Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels?
⦁ Avoid prolonged elevation of the head of the bed
⦁ Order a standard hospital foam mattress
⦁ Consider an alternating pressure support sur...
NURC 1104 Exam 1 Questions &
Answers
Which nursing action is appropriate when providing care to a
patient who has intact skin but is at high risk for impaired skin
integrity of the heels?
• Avoid prolonged elevation of the head of the bed
• Order a standard hospital foam mattress
• Consider an alternating pressure support surface
• Place a pillow under the calves - D. Place a pillow under the
calves
Which of a novice nurse's actions would necessitate
intervention when providing care for a patient who is
prescribed negative-pressure wound therapy?
• Retaining hair around the wound
• Using a skin barrier around the wound
• Drying around the wound thoroughly
• Filling uneven wound surfaces with a hydrocolloid
product - A. Retaining hair around the wound
Which patient statement indicates understanding of the
disadvantages of using moist applications for wound
therapy?
• "It increases body fluid loss."
• "It causes maceration of the skin."
• "It causes increased drying of the skin."
• "It does not penetrate deep into tissues." - B. "It causes
maceration of the skin."
Which nursing actions are appropriate when removing tape
from the patient's skin during wound care? Select all that
apply.
• Loosen the ends
• Pull the tape in the direction of hair growth
• Use adhesive remover to loosen the tape
• Apply hard traction to the skin next to the wound
• Gently pull the outer end perpendicular to the skin surface -
A, B, C
Which factor increases the risk for injury when applying heat
therapy to a wound for a patient with a spinal cord injury?
• Thinner layers of skin
• Alteration in nerve pathways
• Rupture and systemic infection
• Decreased peripheral circulation - B. Alteration in nerve
pathways
Why is maintaining an airtight seal when providing care to a
patient who is receiving negative- pressure wound therapy
important?
• To avoid a wound infection
• To avoid wound desiccation
,• To avoid accelerated wound healing
• To avoid discomfort with wound dressing changes - B. To
avoid wound desiccation
Which nursing intervention is appropriate for a patient who is
at risk for skin breakdown due to friction and shear?
• Keep the skin dry and free of maceration
• Provide pressure-redistribution surface
• Consult a dietician for nutritional assessment
• Provide a trapeze to facilitate movement in bed - D.
Provide a trapeze to facilitate movement in bed
Which type of dressing is preferred for dry wounds?
• Hydrogel
• Hydrocolloid
• Calcium alginate
• Debriding enzymes - A. Hydrogel
Which nursing action is appropriate when providing care to a
patient who exhibits no risk for skin breakdown?
• Using a standard surface
• Using a pillow under the calves
• Using an active support surface
• Using a pressure-redistribution seat cushion - A. Using a
standard surface
Which nursing intervention is appropriate for a patient who is
at risk for skin breakdown due to moisture?
• Keep the skin dry and free of maceration
• Provide a pressure-redistribution surface
• Consult a dietician for nutritional assessment
• Provide a trapeze to facilitate movement in bed - A. Keep
the skin dry and free of maceration
Which nursing intervention is appropriate for a patient who is
at risk for skin breakdown due to decreased sensory
perception?
• Keep the skin dry and free of maceration
• Provide a pressure-redistribution surface
• Consult a dietician for nutritional assessment
• Provide a trapeze to facilitate movement in bed - B. Provide
a pressure-redistribution surface
Which nursing action during removing tape from the
patient's skin during wound care requires which correction?
• Loosening the ends
• Pulling the tape in the direction of hair growth
• Using adhesive remover to loosen the tape
• Applying hard traction to the skin next to the wound - D.
Applying hard traction to the skin next to the wound
The nurse is providing care to a patient with a pressure ulcer
that is covered in eschar. Which dressing prescription will the
,nurse use for this patient?
• None
• Adherent film
• Composite film
• Calcium alginate - B. Adherent film
Which is the most effective intervention for compromised
skin integrity?
• Preventing breakdown
• Administering medication
• Implementing wound care
• Monitoring wound healing - A. Preventing breakdown
• The nurse is assigned a group of patients. Which patient
would the nurse identify as being at increased risk for
impaired gasexchange? A patient
• with a blood glucose of 350 mg/dL
• who has been on anticoagulants for 10 days
• with a hemoglobin of 8.5 g/dL
• with a heart rate of 100 beats/min and blood pressure of
100/60
ANS: C
The hemoglobin is low (anemia), therefore the ability of
the blood to carry oxygen is decreased. High blood glucose
and/or anticoagulants do not alter the oxygen carrying
capacity of the blood. A heart rate of 100 beats/min and
blood pressure of 100/60 are not indicative of oxygen
carrying capacity of the blood.
• The nurse is reviewing the patient’s arterial blood gas
results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is
55 mm Hg, and HCO3 is 25 mEq/L. What would the
nurse expect to observe on assessment of this patient?
• Disorientation and tremors
• Tachycardia and decreased blood pressure
• Increased anxiety and irritability
• Hyperventilation and letharg
, The patient is experiencing respiratory acidosis ( pH, and
PaCO2 ) which may
be manifested by disorientation, tremors, possible seizures,
and decreased level of consciousness. Tachycardia and
decreased blood pressure are not characteristic of a problem
of respiratory acidosis. Increased anxiety and
hyperventilation will cause respiratory alkalosis, which is
manifested by an increase in pH and a decrease in PaCO2.
• The nurse would identify which patient as having a
problem of impaired gas exchange secondary to a
perfusion problem? Apatient with
• peripheral arterial disease of the lower extremities
• chronic obstructive pulmonary disease (COPD)
• chronic asthma
• severe anemia secondary to chemotherapy
ANS: A
Perfusion relates to the ability of the blood to deliver oxygen
to the cellular level and return the carbon dioxide to the lung
forremoval. COPD and asthma are examples of a ventilation
problem. Severe anemia is an example of a transport problem
of gas exchange.
• The nurse is assessing a patient’s differential white blood
cell count. What implications would this test have on
evaluating theadequacy of a patient’s gas exchange?
• An elevation of the total white cell count indicates
generalized inflammation.
• Eosinophil count will assist to identify the presence of a
respiratory infection.
• White cell count will differentiate types of respiratory
bacteria.
• Level of neutrophils provides guidelines to monitor a
chronic infection.
Elevation of total white cell count is indicative of
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