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BSN 205 Hallmark Final Exam-211 Questions and Answers.
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BSN 205 Hallmark Final Exam-211 Questions and Answers.BSN 205 Hallmark Final Exam-211 Questions and Answers.
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BSN 205 Hallmark Final Exam-211 Questions andAnswers.
Which of the following is an example of healing by secondary intention?
A. A Full thickness pressure injury
B. A surgical incision
C. A dog bite
D. A burn
E. A skin tear - ANS A Full thickness pressure injury
A dog bite
A burn
It is suspected that a patient is developing a wound infection. Which assessment data
would support this conclusion? (Select all that apply.)
A. Yellow-tinged drainage
B. Temperature 100.3°F (37.94°C)
C. Increased complaints of pain at wound site
D. White blood cell count 13,000 mm3 (elevated)
E. Wound edges of pink to normal skin color
F. Foul odor noted from previous dressing - ANS Foul noted odor
Temp of 100.3
White blood cell count 13,000 mm3 (elevated)
Yellow-tinged drainage
Increased complaints of pain at wound site
Which of the following lab results or measurements indicate a risk for impaired wound
healing? (Select all that apply.)
A hemoglobin of 10.0 g per dL (decreased)
A serum albumin of 2.9 g/dl (decreased)
Fasting blood glucose of 215 mg/dl (elevated)
A BMI (body mass index) of 35 (elevated)
A white blood cell count of 7000 per mm3 (normal) - ANS A hemoglobin of 10.0 g per dL
(decreased)
A serum albumin of 2.9 g/dl (decreased)
Fasting blood glucose of 215 mg/dl (elevated)
A BMI (body mass index) of 35 (elevated)
Identify the functions of dressings. (Select all that apply.)
Removing surface bacteria.
Preventing shear.
Protection from outside contaminants and further tissue injury.
Control of bleeding and drainage.
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,Increased patient comfort.
Maintaining a moist environment. - ANS Protection from outside contaminants and
further tissue injury.
Control of bleeding and drainage.
Increased patient comfort.
Maintaining a moist environment.
Which of the following regarding removal of the old dressing on a surgical incision are
accurate? (Select all that apply.)
If dressing is over a hairy area, remove tape in the direction of hair growth.
Tape should be pulled parallel to the skin in a direction away from the incision.
Use caution to avoid tension on any drains that are present.
While wearing clean gloves, remove the dressing layers all at one time and discard.
Wear sterile gloves to remove old dressing. - ANS If dressing is over a hairy area,
remove tape in the direction of hair growth.
Use caution to avoid tension on any drains that are present.
Which of the following is a method of wound debridement?
Gauze dressing.
Hemovac drain.
Transparent dressing.
Damp-to-dry dressing. - ANS Damp-to-dry dressing
The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about
daily routine measures to reduce the incidence of pressure injuries within the agency.
Which of the following should the nurse include in the teaching? (Select all that apply.)
Using a turn sheet to reposition patients.
Rubbing reddened bony prominences.
Decreasing patients' fluid intake to decrease incidence of incontinence.
Use of pillow bridging when needed.
Positioning patient in the 30-degree lateral position.
Turning patients at least every 2 hours. - ANS Using a turn sheet to reposition patients.
Use of pillow bridging when needed.
Positioning patient in the 30-degree lateral position.
Turning patients at least every 2 hours.
How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain
or Hemovac?
By keeping the drain lower than the insertion site.
By turning the suction on.
By "milking" the tubing.
By compressing the drain reservoir. - ANS By compressing the drain reservoir.
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,A nurse is explaining how to perform a dressing change. Which of the following
sequences for changing a surgical wound dressing (wound drain present) indicates that
the nurse requires further education regarding this procedure?
Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain
by using a circular stroke starting near the drain and moving outward. Clean incision in
direction of bottom to top.
Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top
to bottom. Cleanse around drain by using a circular stroke starting near the drain and
moving outward.
Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the
same technique as for cleansing. Apply loose, woven gauze as contact layer. Place
drain sponge (precut gauze) around drain. Apply additional layers of gauze as needed.
Apply thicker woven pad (e.g., ABD or Surgipad).
Dispose - ANS Cleanse wound. Use a separate swab for each cleansing stroke.
Cleanse around drain by using a circular stroke starting near the drain and moving
outward. Clean incision in direction of bottom to top.
A patient is to have frequent dressing changes. What should the nurse use to secure
the dressing?
Paper tape.
Adhesive tape.
Hypoallergenic tape.
Montgomery ties. - ANS Montgomery Ties
Why does a wound bed need to stay moist?
To prevent excessive fluid loss from the body.
To support healing by enabling granulation tissue to grow.
To determine if the area has reactive hyperemia.
To decrease patient discomfort. - ANS To support healing by enabling granulation
tissue to grow.
A nurse is applying negative-pressure wound therapy (e.g., wound vacuum-assisted
closure [V.A.C.]) independently for the first time. Assuming all other steps are performed
correctly, which action, if made by the nurse, indicates that further instruction is needed
in performing this procedure?
With dressing tube unclamped, the nurse instills 10 to 30 mL of normal saline into the
tubing to soak the foam underneath.
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, With the V.A.C. unit off, the nurse applies clean gloves and disconnects the tubes to
drain fluids into the canister.
The nurse cuts the foam approximately one-half inch smaller than the size of the wound
and gently places the foam in the wound, avoiding any tunneled and undermined areas.
The nurse applies the tubing to the foam in the wound, applies a skin protectant to skin
around the wound, and applies the transparent dressing, covering 3 to 5 cm (1.2 to 2
inches) of surrounding healthy tissue. - ANS The nurse cuts the foam approximately
one-half inch smaller than the size of the wound and gently places the foam in the
wound, avoiding any tunneled and undermined areas.
The nurse may use clean gloves for changing the dressing on which of the following?
1.Chronic pressure injury.
2.Sterile gloves should always be used for dressing changes performed in the hospital
setting.
3. Sterile gloves should always be used for dressing changes performed by nurses.
4. Surgical wound. - ANS Chronic Pressure Injury
The nurse is reading electronic documentation from the emergency room on a patient
who is to be admitted to the unit. The documentation states that the patient has a
hematoma on the right knee. What does the nurse expect to see?
An area of skin that has been scraped away.
A deep wound extending into the dermis.
A shallow wound with loss of the epidermis and partial loss of the dermis.
A localized collection of blood underneath the tissues that often takes on a bluish
discoloration. - ANS A localized collection of blood underneath the tissues that often
takes on a bluish discoloration.
When is a surgical wound at greatest risk for hemorrhage?
Five to seven days after surgery.
Four to five days after surgery.
During the first 24 to 48 hours after surgery.
Two to three days after surgery.
The greatest risk of hemorrhage is during the first 24 to 48 hours after surgery or injury,
indicating inadequate hemostasis. The nurse should monitor for decreased blood
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