VSIM Josephine Morrow Pre-Sim & Post-Sim Answers

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? - Prealbumin The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? - -Have you noticed any swelling on your feet, ankles, or fingers? -Do some areas of your skin seem warmer or colder than others? -Have you used pads or special pants because you can't control your urine? -Do you have any sores on your body? The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history? - -When did the edema start? -Can you describe the edema? -Do you have any recent history of surgery or illness? The nurse is conducting a skin assessment using the Braden scale. How would the nurse interpret a score of 12? - High Risk The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? - Dark discoloration of the skin surrounding the wound site The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? - I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound. The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? - Purulent The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? - Ask the patient to press the call bell to summon a co-worker to obtain another dressing. The nurse is completing an admission assessment on a patient for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? - -Diabetes Mellitus -Obesity