Exam 3 Ch. 29

19問 • 3年前

問題一覧

1. The nurse knows which description would be classified as a closed wound?

a. A large bruise on the side of the face

2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?

b. “The wound will have pus.”

3. The nurse identifies which type of wounds heals by tertiary intention?

d. A wound that was left open initially and closed later with sutures

4. The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a “popping sensation” and a wetness in the dressing, the nurse immediately suspects which complication?

c. Wound dehiscence

5. The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?

d. Cover the wound with gauze soaked with normal saline.

6. The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure injury who has a nursing diagnosis of impaired skin integrity?

b. Wound will show signs of healing within 2 weeks.

7. A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?

a. The nurse asks the UAP to assess the wound.

8. The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure injuries, the nurse should place the head of the bed in which position?

c. 30 degrees

9. The nurse recognizes which intervention is not a form of mechanical debridement?

d. Enzymatic dressing

10. The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?

c. “Occlusive dressings can be used on infected wounds.”

11. The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?

d. A wound with a moderate amount of drainage

12. When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?

c. The drain is not sutured in place so care is taken to not dislodge it.

13. The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?

c. “I can warm up my hot pack in the microwave.”

14. The nurse identifies which syringe to use when irrigating a patient’s deep wound?

d. 30-mL syringe

15. The nurse understands which rationale to be appropriate for drying a wound after irrigation?

c. Prevent skin breakdown from moisture.

16. The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

c. Stop the procedure.

17. The nurse knows what goal to be appropriate for a patient with a stage 3 pressure injury with the nursing diagnosis Impaired Physical Mobility?

c. Patient will be able to assist with position changes using over bed trapeze within 1 week.

18. When discussing stage 3 pressure injuries with the student nurse, which description would the staff nurse include?

b. A pressure injury that does not extend through the fascia.

19. The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?

c. Subcutaneous layer

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4