Practice Quiz Answers Unit 4

Question 1 When cleaning a wound, the nurse should: A) Go over the wound twice and discard that swab B) Move from the outer region of the wound toward the center C) Start at the drainage site and move outward with circular motions D) Cleanse the area around the drain and then clean the incision Correct Answer: C Explanation: To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. A. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. B. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. D. The incision is cleansed first followed by the area around the drain Question 2 Using the Braden scale, which client is at highest risk for developing a pressure ulcer? A) One with a score of 15 B) One with a score of 18 C) One with a score of 20 D) One with a score of 23 Correct Answer: A: clients with a score of less than 18 are at risk for developing a pressure ulcer. A maximum score is 23. Question 3 A client has an ischemic wound. This means that there has been: A) A deficient blood supply to the tissue B) Damage to the small blood vessels C) Compression of the tissue D) A combination of friction and pressure Correct Answer: A: insufficient blood supply to the tissue is ischemia. It is the cause of pressure ulcer formation. B: ischemia is not due to small blood vessel damage C: compression of the tissue may contribute to ischemia but it is not the definition. D: Friction is the force acting parallel to the skin. The top layers of skin become eroded. Shearing force is a combination of friction and pressure. The deeper layers of tissue are damaged.

Question 4 Which of the following is an example of a wound or injury that heals from secondary intention? A) Pressure ulcer B) Fracture C) Sprained ankle D) Surgical incision Correct Answer: A Explanation: A: a pressure ulcer heals by secondary intention. The ends of the ulcer cannot be approximated. The wound must heal from the inside first. B a fracture does not heal by secondary intention C- a sprained ankle does not heal by secondary intention D a surgical incision heals by primary intension Question 5 When turning a client the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? A) Clean area with mild soap, and dry. B) Apply a dilute hydrogen peroxide and water mixture, and use a heat lamp on the area C) Soak the area in normal saline solution D) Wash the area with an astringent Correct Answer: A Explanation: The skin should be cleansed and completely dried. B. Hydrogen peroxide can be irritating to the tissue and should not be used. A heat lamp is not necessary and would increase the clients risk of an accidental burn. C. The area should not be soaked, as this may lead to maceration of the skin. D. The area should not be cleansed with an astringent. An astringent may cause excessive drying of the tissue. Question 6 A client has been lying on her back for two hours. When the nurse turns her, the nurse notices the skin over her sacrum is very white. By the time the nurse finishes repositioning her, the spot has turned bright red. The nurse should: A) Massage the spot with lotion B) Apply a warm compress for 30 minutes C) Return in 30-45 minutes to see if the redness has disappeared D) Wash the area with soap and water and notify the physician Correct Answer: C Explanation C: the nurse would return to see if the skin has returned to its normal color. If not, it is a sign of damage to the tissue. A: Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue and pressure ulcer formation.

B: A warm compress will increase circulation to the area. However the nurse would want to assess the area prior to application of the compress. C: The nurse would make sure the area is clean but it is not the first nursing action. In some situations the physician would be notified. Question 7 To reduce pressure points that may lead to pressure ulcers, the nurse should: A) Position the client directly on the trochanter when side-lying B) Use a donut device for the client when sitting up C) Elevate the head of the bed as little as possible D) Massage over the bony prominences Correct Answer: C Explanation: Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. A. The client should not be positioned directly on the trochanter, as this can create pressure over the bony prominence. B. Donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia. D. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue and pressure ulcer formation. Question 8 The nurse notes a client's skin is reddened, with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4 Correct Answer: B Explanation: This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater. A. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. The description is not consistent with a stage I pressure ulcer. C. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through the muscle. The description is not consistent with a stage III pressure ulcer. D. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. The description is not consistent with a stage IV pressure ulcer.

Question 9 The nurse is applying a heating pad to a client's back. Which action is most appropriate? A) Remove the pad in one hour. B) Have the client lie on the pad. C) Use a pad with a preset heating switch. D) Pin the pad to the client's gown. Correct Answer: C Explanation: C: using a preset heating switch will prevent the temperature from exceeding a safe level which could result in a burn. A: A therapeutic application of heat should be applied for a maximum of 30 - 45 minutes. B: Lying on the pad can increase the risk for burns because the heat will not dissipate. D: Avoid using pins with heating pads which could damage the wiring causing electric shock. Question 10 An open wound resulting from friction is called a(n): A) Abrasion B) Contusion C) Incision D) Laceration Correct Answer: A Explanation: A: an abrasion is a wound where the tissue is worn away as is what happens with friction. The top layer of tissue is abraded. A floor burn is an example of a friction wound. B: A contusion is a tissue injury where there is no break in the skin. There may be discoloration of the tissue. It is also known as a bruise. C: An incision is a wound made by a sharp instrument. D: A laceration is a wound produced by tearing of the tissue. The edges are not cleanly cut as with an incision.