A client has an area of nonblanchable erythema on his coccyx. The nurse has
determined this to be a stage 1 pressure ulcer. What would be the most
important treatment for this client?
A. Frequent turn schedule
B. Enzymatic debridement
C. Transparent film dressing
D. Hydrogel Right Ans - A. Frequent turn schedule
A client hospitalized in a long-term rehabilitation facility is immobile and
requires mechanical ventilation with a tracheostomy. There is a pressure area
on the client's coccyx measuring 5 x 3 cm. The area is covered with 100%
eschar. What would the nurse identify this as?
A. Stage 4 pressure injury
B. Stage 3 pressure injury
C. Stage 2 pressure injury
D. Unstageable pressure injury Right Ans - D. Unstageable pressure injury
A client underwent emergency abdominal surgery for a ruptured appendix.
The surgeon did not surgically close the wound. The wound healing process
described in this situation is:
A. Tertiary intention healing
B. Approximation intention healing
C. Secondary intention healing
D. Primary intention healing Right Ans - C. Secondary intention healing
The home-health nurse learns that an elderly client isn't able to get to the
grocery store. They don't have much food in their home, and they eat and
drink little. Most of their time is spent sitting in their chair watching
television, often not realizing that they have had bladder leakage. Which
nursing actions would be implemented to reduce the risk of this client
developing a pressure injury? Select all that apply.
, A. Encourage the client to wear incontinence products
B. Help the client to get out of the chair every 2 hours
C. Change the client's clothing frequently
D. Promote intake of green tea throughout the day Right Ans - A, B, C
The nurse assesses assigned clients and determines which of the following has
the highest risk for altered skin integrity?
A. An adolescent in bed with influenza, having periods of high fever and
diaphoresis
B. A middle-aged adult with metabolic syndrome taking antihypertensives
C. An older client diagnosed with well-controlled type 2 diabetes
D. A young adult in traction who has a low-protein diet and dehydration
Right Ans - A. An adolescent in bed with influenza, having periods of high
fever and diaphoresis
The nurse caring for a patient who is 24 hours post-op after a major
abdominal surgery is assessing the operative site. The nurse observes internal
viscera protruding through the incision site. The nurse acts quickly and
should complete all of the following, except:
A. Having the patient bend their knees and remain in bed.
B. Immediately notifying the surgeon.
C. Putting a binder on the patient.
D. Covering the wound with a sterile saline dressing. Right Ans - C. Putting
a binder on the patient.
The nurse documents that the new wound has serosanguineous drainage.
How is serosanguineous described?
A. Straw colored
B. Red, watery, clear
C. Bloody
D. Purulent drainage Right Ans - B. Red, watery, clear
The nurse is assessing the client with a chronic wound. The client asks the
nurse to explain the difference between chronic and acute wounds. Which of
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