question 1

Type: MCSA

The nurse admits a client who has fallen from a ladder to the !mergency 3epartment with a deep wound on theleg. There is a &lood-saturated pressure dressing on the wound. The nurse assesses the client and finds a heart rate

of 0E, respirations of $/, and &lood pressure of F5/. The priority action &y the nurse at this time is which of th

following

1. *otify the physician immediately.

2. +einforce the pressure dressing and elevate the extremity.

. +emove the pressure dressing, assess the wound, and apply a new dressing.

4. Start an )> line for the administration of fluids.

Corre!t "ns#er:

Rationa$e 1% The client is in shoc# from &lood loss, as indicated &y vital signs. The priority action is to prevent

further loss of &lood &y reinforcing the current pressure dressing. +emoving the old dressing will result in

increased &lood loss. 1hile the nurse might need to call the physician, the dressing should &e reinforced first in





order to prevent further &lood loss &efore the physician arrives. An )> line re?uires an order, and cannot &e placedindependently &y the nurse.



increased &lood loss. 1hile the nurse might need to call the physician, the dressing should &e reinforced first inorder to prevent further &lood loss &efore the physician arrives. An )> line re?uires an order, and cannot &e placed

independently &y the nurse.

Rationa$e % The client is in shoc# from &lood loss, as indicated &y vital signs. The priority action is to preventfurther loss of &lood &y reinforcing the current pressure dressing. +emoving the old dressing will result in


order to prevent further &lood loss &efore the physician arrives. An )> line re?uires an order, and cannot &e placed

independently &y the nurse.




order to prevent further &lood loss &efore the physician arrives. An )> line re?uires an order, and cannot &e placedindependently &y the nurse.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: )dentify interventions for nursing care of clients with wounds.

Question 14

Type: MCSA

The nurse caring for a comatose client does which of the following to prevent a pressure ulcer on the &ac# of the

client2s head

1. (laces a small pillow under the client2s shoulders.

2. (laces the client in the prone position several times a day.

. "ses a gel floatation pad directly under the occiput when supine.

4. Consistently turns the client2s head to the right.

Corre!t "ns#er: $

Rationa$e 1% Gel pads are a very good way of protecting pressure points on the client, such as the &ac# of the

head. (lacing a pillow under the client2s shoulders acts to open the airway, &ut the head remains on the &ed. Many





clients cannot tolerate the prone position. Consistently turning the client2s head to the right would avoid a pressurulcer at the &ac# of the head &ut cause a pressure ulcer on the right side of the head.


head. (lacing a pillow under the client2s shoulders acts to open the airway, &ut the head remains on the &ed. Many

clients cannot tolerate the prone position. Consistently turning the client2s head to the right would avoid a pressurulcer at the &ac# of the head &ut cause a pressure ulcer on the right side of the head.

Rationa$e % Gel pads are a very good way of protecting pressure points on the client, such as the &ac# of the

head. (lacing a pillow under the client2s shoulders acts to open the airway, &ut the head remains on the &ed. Manyclients cannot tolerate the prone position. Consistently turning the client2s head to the right would avoid a pressur

ulcer at the &ac# of the head &ut cause a pressure ulcer on the right side of the head.


head. (lacing a pillow under the client2s shoulders acts to open the airway, &ut the head remains on the &ed. Manyclients cannot tolerate the prone position. Consistently turning the client2s head to the right would avoid a pressur

ulcer at the &ac# of the head &ut cause a pressure ulcer on the right side of the head.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: !xplain the mechanism of pressure ulcer formation, as well as ris# factors and preventive

measures for it.

Question 1-

Type: MCSA

The nurse documents the first sign of a pressure ulcer that has not yet progressed to stage 0 when noting which of

the following

1. *on&lancha&le reddened area on the coccyx

2. Mushy area on the &uttoc#s that is cool to the touch

. 1ound covered with eschar

4. A &lister on the &uttoc#s

Corre!t "ns#er:

Rationa$e 1% efore non&lancha&le erythema appears, many clients develop an area that suggests deep tissue

in4ury evidenced &y pain, a mushy or &oggy area that can &e cool or warm to the touch. *on&lancha&le erythema

is a stage 0 pressure ulcer. A wound covered with eschar is a stage 7 or unstagea&le tissue in4ury. A &lister is a

stage pressure ulcer.





Rationa$e 2% efore non&lancha&le erythema appears, many clients develop an area that suggests deep tissuein4ury evidenced &y pain, a mushy or &oggy area that can &e cool or warm to the touch. *on&lancha&le erythema



Rationa$e % efore non&lancha&le erythema appears, many clients develop an area that suggests deep tissuein4ury evidenced &y pain, a mushy or &oggy area that can &e cool or warm to the touch. *on&lancha&le erythema

is a stage 0 pressure ulcer. A wound covered with eschar is a stage 7 or unstagea&le tissue in4ury. A &lister is astage pressure ulcer.

Rationa$e 4% efore non&lancha&le erythema appears, many clients develop an area that suggests deep tissue

in4ury evidenced &y pain, a mushy or &oggy area that can &e cool or warm to the touch. *on&lancha&le erythema



%$o&a$ Rationa$e:


C$ient Need: (hysiological )ntegrityC$ient Need )u&:


(earning ut!ome: 3escri&e stages of pressure ulcer formation and methods of collecting data to assess status.

Question 1

Type: MCMA

The nurse conducting a pressure ulcer ris# assessment on clients in a long-term care facility identifies which of

the following as ris# factors Select all that apply.


1. !levated temperature of 0/0B=

2. 3ecreased response to painful stimuli

. Consumes a high-protein diet.

4. 3rin#s six glasses of water daily.

-. 1al#s occasionally for a short distance.

Corre!t "ns#er: 0,,5

Rationa$e 1% An elevated temperature puts the client at ris# due to the increased need for oxygen to the tissues.

The client who has limited sensory response is at ris# &ecause she does not feel the pain associated withcompressed tissues. A client who wal#s only occasionally is at ris# &ecause the client is in &ed or a chair for the





ma4ority of the time. The client who consumes ade?uate protein and fluids is not at a high ris#, althoughassessment in the elderly for pressure ulcers is a priority.


The client who has limited sensory response is at ris# &ecause she does not feel the pain associated with

compressed tissues. A client who wal#s only occasionally is at ris# &ecause the client is in &ed or a chair for thema4ority of the time. The client who consumes ade?uate protein and fluids is not at a high ris#, although

assessment in the elderly for pressure ulcers is a priority.

Rationa$e % An elevated temperature puts the client at ris# due to the increased need for oxygen to the tissues.The client who has limited sensory response is at ris# &ecause she does not feel the pain associated with

compressed tissues. A client who wal#s only occasionally is at ris# &ecause the client is in &ed or a chair for the

ma4ority of the time. The client who consumes ade?uate protein and fluids is not at a high ris#, although



The client who has limited sensory response is at ris# &ecause she does not feel the pain associated with

compressed tissues. A client who wal#s only occasionally is at ris# &ecause the client is in &ed or a chair for the

ma4ority of the time. The client who consumes ade?uate protein and fluids is not at a high ris#, althoughassessment in the elderly for pressure ulcers is a priority.

Rationa$e -% An elevated temperature puts the client at ris# due to the increased need for oxygen to the tissues.

The client who has limited sensory response is at ris# &ecause she does not feel the pain associated withcompressed tissues. A client who wal#s only occasionally is at ris# &ecause the client is in &ed or a chair for the

ma4ority of the time. The client who consumes ade?uate protein and fluids is not at a high ris#, although


%$o&a$ Rationa$e:


C$ient Need )u&:


(earning ut!ome: 3escri&e stages of pressure ulcer formation and methods of collecting data to assess status.

Question 1/

Type: MCSA

A client has a stage decu&itus ulcer on the left foot. The nurse is completing discharge instructions for the client

and spouse a&out care of the wound and s#in assessment. The nurse concludes that the client has understoodteaching if the client states which of the following

1. H) will soa# in the tu& in hot water for $/ minutes every day.H

2. H) will call the doctor if ) notice a &lister anywhere on my &ody.H

. H) will call the doctor if ) notice a &lister on a pressure point.H





4. H) will call the doctor if ) feel pain or see redness over a pressure point.H

Corre!t "ns#er: 7

Rationa$e 1% The nurse would want the client to understand that the time to call the doctor is &efore a pressure

ulcer forms. *oticing tissue pain or redness would &e an early sign of a potential ulcer. Dot-water &aths will

contri&ute to s#in &rea#down. A &lister on an area of the &ody is not necessarily a reason to notify the doctor. A

&lister on a &ony prominence is already a stage decu&itus, and the client needs to notify the doctor at stage 0 or &efore.



contri&ute to s#in &rea#down. A &lister on an area of the &ody is not necessarily a reason to notify the doctor. A &lister on a &ony prominence is already a stage decu&itus, and the client needs to notify the doctor at stage 0 or

&efore.

Rationa$e % The nurse would want the client to understand that the time to call the doctor is &efore a pressureulcer forms. *oticing tissue pain or redness would &e an early sign of a potential ulcer. Dot-water &aths will

contri&ute to s#in &rea#down. A &lister on an area of the &ody is not necessarily a reason to notify the doctor. A &lister on a &ony prominence is already a stage decu&itus, and the client needs to notify the doctor at stage 0 or

&efore.



contri&ute to s#in &rea#down. A &lister on an area of the &ody is not necessarily a reason to notify the doctor. A

&lister on a &ony prominence is already a stage decu&itus, and the client needs to notify the doctor at stage 0 or &efore.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: 3iscuss the nursing process in relation to clients with pressure ulcers.

Question 10

Type: MCSA

The nurse understands that wounds in infants and children heal more rapidly &ecause

1. )t is more fragile

2. Their s#in has not &een exposed to sun

. Their s#in is thinner





4. 3ue to rapid cell division

Corre!t "ns#er: 7

Rationa$e 1% )nfant s#in is more fragile and suscepti&le to in4ury, &ut this is not why it heals more rapidly

Rationa$e 2% Most infant s#in has not &een damaged from environmental exposure to light, heat or cold, &ut this

is not why it heals more rapidly

Rationa$e % Clients who use steroids may develop thinning of the s#in

Rationa$e 4% 1ounds tend to heal much more rapidly in infants and children &ecause of the rapid cell division thais associated with growth

%$o&a$ Rationa$e:

Cogniti'e (e'e$: "nderstanding


C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The nurse is ta#ing a clientIs history on admission to a reha&ilitation facility. =actors that may cause s#in integrity

to &e impaired in the 75-year-old post-surgical client include%@Select all that apply


1. Genetics

2. "se of anti&iotics

. (oor nutrition

4. )ntact s#in

-. +estricted mo&ility

Corre!t "ns#er: 0,$,5

Rationa$e 1% Sensitivity to light or allergens, characteristics that can affect integrity, are governed largely &y

genetics


genetics





Rationa$e % Sensitivity to light or allergens, characteristics that can affect integrity, are governed largely &ygenetics


genetics

Rationa$e -% Sensitivity to light or allergens, characteristics that can affect integrity, are governed largely &y

genetics

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 23

Type: MCMA

The parents of a new&orn are interested in learning a&out s#in care for the infant. The nurse shows the parents a

picture of normal s#in structure, and discusses information important to #now a&out s#in including%@Select all tha

apply


1. S#in protects the &ody

2. S#in is the first line of defense

. Some s#in characteristics are governed &y genetics

4. 1ounds in the s#in of infants heal slowly

-. S#in of infants is suscepti&le to in4ury

Corre!t "ns#er: 0,,$,5

Rationa$e 1% The s#in is the largest organ of the &ody, and helps to maintain health

Rationa$e 2% )ntact s#in is the first line of defense against invasion &y microorganisms

Rationa$e % Some characteristics, such as sensitivity to light or allergens, are governed largely &y genetics

Rationa$e 4% 1ounds in the s#in of infants and children tend to heal more rapidly in infants and children &ecauseof the rapid cell division that is associated with growth





Rationa$e -% S#in of infants is more fragile and suscepti&le to in4ury

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 21

Type: MCMA

The nurse is preparing to examine the s#in of a new client. (rior to assessing the client, the nurse reviews the

clients medical record for factors that increase ris# for impaired s#in integrity such as%@Select all that apply


1. Joung adulthood

2. Chronic illness

. Trauma

4. (eripheral vascular disease

-. Steroid use

Corre!t "ns#er: ,$,7,5

Rationa$e 1% The s#in of infants and older adults is more fragile than the s#in of a young adult

Rationa$e 2% Chronic illness, such as dia&etes, increases the ris# of impaired s#in integrity

Rationa$e % Trauma, such as falls or surgery, increases the ris# of impaired s#in integrity

Rationa$e 4% )mpaired peripheral arterial circulation cause a client to have s#in on the legs that damages easilyand heals slowly

Rationa$e -% Clients who use steroids may develop thinning of the s#in, which allow it to &e damaged more easil

%$o&a$ Rationa$e:



C$ient Need )u&:






(earning ut!ome:

Question 22

Type: MCMA

1ounds are fre?uently descri&ed according to how they are ac?uired. The nurse expects to see an open wound in

the following types of wounds%@Select all that apply


1. )ncision

2. Contusion

. A&rasion

4. aceration

-. (uncture

Corre!t "ns#er: 0,$,7,5

Rationa$e 1% An incision is an open wound cause &y a sharp instrument

Rationa$e 2% A contusion is a closed wound cause &y a &low from a &lunt instrument

Rationa$e % An a&rasion is an open wound caused &y a surface scrape

Rationa$e 4% A laceration is an open wound cause &y tissue &eing torn apart, often from accidents

Rationa$e -% A puncture is an open wound cause &y penetration of the s#in and often the underlying tissues &y a

sharp instrument

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCSA

An example of a wound that occurs during therapy would &e%

1. (ressure ulcers





2. >enipuncture

. ro#en &ones

4. Closed wound

Corre!t "ns#er:

Rationa$e 1% (ressure ulcers are not wounds that would occur intentionally: nurses wor# to prevent pressure

ulcers

Rationa$e 2% >enipuncture and surgery are examples of intentional trauma that may occur during therapy

Rationa$e % ro#en &ones are generally unintentional, or accidental

Rationa$e 4% 3amaged tissue with no &rea# in the s#in is a closed wound: and example would &e a contusion

which is generally not part of therapy

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 24

Type: MCMA

The nurse identifies clients li#ely to have clean wounds, including%@Select all that apply


1. A client with multiple contusions

2. A client with a fresh surgical wound

. A client who was in a motorcycle accident

4. A client who has purulent drainage

-. A client with a laceration from a #nife

Corre!t "ns#er: 0,

Rationa$e 1% Contusions are closed wounds, and unli#ely to &e contaminated





Rationa$e 2% A client with a fresh surgical wound is unli#ely to have a contaminated or infected wound

Rationa$e % The client who was in a motorcycle accident is li#ely to have contaminated or dirty wounds, such as

a&rasions

Rationa$e 4% The client with a wound with purulent drainage has a dirty or infected wound

Rationa$e -% The client with a laceration from a #nife is li#ely to have a contaminated wound

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2-

Type: MCSA

The nurse anticipates the following healing process of the surgical wound%

1. Minimal granulation tissue and scarring

2. onger repair time

. Significant scarring

4. )ncreased ris# of infection

Corre!t "ns#er: 0

Rationa$e 1% The surgical wound typically heals &y primary intention, where tissues have &een approximated and

there is minimal or no tissue loss: it characteristically has minimal granulation tissue and scarring

Rationa$e 2% The wound that heals &y primary intention, such as a surgical wound, heals more ?uic#ly that awound that is extensive and involves considera&le tissue loss

Rationa$e % The wound that heals &y primary intention, such as a surgical wound, has less scarring that a wound

that heals &y secondary intention

Rationa$e 4% The surgical wound, with closed, approximated tissue surfaces is less li#ely to &ecome infection.

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 2

Type: S!K

The nurse understands the phases of wound healing are the steps in the &odyIs natural process of tissue repair. Th

processes that are involved occur in the following order%

)tandard Tet: Clic# and drag the options &elow to move them up or down.

Choi!e 1. Demostasis

Choi!e 2. (hagocytosis

Choi!e . Collagen synthesis

Choi!e 4. !pitheliali'ation

Choi!e -. +emodeling

Corre!t "ns#er: 0,,$,7,5

Rationa$e 1% The inflammatory phase &egins with hemostasis


Rationa$e % The inflammatory phase &egins with hemostasis


Rationa$e -% The inflammatory phase &egins with hemostasis

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: *ursing (rocess% Assessment(earning ut!ome:

Question 2/

Type: MCMA

The nurse is discussing wound healing with a group of preoperative clients. =actors that inhi&it wound healing

include%@Select all that apply






1. +egular exercise

2. Smo#ing

. &esity

4. Aspirin

-. 3aily orange 4uice consumption

Corre!t "ns#er: ,$,7

Rationa$e 1% +egular exercise tend to have good circulation and are more li#ely to heal ?uic#ly

Rationa$e 2% Smo#ing reduces the amount of functional hemoglo&in in the &lood and causes vasoconstriction,thus limiting the oxygen carrying capacity of the &lood

Rationa$e % &ese clients are at increased ris# of wound infection and slower healing &ecause adipose tissue

usually has a minimal &lood supply

Rationa$e 4% Anti-inflammatory drugs, such as aspirin and steroids interfere with healing

Rationa$e -% >itamin C has an important role in collagen synthesis, helping in the formation of &onds amongstrands of collagen fi&er

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 20

Type: MCSA

A client uses the call light and reports that while coughing, the surgical wound opened up, with Lstuff falling

through. The nurse anticipates which complication of wound healing

1. Demorrhage

2. )nfection

. !visceration





4. 3ehiscence

Corre!t "ns#er: $

Rationa$e 1% hemorrhage is persistent &leeding that may &e caused &y a dislodged clot, slipped suture, or erosion

of a &lood vessel

Rationa$e 2% )nfection with microorganisms can occur during the time of in4ury, and is most li#ely to &ecomeapparent -00 days postoperatively

Rationa$e % !visceration is the protrusion of the internal viscera through an incision

Rationa$e 4% 3ehiscence is the partial or total rupturing of a sutured wound

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is applying a dry gau'e dressing to the clientIs large a&rasion. The client as#s the nurse why he needs a

dressing on it. Appropriate responses include%@Select all that apply


1. The dressing will protect the wound from &eing contaminated &y germs

2. 1ounds heal &etter when they are #ept warm, and the dressing will provide insulation

. The wound may drain as it heals, and the dressing will a&sor& the drainage

4. The wound needs to &e #ept moist

-. This will prevent the wound from hemorrhaging

Corre!t "ns#er: 0,,$

Rationa$e 1% The dressing will protect the wound from micro&ial contamination


Rationa$e % The dressing will protect the wound from micro&ial contamination






Rationa$e -% The dressing will protect the wound from micro&ial contamination

%$o&a$ Rationa$e:




(earning ut!ome:

Question 3

Type: MCSA

The nurse has several choices of wound dressings. The most appropriate dressing to use to cover, soothe and

protect a wound without exudate is aFan

1. Transparent adhesive film

2. )mpregnated nonadherent dressing

. Dydrogel

4. (olyurethane foam

Corre!t "ns#er:

Rationa$e 1% A transparent adhesive film is used to provide protection against contamination and friction, andmaintain a clean, moist surface that facilitates cellular migration


Rationa$e % A transparent adhesive film is used to provide protection against contamination and friction, and

maintain a clean, moist surface that facilitates cellular migration


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 1

Type: MCSA

The nurse decides to use a wet-to-dry gau'e dressing on a clientIs wound. The primary purpose of this type of

dressing is%

1. (rotect the wound

2. 3e&ride the wound

. Neep the wound continually moist

4. 3ilute viscous exudate

Corre!t "ns#er:

Rationa$e 1% A dry-to-dry dressing is used primarily to protect the wound

Rationa$e 2% The wet-to-dry dressing is used primarily to de&ride the wound

Rationa$e % The wet-to-wet dressing is used to #eep the wound moist

Rationa$e 4% The purpose of the wet-to-wet dressing is to #eep the wound moist and dilute viscous exudate

%$o&a$ Rationa$e:




(earning ut!ome:

Question 2

Type: MCMA

The nurse chooses a wound vac for the following types of wounds%


1. A venous stasis leg ulcer

2. 3eep pressure ulcers

. (artial thic#ness &urns

4. 1ounds with large volume of drainage





-. 1ounds that need to &e dry to heal


Rationa$e 1% A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded to

uneven &ody surfaces

Rationa$e 2% A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded touneven &ody surfaces

Rationa$e % A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded touneven &ody surfaces


uneven &ody surfaces

Rationa$e -% A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded touneven &ody surfaces

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse is preparing the necessary supplies to change a clientIs large a&dominal wound dressing. )n deciding

what supplies are necessary, the nurse reviews the purpose of the clientIs &andage, including%@Select all that apply


1. Securing a dressing

2. (rotecting the s#in

. (reventing in4ury

4. (adding the s#in surfaces

-. Applying pressure






Rationa$e 1% The &andage is &eing used to secure the dressing

Rationa$e 2% The &andage is used to protect the wound and the surrounding s#in from in4ury

Rationa$e % The &andage is used to prevent in4ury to the healing wound

Rationa$e 4% The a&dominal dressing and &andage is not &eing used to pad the s#in surfaces

Rationa$e -% The a&dominal dressing is used to apply pressure: elastic &andages may &e used to apply pressure on

the lower extremities

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 4

Type: MCSA

The nurse understands that a cold treatment is used for all of the following except%

1. A sprained an#le

2. !dematous extremities

. Dypertension

4. A &ro#en finger

Corre!t "ns#er:

Rationa$e 1% Cold applications are used for sports in4uries to limit swelling and &leeding

Rationa$e 2% Cold should not &e applied to edematous extremities &ecause vasoconstriction reduces the &lood

flow and does not permit accumulated fluids to leave the area

Rationa$e % !xtensive cold applications can increase vasoconstriction and causes &lood to &e shunted from thecutaneous circulation to the internal &lood vessels

Rationa$e 4% Cold applications are used to limit swelling and &leeding in in4uries such as fractures

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question -

Type: MCMA

*urses are responsi&le for the prevention of decu&itus ulcers. =orces that contri&ute the formation of &ed sores



1. "nrelieved pressure

2. )ntermittent pressure

. =riction

4. Shearing

-. >asodilation


Rationa$e 1% (ressure ulcers are caused &y locali'ed ischemia due to the tissue &eing caught &etween two hard

surfaces

Rationa$e 2% )ntermittent pressure will prevent pressure ulcers

Rationa$e % =riction is a force acting parallel to the s#in surface: it can remove the superficial layers, ma#ing the

s#in more prone to &rea#down

Rationa$e 4% Shearing force is a com&ination of friction and pressure: it occurs commonly when a client assumes

a =owlerIs position in &ed

Rationa$e -% >asodilation allows extra &lood to flood to the area

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question





Type: MCSA

The nurse is assessing a clientIs ris# for formation of pressure ulcers. ne of the most important ris# factors is%

1. +epeated in4ections in the same area

2. )ncorrect application of pressure-relieving devices

. (oor lifting techni?ues

4. )mmo&ility

Corre!t "ns#er: 7

Rationa$e 1% +epeated in4ections in the same area contri&ute to tissue ischemia and the formation of pressureulcers, &ut are not one of the most important ris# factors

Rationa$e 2% +epeated in4ections in the same area contri&ute to tissue ischemia and the formation of pressure

ulcers, &ut are not one of the most important ris# factors

Rationa$e % +epeated in4ections in the same area contri&ute to tissue ischemia and the formation of pressure




%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCSA

The nurse is assessing the s#in of a client &eing admitted to the long-term care facility from an acute care facility

A small &lister is noted on the clientIs right heel. This is documented as

1. A stage ) decu&itus ulcer

2. A stage )) decu&itus ulcer

. A stage ))) decu&itus ulcer

4. A stage )> decu&itus ulcer





Corre!t "ns#er:

Rationa$e 1% A stage ) ulcer is a *on&lancha&le redness of intact s#in

Rationa$e 2% A stage )) ulcer is a partial-thic#ness s#in loss involving the epidermis, dermis, or &oth: the ulcer is

superficial and presents as an a&rasion, &lister, or shallow crater

Rationa$e % A stage ))) ulcer is a full-thic#ness s#in loss involving damage or necrosis of su&cutaneous tissuethat may extend down to, &ut not through, underlying fascia: the ulcer presents as a deep crater with or withoutundermining of ad4acent tissue

Rationa$e 4% A stage )> ulcer is a full-thic#ness s#in loss with extensive destruction, tissue necrosis or damage to

muscle, &one, or supporting structures: undermining and sinus tracts may also &e associated with stage )>

pressure ulcers

%$o&a$ Rationa$e:




(earning ut!ome:

Question 0

Type: =)

The nurse is collecting data to help identify clients at high ris# for pressure ulcer development. "sing either the

raden scale or the *orton scale, a score &elowOOOO indicates a potential ris# for pressure ulcer development.

)tandard Tet:

Corre!t "ns#er: 08

Rationa$e % The raden scale and the *orton scales assist the nurse in collecting data in the areas of immo&ility,incontinence, nutrition and level of consciousness. These scales include su&scales and categories that are assigned

points. Scores of 06 or lower may &e indicators of potential ris#

%$o&a$ Rationa$e:

Cogniti'e (e'e$: "nderstandingC$ient Need: (hysiological )ntegrity

C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA





The nurse is responsi&le for maintaining intact s#in for the compromised client. Appropriate nursing priorities



1. Chec#ing pressure points regularly

2. +egular turning and repositioning schedules

. Strict precautions to provide clean care to the wound

4. 3elegation to unlicensed assistive personnel

-. 3ocumenting care given


Rationa$e 1% The nurse chec#s pressure points regularly

Rationa$e 2% +egular turning and repositioning every two hours will assist in preventing s#in &rea# down

Rationa$e % )f pressure &rea#down has occurred the nurse follows strict precautions to provide sterile care to the

wound and assist healing

Rationa$e 4% )t is the responsi&ility of the (*F>* to prevent s#in &rea#down: delegation with follow-up is

appropriate

Rationa$e -% 3ocumentation of appropriate turning and s#in care is the nurseIs responsi&ility

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 43

Type: MCMA

The nurse is reviewing a care plan for the client at ris# for pressure ulcers. Appropriate interventions include%

@Select all that apply


1. (roviding a high car&ohydrate, low protein diet





2. Scru&&ing the s#in with minimal force and friction

. (osition the head of the &ed no more than 75 degrees

4. "se a trape'e when lifting a client to change position

-. Change wound dressings three to four times a ay

Corre!t "ns#er: ,7

Rationa$e 1% Appropriate nutritional support includes ade?uate calories, protein and iron inta#e

Rationa$e 2% S#in should &e cleansed with minimal force and friction

Rationa$e % The head of the &ead should not &e elevated to more than $/ degrees

Rationa$e 4% A trape'e or other lifting device should &e used when lifting a client to change position

Rationa$e -% 1ounds should &e cleaned gently, and covered, and distur&ed as infre?uently as possi&le

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 41Type: MCSA

The nurse understands that wounds heal more rapidly in infants and children &ecause%

1. Their s#in is more fragile.

2. Their s#in has not &een exposed to sun.

. Their s#in is thinner.

4. f rapid cell division.

Corre!t "ns#er: 7

Rationa$e 1% )nfant s#in is more fragile and suscepti&le to in4ury, &ut this is not why it heals more rapidly.

Rationa$e 2% Most infant s#in has not &een damaged from environmental exposure to light, heat, or cold, &ut this

is not why it heals more rapidly.





Rationa$e % Clients who use steroids can develop thinning of the s#in.

Rationa$e 4% 1ounds tend to heal much more rapidly in infants and children &ecause of the rapid cell division tha

is associated with growth.

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Question 42

Type: MCMA

The nurse is ta#ing a clientIs history on admission to a reha&ilitation facility. =actors that could cause s#in

integrity to &e impaired in the 75-year-old post-surgical client include%


1. Genetics.

2. "se of anti&iotics.

. (oor nutrition.

4. )ntact s#in.

-. +estricted mo&ility.


Rationa$e 1% Sensitivity to light or allergens, a characteristic that can affect integrity, is governed largely &y

genetics.

Rationa$e 2% Sensitivity to light or allergens, a characteristic that can affect integrity, is governed largely &ygenetics.

Rationa$e % Sensitivity to light or allergens, a characteristic that can affect integrity, is governed largely &y

genetics.

Rationa$e 4% Sensitivity to light or allergens, a characteristic that can affect integrity, is governed largely &y

genetics.

Rationa$e -% Sensitivity to light or allergens, a characteristic that can affect integrity, is governed largely &y

genetics.





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Question 4

Type: MCMA

The parents of a new&orn are interested in learning a&out s#in care for the infant. The nurse shows the parents a picture of normal s#in structure, and discusses information important to #now a&out s#in, including%


1. S#in protects the &ody.

2. S#in is the first line of defense.

. Some s#in characteristics are governed &y genetics.

4. 1ounds in the s#in of infants heal slowly.

-. The s#in of infants is suscepti&le to in4ury.

Corre!t "ns#er: 0,,$,5

Rationa$e 1% The s#in is the largest organ of the &ody, and helps to maintain health.

Rationa$e 2% )ntact s#in is the first line of defense against invasion &y microorganisms.

Rationa$e % Some characteristics, such as sensitivity to light or allergens, are governed largely &y genetics.

Rationa$e 4% 1ounds in the s#in of infants and children tend to heal more rapidly in infants and children &ecause

of the rapid cell division that is associated with growth.

Rationa$e -% The s#in of infants is more fragile and suscepti&le to in4ury.

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Question 44







2. Contusion

. A&rasion

4. aceration

-. (uncture

Corre!t "ns#er: 0,$,7,5

Rationa$e 1% An incision is an open wound caused &y a sharp instrument.

Rationa$e 2% A contusion is a closed wound caused &y a &low from a &lunt instrument.

Rationa$e % An a&rasion is an open wound caused &y a surface scrape.

Rationa$e 4% A laceration is an open wound caused &y tissue &eing torn apart, often from accidents.

Rationa$e -% A puncture is an open wound caused &y penetration of the s#in and often the underlying tissues, &y asharp instrument.

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Question 4

Type: MCSA

An example of a wound that occurs during therapy would &e%

1. (ressure ulcers.

2. >enipuncture.

. ro#en &ones.

4. Closed wound.

Corre!t "ns#er:

Rationa$e 1% (ressure ulcers are not wounds that would occur intentionally: nurses wor# to prevent pressureulcers.

Rationa$e 2% >enipuncture and surgery are examples of intentional trauma that can occur during therapy.





Rationa$e % ro#en &ones are generally unintentional, or accidental.

Rationa$e 4% 3amaged tissue with no &rea# in the s#in is a closed wound: an example would &e a contusion,

which is generally not part of therapy.

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Question 4/

Type: MCMA

The nurse identifies clients li#ely to have clean wounds, including%


1. A client with multiple contusions.

2. A client with a fresh surgical wound.

. A client who was in a motorcycle accident.

4. A client who has purulent drainage.

-. A client with a laceration from a #nife.

Corre!t "ns#er: 0,

Rationa$e 1% Contusions are closed wounds, and are unli#ely to &e contaminated.

Rationa$e 2% A client with a fresh surgical wound is unli#ely to have a contaminated or infected wound.

Rationa$e % The client who was in a motorcycle accident is li#ely to have contaminated or dirty wounds, such as

a&rasions.

Rationa$e 4% The client with a wound with purulent drainage has a dirty or infected wound.

Rationa$e -% The client with a laceration from a #nife is li#ely to have a contaminated wound.

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Question 40

Type: MCSA

The nurse anticipates the following healing process of the surgical wound%

1. Minimal granulation tissue and scarring

2. onger repair time

. Significant scarring

4. )ncreased ris# of infection

Corre!t "ns#er: 0

Rationa$e 1% The surgical wound typically heals &y primary intention, where tissues have &een approximated and

there is minimal or no tissue loss: it characteristically has minimal granulation tissue and scarring.

Rationa$e 2% The wound that heals &y primary intention, such as a surgical wound, heals more ?uic#ly that a

wound that is extensive and involves considera&le tissue loss.

Rationa$e % The wound that heals &y primary intention, such as a surgical wound, has less scarring that a wound

that heals &y secondary intention.

Rationa$e 4% The surgical wound, with closed, approximated tissue surfaces, is less li#ely to &ecome infected.

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Question 4

Type: S!K

The nurse understands the phases of wound healing are the steps in the &odyIs natural process of tissue repair. Th

processes that are involved occur in the following order%

)tandard Tet: Clic# and drag the options &elow to move them up or down.

Choi!e 1. Demostasis

Choi!e 2. (hagocytosis





Choi!e . Collagen synthesis

Choi!e 4. !pitheliali'ation

Choi!e -. +emodeling

Corre!t "ns#er: 0,,$,7,5

Rationa$e 1% The inflammatory phase &egins with hemostasis.


Rationa$e % The inflammatory phase &egins with hemostasis.


Rationa$e -% The inflammatory phase &egins with hemostasis.

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Question -3

Type: MCMA

The nurse is discussing wound healing with a group of preoperative clients. =actors that inhi&it wound healinginclude%


1. +egular exercise.

2. Smo#ing.

. &esity.

4. Aspirin.

-. 3aily orange 4uice consumption.


Rationa$e 1% +egular exercise tends to promote good circulation, and is more li#ely to heal wounds ?uic#ly.





Rationa$e 2% Smo#ing reduces the amount of functional hemoglo&in in the &lood and causes vasoconstriction,thus limiting the oxygen-carrying capacity of the &lood.

Rationa$e % &ese clients are at increased ris# of wound infection and slower healing &ecause adipose tissue

usually has a minimal &lood supply.

Rationa$e 4% Anti-inflammatory drugs, such as aspirin and steroids, interfere with healing.

Rationa$e -% >itamin C has an important role in collagen synthesis, helping in the formation of &onds amongstrands of collagen fi&er.

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Question -1

Type: MCSA

A client uses the call light and reports that while coughing, the surgical wound opened up, with Lstuff falling

through. The nurse anticipates which complication of wound healing

1. Demorrhage

2. )nfection

. !visceration

4. 3ehiscence

Corre!t "ns#er: $

Rationa$e 1% Demorrhage is persistent &leeding that can &e caused &y a dislodged clot, slipped suture, or erosionof a &lood vessel.

Rationa$e 2% )nfection with microorganisms can occur during the time of in4ury, and is most li#ely to &ecome

apparent P00 days postoperatively.

Rationa$e % !visceration is the protrusion of the internal viscera through an incision.

Rationa$e 4% 3ehiscence is the partial or total rupturing of a sutured wound.

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Question -2

Type: MCMA

The nurse is applying a dry gau'e dressing to the clientIs large a&rasion. The client as#s the nurse why he needs adressing on it. Appropriate responses include%


1. The dressing will protect the wound from &eing contaminated &y germs.

2. 1ounds heal &etter when they are #ept warm, and the dressing will provide insulation.

. The wound could drain as it heals, and the dressing will a&sor& the drainage.

4. The wound needs to &e #ept moist.

-. This will prevent the wound from hemorrhaging.


Rationa$e 1% The dressing will protect the wound from micro&ial contamination.


Rationa$e % The dressing will protect the wound from micro&ial contamination.


Rationa$e -% The dressing will protect the wound from micro&ial contamination.

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Question -

Type: MCSA

The nurse has several choices of wound dressing. The most appropriate dressing to use to cover, soothe, and

protect a wound without exudate is%





1. Transparent adhesive film.

2. An impregnated nonadherent dressing.

. Dydrogel.

4. (olyurethane foam.

Corre!t "ns#er:

Rationa$e 1% A transparent adhesive film is used to provide protection against contamination and friction, and

maintain a clean, moist surface that facilitates cellular migration.

Rationa$e 2% A transparent adhesive film is used to provide protection against contamination and friction, andmaintain a clean, moist surface that facilitates cellular migration.

Rationa$e % A transparent adhesive film is used to provide protection against contamination and friction, and

maintain a clean, moist surface that facilitates cellular migration.

Rationa$e 4% A transparent adhesive film is used to provide protection against contamination and friction, andmaintain a clean, moist surface that facilitates cellular migration.

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Question -4

Type: MCSA

The nurse decides to use a wet-to-dry gau'e dressing on a clientIs wound. The primary purpose of this type ofdressing is%

1. (rotect the wound.

2. 3e&ride the wound.

. Neep the wound continually moist.

4. 3ilute viscous exudate.

Corre!t "ns#er:

Rationa$e 1% A dry-to-dry dressing is used primarily to protect the wound.





Rationa$e 2% The wet-to-dry dressing is used primarily to de&ride the wound.

Rationa$e % The wet-to-wet dressing is used to #eep the wound moist.

Rationa$e 4% The purpose of the wet-to-wet dressing is to #eep the wound moist and dilute viscous exudate.

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Question --

Type: MCMA

The nurse chooses a wound >.A.C. for the following types of wounds%


1. A venous stasis leg ulcer

2. 3eep pressure ulcers

. (artial-thic#ness &urns

4. 1ounds with large volume of drainage

-. 1ounds that need to &e dry to heal


Rationa$e 1% A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded touneven &ody surfaces.


uneven &ody surfaces.

Rationa$e % A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded to




Rationa$e -% A venous stasis ulcer would &e &etter treated with a hydrocolloid dressing that can &e molded to






%$o&a$ Rationa$e:



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Question -

Type: MCMA

The nurse is preparing the necessary supplies to change a clientIs large a&dominal wound dressing. )n decidingwhich supplies are necessary, the nurse reviews the purpose of the clientIs &andage, including%


1. Securing a dressing.

2. (rotecting the s#in.

. (reventing in4ury.

4. (adding the s#in surfaces.

-. Applying pressure.


Rationa$e 1% The &andage is &eing used to secure the dressing.

Rationa$e 2% The &andage is used to protect the wound and the surrounding s#in from in4ury.

Rationa$e % The &andage is used to prevent in4ury to the healing wound.

Rationa$e 4% The a&dominal dressing and &andage is not &eing used to pad the s#in surfaces.

Rationa$e -% The a&dominal dressing is used to apply pressure: elastic &andages may &e used to apply pressure on

the lower extremities.

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Question -/





Type: MCSA

The nurse understands that a cold treatment is used for all of the following except%

1. A sprained an#le.

2. !dematous extremities.

. Dypertension.

4. A &ro#en finger.

Corre!t "ns#er:

Rationa$e 1% Cold applications are used for sports in4uries to limit swelling and &leeding.

Rationa$e 2% Cold should not &e applied to edematous extremities, &ecause vasoconstriction reduces the &lood

flow and does not permit accumulated fluids to leave the area.

Rationa$e % !xtensive cold applications can increase vasoconstriction, and causes &lood to &e shunted from thecutaneous circulation to the internal &lood vessels.

Rationa$e 4% Cold applications are used to limit swelling and &leeding in in4uries such as fractures.

%$o&a$ Rationa$e:



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Question -0

Type: MCMA

*urses are responsi&le for the prevention of decu&itus ulcers. =orces that contri&ute the formation of &ed sores

include%


1. "nrelieved pressure.

2. )ntermittent pressure.

. =riction.

4. Shearing.

-. >asodilation.






Rationa$e 1% (ressure ulcers are caused &y locali'ed ischemia due to the tissueIs &eing caught &etween two hardsurfaces.

Rationa$e 2% )ntermittent pressure will prevent pressure ulcers.

Rationa$e % =riction is a force acting parallel to the s#in surface: it can remove the superficial layers, ma#ing thes#in more prone to &rea#down.

Rationa$e 4% Shearing force is a com&ination of friction and pressure: it occurs commonly when a client assumesa =owlerIs position in &ed.

Rationa$e -% >asodilation allows extra &lood to flood to the area.

%$o&a$ Rationa$e:




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Question -

Type: MCSA

The nurse is assessing a clientIs ris# for formation of pressure ulcers. ne of the most important ris# factors is%

1. +epeated in4ections in the same area.

2. )ncorrect application of pressure-relieving devices.

. (oor lifting techni?ues.

4. )mmo&ility.

Corre!t "ns#er: 7

Rationa$e 1% +epeated in4ections in the same area contri&ute to tissue ischemia and the formation of pressureulcers, &ut are not one of the most important ris# factors.


ulcers, &ut are not one of the most important ris# factors.

Rationa$e % +epeated in4ections in the same area contri&ute to tissue ischemia and the formation of pressure

ulcers, &ut are not one of the most important ris# factors.





Rationa$e 4% +epeated in4ections in the same area contri&ute to tissue ischemia and the formation of pressureulcers, &ut are not one of the most important ris# factors.

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Question 3

Type: MCSA

The nurse is assessing the s#in of a client &eing admitted to the long-term care facility from an acute care facility

A small &lister is noted on the clientIs right heel. This is documented as%

1. A stage ) decu&itus ulcer.

2. A stage )) decu&itus ulcer.

. A stage ))) decu&itus ulcer.

4. A stage )> decu&itus ulcer.

Corre!t "ns#er:

Rationa$e 1% A stage ) ulcer is a non&lancha&le redness of intact s#in.

Rationa$e 2% A stage )) ulcer is a partial-thic#ness s#in loss involving the epidermis, dermis, or &oth: the ulcer issuperficial, and presents as an a&rasion, &lister, or shallow crater.

Rationa$e % A stage ))) ulcer is a full-thic#ness s#in loss involving damage or necrosis of su&cutaneous tissue

that can extend down to, &ut not through, underlying fascia: the ulcer presents as a deep crater with or withoutundermining of ad4acent tissue.

Rationa$e 4% A stage )> ulcer is a full-thic#ness s#in loss with extensive destruction, tissue necrosis, or damage to

muscle, &one, or supporting structures: undermining and sinus tracts also can &e associated with stage )> pressur

ulcers.

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Question 1

Type: =)

The nurse is collecting data to help identify clients at high ris# for pressure ulcer development. "sing either the

raden scale or the *orton scale, a score &elowOOOO indicates a potential ris# for pressure ulcer development.

)tandard Tet:

Corre!t "ns#er: 08

Rationa$e % The raden and *orton scales assist the nurse in collecting data in the areas of immo&ility,incontinence, nutrition, and level of consciousness. These scales include su&scales and categories that are assigne

points. Scores of 06 or lower can &e indicators of potential ris#.

%$o&a$ Rationa$e:



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Question 2

Type: MCMA

The nurse is responsi&le for maintaining intact s#in for the compromised client. Appropriate nursing priorities

include%


1. Chec#ing pressure points regularly.

2. +egular turning and repositioning schedules.

. Strict precautions to provide clean care to the wound.

4. 3elegation to unlicensed assistive personnel.

-. 3ocumenting care given.


Rationa$e 1% The nurse chec#s pressure points regularly.

Rationa$e 2% +egular turning and repositioning every hours will assist in preventing s#in &rea#down.

Rationa$e % )f pressure &rea#down has occurred, the nurse follows strict precautions to provide sterile care to thewound and assist healing.





Rationa$e 4% )t is the responsi&ility of the (*F>* to prevent s#in &rea#down: delegation with follow-up isappropriate.

Rationa$e -% 3ocumentation of appropriate turning and s#in care is the nurseIs responsi&ility.

%$o&a$ Rationa$e:


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Question

Type: MCMA

The nurse is reviewing a care plan for the client at ris# for pressure ulcers. Appropriate interventions include%


1. (roviding a high-car&ohydrate, low-protein diet.

2. Scru&&ing the s#in with minimal force and friction.

. (ositioning the head of the &ed no more than 75 degrees

4. "sing a trape'e when lifting a client to change position

-. Changing wound dressings $P7 times a day.

Corre!t "ns#er: ,7

Rationa$e 1% Appropriate nutritional support includes ade?uate calories, protein, and iron inta#e.

Rationa$e 2% S#in should &e cleansed with minimal force and friction.

Rationa$e % The head of the &ead should not &e elevated to more than $/ degrees.

Rationa$e 4% A trape'e or other lifting device should &e used when lifting a client to change position.

Rationa$e -% 1ounds should &e cleaned gently, covered, and distur&ed as infre?uently as possi&le.

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Ramont2e Rev TIF Ch24

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