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NR224 EXAM 2 – ATI & OTHER PRACTICE QUESTIONS
1. What predisposes someone to pressure ulcer development? (Select all that apply)
A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of
pressure ulcer formation. Which of the following instructions should the nurse include?
a. <Move between the bed and the wheelchair once every 2 hr=
b. <Make sure that your caregiver massages your skin daily
c. <Use a rubber ring when sitting on the bedside=
d. <Shift your weight in the wheelchair every 15 min=
2. Pressure ulcer stage 2
A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse
apply to the ulcer?
a. Hydrocolloid
b. Collagen
c. Calcium alginate
d. Proteolytic enzyme
3. Stage 4 pressure ulcer – priority nursing diagnosis
a. NOT RISK for impaired skin integrity → stage 4 means it’s already happened
b. Impaired skin integrity
c. Skin Infection (don’t assume)
4. R/t Braden risk assessment – score of 8 (Select all that apply)
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale,
which of the following parameters should the nurse evaluate?
a. Incontinence
b. Mental state
c. Nutrition
d. General physical condition
5. Patient with an indwelling urinary catheter. What do you do to decrease the risk of CAUTI? (Select all that apply)
a. HINT – you want to clean the perineal area MORE than every 24 hours
Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)?
a. Daily cleansing of the urinary meatus with antiseptic solution
b. Hanging the urinary drainage bag below the level of the bladder
c. Changing the urinary drainage bag daily
d. Irrigating the urinary catheter with sterile water
What strategies should I use to help keep clients from developing catheter-associated UTIs?
a. Always use sterile technique when placing a Foley catheter
b. Give appropriate and thorough perineal care
c. Assess equipment carefully to ensure a closed system
d. Intervene to prevent prolonged catheter use
6. A patient with stress incontinence
A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes
should the nurse include?
a. Urinary hesitancy
b. Hematuria
c. Stress incontinence
d. Increased vaginal moisture
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