Question 1

The client experiences a burn on the arm that is confined to the skin.How would the nurse describe this burn when documenting this client's care?&#10;A)A clean wound&#10;B)A dirty or infected wound&#10;C)A partial-thickness wound&#10;D)A full-thickness wound&#10;

Accepted Answer

A burn that is confined to the skin is a partial-thickness wound. The burn affects the epidermis and dermis layers of the skin but does not extend into the underlying tissue. A clean wound refers to a wound that has been adequately cleaned and is not infected. A dirty or infected wound is a wound that has bacteria and other foreign material present. A full-thickness wound refers to a wound that extends into the underlying tissue, such as muscle or bone.

Question 2

The nurse changes the client's IV dressing and removes the existing transparent wound barrier.Prior to applying the new barrier,which action by the nurse is the most appropriate?&#10;A)Applying benzoin to make the dressing stick firmly&#10;B)Placing a sterile piece of gauze over the insertion site before placing a new transparent barrier over the wound&#10;C)Cleansing the site with normal saline or a mild cleansing agent&#10;D)Applying sterile gloves&#10;

Accepted Answer

The most appropriate action by the nurse before applying the new barrier is to cleanse the site with normal saline or a mild cleansing agent to prevent infection. Applying benzoin to make the dressing stick firmly may cause skin irritation or an allergic reaction. Placing a sterile piece of gauze over the insertion site before placing a new transparent barrier over the wound is also unnecessary as the transparent barrier is sufficient to cover the site. Applying sterile gloves is important but not specifically related to the application of the new barrier.

Question 3

For which client would the nurse consider applying a transparent film for wound care?&#10;A)The client with a postoperative wound held together by sutures&#10;B)A client with a stage I pressure ulcer&#10;C)The client with a venous stasis ulcer&#10;D)A client with a highly exudative wound&#10;

Accepted Answer

A transparent film is the best choice for a client with a stage I pressure ulcer since it provides a moisture barrier and facilitates wound healing. This type of wound is usually not highly exudative and does not require aggressive wound management.

Question 4

The nurse is assessing the client for pressure ulcer risk.The client has no sensory deficits,and the skin is dry and not exposed to moisture.The client is,however,confined to bed and is completely immobile and requires moderate assistance in moving.The client's nutritional status is adequate.Which score documented by the nurse is the most appropriate based on the assessment data?

A)14,indicating moderate risk
B)15,indicating high risk
C)12,indicating risk
D)14,indicating high risk

Accepted Answer

The Braden Scale is commonly used to assess pressure ulcer risk. Based on the assessment data provided, the client has no sensory deficits and adequate nutritional status, which are protective factors against pressure ulcers. However, the client is completely immobile and requires moderate assistance in moving, which puts the client at risk for pressure ulcers. The score of 14 on the Braden Scale indicates moderate risk. A score of 15 or less is considered high risk, but based on the assessment data, the client's score is 14, indicating moderate risk. A score of 12 or less is indicative of significant risk for pressure ulcers.

Question 5

The nurse is performing a damp-to-damp dressing change,and is removing the old dressing.Part of the dressing is adhered to the tissue.Which action by the nurse is the most appropriate?&#10;A)Removing that part of the dressing quickly,to reduce the pain&#10;B)Wetting the dressing with alcohol to release the section adhered to the wound&#10;C)Wetting the dressing with tap water to release the section adhered to the wound&#10;D)Wetting the dressing with sterile saline to release the section adhered to the wound&#10;

Accepted Answer

Wetting the dressing with sterile saline is the most appropriate action by the nurse, as it is gentle and aseptic. Using tap water or alcohol may cause further irritation or contamination of the wound. Removing the dressing quickly to reduce pain may also cause tissue trauma.

Question 6

The nurse is bandaging the client's right knee.Where does the nurse begin the bandage?&#10;A)Above the knee&#10;B)Over the knee&#10;C)At the top of the thigh&#10;D)Below the knee&#10;

Accepted Answer

The nurse should begin the bandage below the knee, as this allows for proper coverage and support of the knee joint. Starting above the knee or at the top of the thigh may not provide enough support, while starting over the knee may cause discomfort or restrict movement.

Question 7

The nurse is irrigating a wound with tracts and crevices,and applies which piece of equipment to the syringe in order to irrigate these areas?&#10;A)A 22 gauge needle&#10;B)A small gauge Robinson catheter&#10;C)An IV catheter with the needle removed&#10;D)An IV catheter with the needle in place&#10;

Accepted Answer

The answer of The nurse is irrigating a wound with...

Question 8

The nurse is admitting a client with a pressure ulcer to the long-term care facility.When assessing the wound,the nurse finds partial-thickness skin loss free of eschar.Which stage will the nurse document this ulcer as based on the assessment data?

A)Stage I
B)Stage II
C)Stage III
D)Stage IV

Accepted Answer

Partial-thickness skin loss without exposed bone, tendon or muscle is classified as a Stage II pressure ulcer. Stage I indicates intact skin with non-blanchable redness, while Stage III and IV involve deeper tissue involvement with full thickness skin loss and potential muscle or bone involvement.

Question 9

When the nurse documents a client's wound,which is the best means of describing the wound?&#10;A)Measuring the wound and documenting size&#10;B)Comparing the wound to a universally understood object,such as a quarter or cashew&#10;C)Using terms such as small,medium,or large&#10;D)Taking a picture and inserting it into the record&#10;

Accepted Answer

Measuring the wound and documenting the size is the most accurate and objective way to describe the wound. It allows for consistency in documenting and tracking wound healing progress.

Question 10

When assessing a client with a new contaminated wound,which is the most important factor for the nurse to assess?&#10;A)The cleanliness of the object that caused the wound&#10;B)The presence of any rust on the object that caused the wound&#10;C)When the client last had a tetanus toxoid&#10;D)Where the client was when the wound occurred&#10;

Accepted Answer

When assessing a client with a new contaminated wound, the most important factor for the nurse to assess is when the client last had a tetanus toxoid. This is because a contaminated wound puts the client at risk for developing tetanus, which is a serious and potentially life-threatening infection. Therefore, the nurse should determine if the client needs a tetanus shot or booster to prevent this complication. The cleanliness of the object that caused the wound, the presence of rust on the object, and where the client was when the wound occurred are also important factors to assess, but they are not as urgent as determining tetanus status.

Question 11

The nurse is preparing to assess a wound on a new admission on a medical-surgical unit.Which items should the nurse review in the medical record prior to assessing the client's wound?&#10;A)The cause of the wound&#10;B)The length of time the wound has been present&#10;C)The previous treatments and client responses&#10;D)The equipment used by other nurses&#10;E)The current medication list&#10;

Accepted Answer

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

Question 12

The nurse is assisting the client with a sitz bath,and would perform which steps? A)Fill the solution bag with water warmed to 37^°C to 40^°C (98^°F to 109^°F). B)Fill the basin three-quarters full. C)Place the basin in the toilet. D)Assist the client to sit securely on the sitz bath. E)Open the clamp and begin a slow flow of solution from the bag as the solution in the basin cools.

Accepted Answer

The answer of The nurse is assisting the client with...

Question 13

The nurse notes black necrotic tissue on the client's wound.Which term is appropriate for the nurse to use when documenting this finding?&#10;A)Debridement&#10;B)Eschar&#10;C)Alginate&#10;D)Purulence&#10;

Accepted Answer

The answer of The nurse notes black necrotic tissue on...

Question 14

Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?&#10;A)Changing the postoperative dressing on a clean wound&#10;B)Irrigating the client's wound&#10;C)Establishing and monitoring a sitz bath&#10;D)Performing a damp-to-damp dressing change&#10;

Accepted Answer

The answer of Which task could the nurse safely delegate...

Question 15

The nurse is applying a hydrocolloid dressing to a client's wound,which measures 2 inches by 3 inches.The nurse would cut the dressing to which dimensions?&#10;A)3.5 inches by 4.5 inches&#10;B)2 inches by 3 inches&#10;C)1 1/2 inches by 2 1/2 inches&#10;D)1 inch by 1 1/2 inches&#10;

Accepted Answer

The answer of The nurse is applying a hydrocolloid dressing...

Question 16

The nurse is changing the client's dressing on a postoperative nondraining wound.Which personal protective equipment (PPE)would the nurse don prior to the dressing change?&#10;A)Sterile gown,mask,and sterile gloves&#10;B)Sterile gown,mask,and goggles&#10;C)Sterile gloves and mask&#10;D)Sterile gloves&#10;

Accepted Answer

The answer of The nurse is changing the client's dressing...

Deck 31: Performing Wound and Pressure Ulcer Care