Question 1

The patient is admitted with an open pressure injury with necrotic tissue around the base of the wound.How would the nurse classify this ulcer?

Accepted Answer

A)  Stage 3 pressure injury 
B)  Stage 4 pressure injury 
C)  Wound that cannot be staged 
D)  Stage 2 pressure injury 
A)  Stage 3 pressure injury 
B)  Stage 4 pressure injury 
C)  Wound that cannot be staged 
D)  Stage 2 pressure injury

Question 2

What should the nurse do when removing intermittent sutures?

Accepted Answer

A)  Snip both sides of the suture before removing. 
B)  Snip the suture as close to the knot as possible. 
C)  Snip the suture as close to the skin as possible. 
D)  Pull up the knot to apply as much tension as possible. 
A)  Snip both sides of the suture before removing. 
B)  Snip the suture as close to the knot as possible. 
C)  Snip the suture as close to the skin as possible. 
D)  Pull up the knot to apply as much tension as possible.

Question 3

The nurse is planning care for her patient who has a stage 2 pressure injury.Care should include which of the following? (Select all that apply.)

Accepted Answer

A)  A heat lamp to dry the wound 
B)  Application of topical antibiotics 
C)  Nutritional assessment 
D)  Maintaining moisture in the wound 
A)  A heat lamp to dry the wound 
B)  Application of topical antibiotics 
C)  Nutritional assessment 
D)  Maintaining moisture in the wound

Question 4

The nurse is changing a surgical dressing and is cleansing the wound.She knows that

Accepted Answer

A)  the incision line should be cleansed last. 
B)  she should start at one end of the incision line and swab the entire length. 
C)  she should start at the centre of the incision line and swab toward one end. 
D)  she should work in a circular motion around the incision line. 
A)  the incision line should be cleansed last. 
B)  she should start at one end of the incision line and swab the entire length. 
C)  she should start at the centre of the incision line and swab toward one end. 
D)  she should work in a circular motion around the incision line.

Question 5

In a patient with a stage 2 pressure injury,the nurse describes the wound as

Accepted Answer

A)  superficial blistering. 
B)  nonblanchable redness. 
C)  loss of skin without bone exposure. 
D)  loss of skin with exposed muscle. 
A)  superficial blistering. 
B)  nonblanchable redness. 
C)  loss of skin without bone exposure. 
D)  loss of skin with exposed muscle.

Question 6

The nurse knows that which of the following factors contribute to the development of pressure injuries? (Select all that apply.)

Accepted Answer

A)  Friction and shear 
B)  Immobility 
C)  Poor nutrition 
D)  Moisture and ammonia 
E)  Uncontrolled pain 
A)  Friction and shear 
B)  Immobility 
C)  Poor nutrition 
D)  Moisture and ammonia 
E)  Uncontrolled pain

Question 7

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

Accepted Answer

A)  The wound edges are separated. 
B)  No drainage or erythema is present. 
C)  The patient is anxious about their removal. 
D)  A cosmetically aesthetic result would not be achieved. 
A)  The wound edges are separated. 
B)  No drainage or erythema is present. 
C)  The patient is anxious about their removal. 
D)  A cosmetically aesthetic result would not be achieved.

Exam 39: Prevention and Care of Skin Breakdown

The patient is admitted with an open pressure injury with necrotic tissue around the base of the wound.How would the nurse classify this ulcer?

What should the nurse do when removing intermittent sutures?

The nurse is planning care for her patient who has a stage 2 pressure injury.Care should include which of the following? (Select all that apply.)

The nurse is changing a surgical dressing and is cleansing the wound.She knows that

In a patient with a stage 2 pressure injury,the nurse describes the wound as

The nurse knows that which of the following factors contribute to the development of pressure injuries? (Select all that apply.)

Which situation noticed during evaluation would determine that the staples or sutures should remain in place?

Evidence-Informed Nursing Practice

Transitions in Care

Communication and Collaboration

Documentation and Informatics

Medical Asepsis

Sterile Technique

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Patient Safety

Emergency Preparedness and Disaster Management

Pain Assessment and Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Nonparenteral Medications

Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Vascular Access and Infusion Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination and Catheterization

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Wound Care Management and Dressings

Therapeutic Use of Heat and Cold

Safety in the Community

Self-Care Teaching in the Community

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