Nurs 204 - Exam 2 Questions With 100% Correct Answers

Nurs 204 - Exam 2 Questions With 100% Correct Answers When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? a. A local skin infection requiring antibiotics b. Sensitive skin that requires special bed linen c. A stage III pressure ulcer needing the appropriate dressing d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode - answerd. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid. - answer1a, 2d, 3b, 4c When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? a. Necrotic tissue b. Wound drainage c. Wound circumference d. Cleansed wound - answerd. Cleansed wound After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (select all that apply) a. Notify the surgeon b. Allow the area to be exposed to air until all drainage has stopped c. Place several cold packs over the area, protecting the skin around the wound d. Cover the area with sterile, saline-soaked towels immediately e. Cover the area with sterile gauze and apply an abdominal binder - answera. Notify the surgeon d. Cover the area with sterile, saline-soaked towels immediately What is the correct sequence of steps when performing wound irrigation to a large open wound? a. Use slow, continuous pressure to irrigate the wound b. Attach a 19-gauge angiocatheter to syringe c. Fill syringe with irrigation fluid d. Place waterproof bag near bed e. Position angiocatheter over wound - answerd. Place waterproof bag near bed c. Fill syringe with irrigation fluid b. Attach a 19-gauge angiocatheter to syringe e. Position angiocatheter over wound a. Use slow, continuous pressure to irrigate the wound For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? a. Binder b. Ice bag c. Elastic bandage d. Absorptive dressing - answerb. Ice bag Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (select all that apply) a. Frequent position changes b. Keeping the buttocks exposed to air at all times c. Using a large absorbent diaper, changing when saturated d. Using an incontinence cleaner e. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel f. Applying a moisture barrier ointment - answera. Frequent position changes d. Using an incontinence cleaner f. Applying a moisture barrier ointment Which of the following describes hydrocolloid dressing? a. A seaweed derivative that is highly absorptive b. Premoistened gauze placed over a granulating wound c. A debriding enzyme that is used to remove necrotic tissue d. A dressing that forms a gel that interacts with the wound surface - answerd. A dressing that forms a gel that interacts with the wound su