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NUR 222 Exam 4 Questions And Answers
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NUR 222 Exam 4 Questions And Answers NUR 222 Exam 4 Questions And Answers NUR 222 Exam 4 Questions And Answers
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NUR 222 Exam 4The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a
Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the
nurse document this ulcer in the patient's medical record?
Select one:
a. Stage I pressure ulcer
b. Healing Stage III pressure ulcer
c. Stage III pressure ulcer
d. Healing Stage II pressure ulcer - ANS b. Healing Stage III pressure ulcer
The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse
take? (Select all that apply.)
Select one or more:
a. Monitor for shock.
b. Contact the surgical team.
c. Offer a glass of water.
d. Gently place the organs back.
e. Place moist sterile gauze over the site. - ANS A, B, E
,The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an
abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use
when teaching the patient the reason for the binder?
Select one:
a. It reduces edema at the surgical site.
b. It supports the abdomen.
c. It secures the dressing in place.
d. It immobilizes the abdomen. - ANS b. It supports the abdomen.
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse
has implemented interventions. Upon reassessment, which Braden score will be the best sign that the
risk for skin breakdown is removed?
Select one:
a. 13
b. 20
c. 12
d. 23 - ANS D. 23
, A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by
secondary intention?
Select one:
a. Permanent dark redness at site
b. Scarring that may be severe
c. Minimal scar tissue
d. Minimal loss of tissue function - ANS b. Scarring that may be severe
The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and
granulating. Which health care provider's order will the nurse question?
Select one:
a. Apply a hydrogel dressing.
b. Irrigate with Dakin's solution.
c. Consult a dietitian.
d. Use a low-air-loss therapy unit. - ANS b. Irrigate with Dakin's solution.
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is
odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-
concept?
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