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Intro to Nursing - Exam 2 Concepts - Modules 5-8 questions with correct answers.
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Intro to Nursing - Exam 2 Concepts -Modules 5-8 questions with correct
answers
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is
indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: D.
When repositioning an immobile patient, it is important to assess all bony prominences for the presence
of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the
blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and
then returns to the red color. However, if the area does not blanch when pressure is applied, tissue
damage is likely.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the
following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: A.
A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch.
Depending on the skin color, there may be a discoloration; the area may feel warm because of the
,vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in
the area or soft if the blood flow is compromised. The patient may report pain in the area.
When obtaining a wound culture to determine the presence of a wound infection, from where should
the specimen be taken?
A. Necrotic tissue
B. Wound drainage
C. Drainage on the dressing
D. Wound after it has first been cleaned with normal saline
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: D.
Drainage that has been present on the wound surface can contain bacteria from the skin, and the
culture may not contain the true causative organisms of a wound infection. By cleaning the area before
obtaining the culture, the skin flora is removed.
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When
the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted
at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?
A. Allow the area to be exposed to air until all drainage has stopped
B. Place several cold packs over the area, protecting the skin around the wound
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is
likely to indicate a wound evisceration
D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for
30 minutes because this is a minor opening in the surgical wound and should reseal quickly
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: C.
If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small
bowel must be protected until an emergency surgical repair can be done. The small bowel and
abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened
with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
,Which description best fits that of serous drainage from a wound?
A. Fresh bleeding
B. Thick and yellow
C. Clear, watery plasma
D. Beige to brown and foul smelling
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: C.
Serous fluid generally is serum and presents as light red, almost clear fluid.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product
helps prevent edema formation, control bleeding, and anesthetize the body part?
A. Binder
B. Ice bag
C. Elastic bandage
D. Absorptive diaper
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: B.
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become
constricted, help to control bleeding, and can decrease pain where the ice bag is placed.
Which skin care measures are used to manage a patient who is experiencing fecal and urinary
incontinence?
A. Keeping the buttocks exposed to air at all times
B. Using a large absorbent diaper, changing when saturated
C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment
D. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel
, (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: C.
Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged.
The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a
prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and
urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and
the next incontinence episode.
Which of the following describes a hydrocolloid dressing?
A. A seaweed derivative that is highly absorptive
B. Premoistened gauze placed over a granulating wound
C. A debriding enzyme that is used to remove necrotic tissue
D. A dressing that forms a gel that interacts with the wound surface
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: D.
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of
the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper
environment for healing.
Which of the following is an indication for a binder to be placed around a surgical patient with a new
abdominal wound?
A. Collection of wound drainage
B. Reduction of abdominal swelling
C. Reduction of stress on the abdominal incision
D. Stimulation of peristalsis (return of bowel function) from direct pressure
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48) - correct answer -Answer: C.
A binder placed over the abdomen can provide protection to the abdominal incision by offering support
and decreasing stress from coughing and movement.
When is an application of a warm compress indicated? (Select all that apply.)
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