NURS 315 Exam 2 Questions With Solutions
Which client does the nurse assess to be at greatest risk for pressure ulcer development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Client with hypertension on multiple medications
d. Incontinent client with limite...
Which client does the nurse assess to be at greatest risk for pressure ulcer development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Client with hypertension on multiple medications
d. Incontinent client with limited mobility d
The charge nurse observes a new graduate performing a dressing change on a stage II left heel
pressure ulcer. Which action by the new graduate indicates a need for further education about
pressure ulcer care?
a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.
b. The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer.
c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline.
d. The new graduate cleans the ulcer with a sterile dressing soaked in a cytotoxic solution half-
strength peroxide. d
A fair-skinned 32-year-old client whose mother recently died from Squamous Cell Carcinoma
asks the nurse, "what can I do to prevent Squamous Cell Carcinoma from developing?" The best
response by the nurse is that
, NURS 315 Exam 2 Questions With Solutions
a. The avoidance of excessive sun exposure will decrease risk.
b. Individuals with fair skin and blue eyes are at increased risk.
c. Squamous Cell Carcinoma is a relatively rare type of skin cancer.
d. The client is at high risk for skin cancer because of family history. a
Which nursing intervention would be most helpful in managing a patient newly admitted with
cellulitis of the right foot?
a. Applying warm, moist heat
b. Wrapping the foot snugly in blankets
c. Encouraging frequent ambulation
d. Not elevating the affected extremity a
In preparation for a client being admitted with herpes zoster, what does the nurse do? (Select all
that apply.)
a. Prepare a room for reverse isolation.
b. Assess staff for a history of or vaccination for chickenpox.
c. Check the admission orders for analgesia.
d. Choose a roommate who also is immune suppressed.
, NURS 315 Exam 2 Questions With Solutions
e. Ensure that gloves are available in the room. b, c, e
The patient has dry skin and pruritis on the legs that causes the patient to scratch at the skin
uncontrollably. What measures can the nurse use to help stop the itch/scratch cycle? Select all
that apply.
a. Moisturize the skin on the legs
b. Provide a warm blanket and room
c. Administer antihistamines at bedtime
d. Use careful hand washing after rubbing her legs
e. Cleanse the legs with a saline solution twice daily a, c
A client has a blood pressure of 120/60 mmHg and an intracranial pressure (ICP) of 24 mmHg.
The nurse determines that the cerebral perfusion pressure (CPP) of this client indicates
a. High blood flow to the brain
b. Adequate cerebral perfusion
c. Impaired brain blood flow
d. Normal ICP c
, NURS 315 Exam 2 Questions With Solutions
When being assessed for airway and breathing, the client presenting with increased intracranial
pressure would most likely exhibit which of the following vital signs?
a. BP 190/84, HR 150, and an irregular respiratory pattern
b. BP 80/50, HR 50, and Kussmaul respiration
c. BP 80/50, HR 150, and Cheyne-Stokes respirations
d. BP 190/84, HR 50, and an irregular respiratory pattern d
Which of the symptoms listed below indicate early , later, and very late stages of increased
intracranial pressure (ICP)
1. Altered level of consciousness
2. Absence of motor function
3. Sluggish pupil reaction
4. Headache
5. Decreased systolic BP
6. Vomiting
7. Decreased pulse rate
8. Increased systolic BP
9. Decorticate posturing
10. Increased pulse rate
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