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Medical-Surgical Nursing Study Guide Questions with 100% correct answers
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Medical-Surgical Nursing Study Guide Questions with 100% correct answers
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Medical-Surgical Nursing Study GuideQuestions with 100% correct answers.
The nurse sees in the patient's record that the patient has a Braden score of 20. Which nursing action is
the nurse most likely to perform in the care of this patient? ANS - Continue routine assessments
A thin, malnourished patient requires emergency abdominal surgery. After the surgery, in order to
promote wound healing, what does the nurse encourage? ANS - High-quality protein diet
The nurse is directing the home health unlicensed assistive personnel (UAP) in the care of an older adult
patient. The patient reports dry skin and wants help in applying an emollient cream. What does the
nurse direct the UAP to do? ANS - Assist the patient to soak for 10 minutes in a warm bath and then
apply the cream to slightly damp skin within 2 to 3 minutes after bathing
Which patients are at risk for pressure ulcers? ANS - -A middle-aged quadriplegic patient who is alert
and conversant
-A bedridden patient who is in the late stage of Alzheimer's
-A very overweight patient who must be assisted to move in the bed
-A thin patient who sits for longer period and refuses meals
The nurse is caring for an obese patient who has been on bedrest for several days. The nurse observes
that the patient is beginning to develop redness on the sacral area. What intervention is used to
decrease the shearing force? ANS - Place the patient in a side-lying position
The nurse is reviewing the results of a pressure mapping on patient at high risk for pressure ulcers. The
map shows a red area over the hips. How does the nurse interpret this evidence? ANS - Greater heat
production associated with greater pressure
The nurse is assessing the nutritional status of a patient at risk for skin breakdown who has been
refusing to eat the hospital food. Which indicator is the most sensitive in identifying inadequate
nutrition for this patient? ANS - Prealbumin level of 17.5 mg/dL
, Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the center of the are
and see that the area blanches with pressure. The nurse interprets this finding as changes related to
which factor? ANS - Blood vessel dilation
The nurse is assessing a wound on a patient's abdomen. What is the correct technique? ANS - Assess
the wound as a clock face with 12 o'clock towards the patient's head and 6 o'cock towards the patient's
feet
The nurse is assessing a patient's wound every day for signs of healing or infection. Which finding is a
positive indication that healing is progressing as expected? ANS - Area appears pale pink, progressing to
a spongy texture with a beefy red color
The nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small opening in the skin with
purulent drainage. Which technique does the nurse use to check for tunneling? ANS - Use a sterile
cotton-tipped applicator to probe gently for a tunnel
The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the coccyx with skin
intact. These findings suggest which stage of a pressure ulcer? ANS - Suspected deep tissue injury
When developing a plan of care for a patient who is at high risk for skin breakdown, what does the nurse
include in the plan of care? ANS - -Applying a pressure reduction overlay to the mattress
-Frequent repositioning of the patient
-Using positioning devices to keep heels pressure-free
Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral decubitus ulcer?
ANS - Wound will show granulation and decrease in size
A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for what
potential complication? ANS - Bleeding
Which class of medication would exclude a patient from participating in NPWT? ANS - Anticoagulants
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