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Therapeutics Exam 3 study test revision questions
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Therapeutics Exam 3 study test revisionquestions
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and
generalized malaise, as well as pain and redness at the surgical site. Which intervention is most
important to include in this patient's nursing care plan?
A) Document the findings and continue to monitor the patient.
B) Administer antipyretics, as prescribed.
C) Increase the frequency of assessment to every hour and notify the patient's primary care
provider.
D) Increase the frequency of wound care and contact the primary care provider for an antibiotic
prescription. - ANS A) Document the findings and continue to monitor the patient.
A nurse caring for patients in the PACU teaches a novice nurse how to assess and document
wound drainage. Which statements accurately describe a characteristic of wound drainage?
Select all that apply.
A) Serous drainage is composed of the clear portion of the blood and serous membranes.
B) Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
C) Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates
older bleeding.
D) Purulent drainage is composed of white blood cells, dead tissue, and bacteria.
E) Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor.
F) Serosanguineous drainage can be dark yellow or green depending on the causative
organism. - ANS A, B, C, D
A patient who has a large abdominal wound suddenly calls out for help because the patient
feels as though something is falling out of her incision. Inspection reveals a gaping open wound
with tissue bulging outward. In which order should the nurse perform the following
interventions? Arrange from first to last.
A) Notify the health care provider of the situation.
B) Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride
solution.
C) Place the patient in the low Fowler's position. - ANS C, B, A
A patient was in an automobile accident and received a wound across the nose and cheek.
After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement,
what nursing diagnosis would be most appropriate?
A) Pain
B) Impaired Skin Integrity
C) Disturbed Body Image
D) Disturbed Thought Processes - ANS C) Disturbed Body Image
,A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in
preventing a wound infection?
A) Using sterile dressing supplies
B) Suggesting dietary supplements
C) Applying antibiotic ointment
D) Performing careful hand hygiene - ANS D) Performing careful hand hygiene
A nurse who is changing dressings of postoperative patients in the hospital documents various
phases of wound healing on the patient charts. Which statements accurately describe these
stages? Select all that apply.
A) Hemostasis occurs immediately after the initial injury.
B) A liquid called exudate is formed during the proliferation phase.
C) White blood cells move to the wound in the inflammatory phase.
D) Granulation tissue forms in the inflammatory phase.
E) During the inflammatory phase, the patient has generalized body response.
F) A scar forms during the proliferation phase. - ANS A, C, E
The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw.
The nurse documents the presence of biofilms in the wound. What is the effect of this condition
on the wound? Select all that apply.
A) Enhanced healing due to the presence of sugars and proteins
B) Delayed healing due to dead tissue present in the wound
C) Decreased effectiveness of antibiotics against the bacteria
D) Impaired skin integrity due to overhydration of the cells of the wound
E) Delayed healing due to cells dehydrating and dying
F) Decreased effectiveness of the patient's normal immune process - ANS C, F
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are
accurate steps in this procedure? Select all that apply.
A) Use standard precautions or transmission-based precautions when indicated.
B) Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out
excess solution.
C) Clean the wound in full or half circles beginning on the outside and working toward the
center.
D) Work outward from the incision in lines that are parallel to it from the dirty area to the clean
area.
E) Clean to at least 1 in beyond the end of the new dressing if one is being applied.
F) Clean to at least 3 in beyond the wound if a new dressing is not being applied. - ANS A, B,
E
A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip
arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure
injury development for this patient? Select all that apply.
,A) The patient takes time to think about responses to questions.
B) The patient is 86 years old.
C) The patient reports inability to control urine.
D) The patient is scheduled for a hip arthroplasty.
E) Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult
female normal 0.61 to 1 mg/dL).
F) The patient reports increased pain in right hip when repositioning in bed or chair. - ANS B,
C, D, F
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured
area. What response indicates that the patient understands the explanation?
A) "I can expect to have more discomfort in the area where the cold is applied."
B) "I should expect more drainage from the incision after the ice has been in place."
C) "I should see less swelling and redness with the cold treatment."
D) "My incision may bleed more when the ice is first applied." - ANS C) "I should see less
swelling and redness with the cold treatment."
A nurse is providing patient teaching regarding the use of negative pressure wound therapy.
Which explanation provides the most accurate information to the patient?
A) The therapy is used to collect excess blood loss and prevent the formation of a scab.
B) The therapy will prevent infection, ensuring that the wound heals with less scar tissue.
C) The therapy provides a moist environment and stimulates blood flow to the wound.
D) The therapy irrigates the wound to keep it free from debris and excess wound fluid. - ANS
C) The therapy provides a moist environment and stimulates blood flow to the wound.
After an initial skin assessment, the nurse documents the presence of a reddened area that has
blistered. According to recognized staging systems, this pressure injury would be classified as:
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4 - ANS B) Stage 2
The nurse uses the RYB wound classification system to assess the wound of a patient whose
arm was cut on a factory machine. The nurse documents the wound as "red." What would be
the priority nursing intervention for this type of wound?
A) Irrigate the wound.
B) Provide gentle cleansing of the wound.
C) Debride the wound.
D) Change the dressing frequently. - ANS B) Provide gentle cleansing of the wound.
A nurse is developing a care plan related to prevention of pressure injuries for residents in a
long-term care facility. Which action accurately describes a priority intervention in preventing a
patient from developing a pressure injury?
A) Keeping the head of the bed elevated as often as possible
, B) Massaging over bony prominences
C) Repositioning bed-bound patients every 4 hours
D) Using a mild cleansing agent when cleansing the skin - ANS D) Using a mild cleansing
agent when cleansing the skin
A nurse is measuring the depth of a patient's puncture wound. Which technique is
recommended?
A) Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a
90-degree angle with the tip down.
B) Draw the shape of the wound and describe how deep it appears in centimeters.
C) Gently insert a sterile applicator into the wound and move it in a clockwise direction.
D) Insert a calibrated probe gently into the wound and mark the point that is even with the
surrounding skin surface with a marker. - ANS A) Moisten a sterile, flexible applicator with
saline and insert it gently into the wound at a 90-degree angle with the tip down.
A pediatric nurse is familiar with specific characteristics of skin across the life span. Which
statement accurately describes skin characteristics?
A) An infant's skin and mucous membranes are easily injured and at risk for infection.
B) In children younger than 2 years, the skin is thicker and stronger than in adults.
C) A child's skin becomes less resistant to injury and infection as the child grows.
D) An individual's skin changes little over the life span. - ANS A) An infant's skin and mucous
membranes are easily injured and at risk for infection.
The nurse would recognize which client as being particularly susceptible to impaired wound
healing?
A) an obese woman with a history of type 1 diabetes
B) a client whose breast reconstruction surgery required numerous incisions
C) a man with a sedentary lifestyle and a long history of cigarette smoking
D) A client who is NPO (nothing by mouth) following bowel surgery - ANS A) an obese
woman with a history of type 1 diabetes
Which activity should the nurse implement to decrease shearing force on a client's stage II
pressure injury?
A) lubricating the area with skin oil
B) preventing the client from sliding in bed
C) improving the client's hydration
D) pulling the client up from under the arms - ANS B) preventing the client from sliding in bed
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement
should the nurse use to measure the depth accurately?
A) a small plastic ruler
B) a sterile tongue blade lubricated with water soluble gel
C) an otic curette
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