Chapter 36 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 36

Question 1

Type: MCSA

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study?

1. Gastric resection

2. Uncomplicated abdominal hysterectomy

3. Breast biopsy

4. Lung resection

Correct Answer: 3

Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A gastric resection would be included in the study.

Rationale 2: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. An uncomplicated abdominal hysterectomy would be included in the study.

Rationale 3: A breast biopsy is considered a clean wound. Clean wounds are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds.

Rationale 4: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A lung resection would be included in the study.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy;

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify the main complications of and factors that affect wound healing.

MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity.

Page Number: 829

Question 2

Type: MCSA

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound should the receiving nurse plan care for this client?

1. Clean-contaminated

2. Contaminated

3. Dirty

4. Infected

Correct Answer: 2

Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered, but minimal to no spillage has occurred.

Rationale 2: A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound.

Rationale 3: A dirty wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage.

Rationale 4: An infected wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Identify the main complications of and factors that affect wound healing.

MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity.

Page Number: 829

Question 3

Type: MCSA

A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this clients care?

1. Obtain ice packs to apply to the wounds.

2. Request gauze to pack the wounds.

3. Organize suture material to close the wounds.

4. Notify the surgical staff that a surgical client will soon be arriving.

Correct Answer: 1

Rationale 1: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours.

Rationale 2: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Because these wounds are closed, there is no need for packing.

Rationale 3: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Because these wounds are closed, there is no need for suturing.

Rationale 4: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Because these wounds are closed, there is no need for surgery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 829

Question 4

Type: MCSA

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?

1. Reactive hyperemia

2. Stage I pressure ulcer

3. Stage II pressure ulcer

4. Stage III pressure ulcer

Correct Answer: 1

Rationale 1: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred.

Rationale 2: Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time.

Rationale 3: Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters.

Rationale 4: Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Describe the four stages of pressure ulcer development.

MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing.

Page Number: 830

Question 5

Type: MCSA

The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

1. There is undermining of adjacent tissues.

2. The crater extends into the subcutaneous tissue.

3. The joint capsule of the hip is visible.

4. The ulcer has thick dark eschar over the top.

Correct Answer: 3

Rationale 1: Undermining of adjacent tissues can occur in either a stage III or stage IV pressure ulcer.

Rationale 2: Extension into the subcutaneous tissue is a characteristic of a stage III pressure ulcer.

Rationale 3: Stage IV ulcers demonstrate damage to muscle, bone, tendons, or the joint capsule.

Rationale 4: If there is eschar present, the ulcer cannot be staged. Staging can occur only when the bottom of the ulcer can be seen and evaluated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe the four stages of pressure ulcer development.

MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing.

Page Number: 831

Question 6

Type: MCSA

The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After assessing the wound the nurse should take which action?

1. Obtain a transparent dressing for the UAP to place on the wound.

2. Request a consult with the wound care nurse.

3. Cleanse the wound and apply a dressing.

4. Tell the UAP to reevaluate the wound in 20 minutes.

Correct Answer: 3

Rationale 1: The UAP is not educationally prepared to dress the wound.

Rationale 2: At this point a consult with the wound care nurse is not required.

Rationale 3: The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing.

Rationale 4: The UAP is not educationally prepared to evaluate the wound.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 847

Question 7

Type: MCSA

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse

1. should receive specific training.

2. must be certified.

3. is required to ask the clients permission.

4. has to obtain special assessment equipment.

Correct Answer: 1

Rationale 1: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate.

Rationale 2: The nurse does not need to be certified in the use of the Braden Scale.

Rationale 3: There is no specific permission required from the client.

Rationale 4: There is no special assessment equipment required.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 833

Question 8

Type: MCSA

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores?

1. Trending can only be accurate if the same scale is used.

2. There is a definite trend of low risk for pressure ulcer development.

3. Trending would be more accurate if the same scale was used.

4. The scores indicate opposite risks for pressure ulcer development.

Correct Answer: 3

Rationale 1: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used.

Rationale 2: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used.

Rationale 3: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used.

Rationale 4: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 832

Question 9

Type: MCSA

A clients laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing?

1. Primary intention

2. Open approximation

3. Secondary healing

4. Delayed closure

Correct Answer: 1

Rationale 1: The nurse should instruct the client regarding primary intention wound healing. The edges of these wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds.

Rationale 2: Secondary healing involves wounds that cannot be approximated and that must heal in.

Rationale 3: Secondary healing involves wounds that cannot be approximated and that must heal in. These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring.

Rationale 4: Wounds that are left open for 3 to 5 days allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention. This is also called delayed primary intention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Differentiate primary and secondary wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 834

Question 10

Type: MCSA

A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause

1. decreased oxygen supply to tissues.

2. suppression of the inflammatory process necessary for healing.

3. a decrease in the amount of nutrients such as glucose in the blood.

4. blood vessel constriction, which impairs waste product removal.

Correct Answer: 2

Rationale 1: Steroids do not decrease oxygen supply to the tissues.

Rationale 2: Steroids suppress the inflammatory process, which is a normal part of the healing process.

Rationale 3: Steroids generally increase blood glucose.

Rationale 4: Blood vessels are not constricted by steroids.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 835

Question 11

Type: MCSA

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that something popped in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first?

1. Notify the clients surgeon.

2. Cover the area with a large saline-soaked dressing.

3. Position the client in bed with knees bent.

4. Pack the wound with nonadherent gauze.

Correct Answer: 2

Rationale 1: Although notifying the surgeon is important, it is not the nurses first action.

Rationale 2: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurses first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist.

Rationale 3: Although positioning the client is important, it is not the nurses first action.

Rationale 4: Nothing should be packed into this wound.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 836

Question 12

Type: MCSA

A client is prescribed antiembolic stockings. How should the nurse assess the skin on the clients legs?

1. Defer the assessment because the stockings are in place.

2. Remove the stockings for this assessment.

3. Review the morning assessment, but dont repeat it unless a problem occurs.

4. Assess the skin when the client removes the stockings at bedtime.

Correct Answer: 2

Rationale 1: The stockings are worn day and night, so the client will not remove them for sleep.

Rationale 2: The stockings should be removed to do this assessment.

Rationale 3: The nurse is responsible for assessing the skin under the stockings and should not assume that the morning nurses assessment is still accurate 12 hours later.

Rationale 4: The stockings are worn day and night, so the client will not remove them for sleep.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify the main complications of and factors that affect wound healing.

MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity.

Page Number: 837

Question 13

Type: MCSA

Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take?

1. Place a tourniquet above the wound.

2. Remove the dressing and place direct pressure on the wound.

3. Add an additional dressing to the wound without removing the original.

4. Remove the dressing and replace it with a new sterile dressing.

Correct Answer: 3

Rationale 1: A tourniquet should not be applied because of the risk of interrupting arterial flow to the tissues.

Rationale 2: Removing the dressing and applying direct pressure would take too much time at this point.

Rationale 3: In this scenario, where there are multiple clients in need of care and because this client is stable, the correct nursing action is to add an additional dressing to the wound without removing the original.

Rationale 4: Removing the dressing and replacing the dressing with a new sterile dressing would take too much time at this point.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 847

Question 14

Type: MCSA

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?

1. Clean areas of granulation tissue

2. Exudate in the bottom of the wound

3. A pus-coated area on the side of the wound

4. Intact skin at the edge of the wound

Correct Answer: 1

Rationale 1: Microorganisms that are most likely to be responsible for wound infections live in viable tissue such as granulation tissue.

Rationale 2: Exudate contains a variety of components and will not give a good indication of what is causing the infection.

Rationale 3: Pus contains a variety of components and will not give a good indication of what is causing the infection.

Rationale 4: The skin at the edge of the wound contains skin organisms that may or may not be present in the wound itself.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Verbalize the steps used in: a. Obtaining wound specimens.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 841

Question 15

Type: MCSA

The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client?

1. Altered Tissue Perfusion

2. Impaired Skin Integrity

3. Impaired Tissue Integrity

4. Risk for Injury

Correct Answer: 3

Rationale 1:Although it is true that pressure ulcers result from altered tissue perfusion, the diagnosis problem statement Impaired Tissue Integrity is more specific.

Rationale 2: Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue.

Rationale 3: Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria for using the NANDA nursing diagnosis problem statement Impaired Tissue Integrity.

Rationale 4: This client has already suffered injury, so this is not a Risk for Injury situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9. Identify nursing diagnoses associated with impaired skin integrity.

MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing.

Page Number: 842

Question 16

Type: MCSA

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing?

1. Materials used in dressing this wound should keep the wound bed moist.

2. The dressing should allow good air circulation through the wound.

3. Dressings should be simple as they will be changed at least every 4 hours.

4. Absorbent material to wick exudates away and support drying should be used.

Correct Answer: 1

Rationale 1: Wounds that are expected to heal by secondary intention heal by granulating in. In order to support the growth of granulation tissue, the wound bed should be kept moist and oxygen should be kept out of the wound.

Rationale 2: Air is drying to tissues and contains oxygen, so air circulation through the dressing is not desirable.

Rationale 3: The dressings will not be changed that often.

Rationale 4: Because the goal is to keep the wound bed moist, dressings should not wick exudates away.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12. Identify purposes of commonly used wound dressing materials and binders.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 846

Question 17

Type: MCSA

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide?

1. Wash the area with soap and hot water at every brief change.

2. Apply a petroleum-based cream to the area after cleaning.

3. Wipe the skin with an alcohol-free barrier film agent after cleaning.

4. Keep the client in bed on absorbent pads until the area clears.

Correct Answer: 3

Rationale 1: Cleansing should be done with a mild cleansing agent and warm water.

Rationale 2: Petroleum-based creams are now thought to offer poor overall skin protection and to interfere with incontinence brief absorption.

Rationale 3: The care should include wiping the skin with an alcohol-free barrier film agent after cleaning.

Rationale 4: Keeping the client in bed to treat this area is not necessary and may lead to problems with immobility.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implement

Learning Outcome: 2. Identify clients at risk for pressure ulcers.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 846

Question 18

Type: MCSA

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the clients skin?

1. Keep the head of the clients bed at 30 degrees.

2. Coat the clients back and buttocks with baby powder after bathing.

3. Use a turn sheet lifted by two staff members to move the client in bed.

4. Dust the linens with cornstarch each morning to allow for easier movement.

Correct Answer: 3

Rationale 1: The head of the clients bed should be kept at less than 30-degrees elevation as much as possible.

Rationale 2: Baby powder should not be used because it causes abrasive grit damage to tissues.

Rationale 3: The nurse should plan to use a turn sheet lifted by two staff members to move the client up in bed.

Rationale 4: Cornstarch should not be used because it causes abrasive grit damage to tissues.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implement

Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 844

Question 19

Type: MCSA

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan?

1. Red

2. Yellow

3. Black

4. A combination of all three

Correct Answer: 3

Rationale 1: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

Rationale 2: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

Rationale 3: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

Rationale 4: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds..

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 846

Question 20

Type: MCSA

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome?

1. The rubber doughnut pressure relief device was not delivered by central supply.

2. The clients serum albumin increased over the last month.

3. Nurses did not document disinfection of the wound with alcohol with each dressing change.

4. Unlicensed assistive personnel (UAP) followed a right sidebackleft sideback turning schedule.

Correct Answer: 4

Rationale 1: A rubber doughnut should not be used, so the fact that it was not delivered did not cause failure to meet the outcome.

Rationale 2: An increase in serum albumin is a good finding and would increase wound healing, not decrease wound healing.

Rationale 3: The use of alcohol interrupts healing, so it is good that nurses did not document its use.

Rationale 4: Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the clients condition. Of the options listed, the only one that would result in poor healing is the right sidebackleft sideback turning schedule. This schedule places the client on the back for 50% of the time. The schedule should be right sidebackleft sideright side.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 861

Question 21

Type: MCSA

The nurse has applied an aquathermia pad to a clients back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. How should the nurse evaluate this request?

1. Because this clients thermal tolerance is higher than normal, increasing the temperature is necessary.

2. This client may be experiencing a rebound effect from the application of moist heat.

3. Adaptation of the thermal receptors often results in the decreased sensation of warmth.

4. The aquathermia pad should be replaced with a standard hot pack.

Correct Answer: 3

Rationale 1: There is no evidence that this client has increased thermal tolerance.

Rationale 2: There is no evidence that the rebound effect is occurring.

Rationale 3: After about 15 minutes of heat application, the thermal receptors adapt to the temperature increase and the sensation of warmth is diminished. Clients often request that the temperature be increased because they do not feel the same amount of heat. This can lead to burns.

Rationale 4: It is not necessary to replace the aquathermia pad with a hot pack.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 857

Question 22

Type: MCMA

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Poor skin turgor.

2. Elevated body temperature.

3. Diminished pain sensation.

4. Thin epidermis.

5. Dry skin.

Correct Answer: 1, 3, 4, 5

Rationale 1: The older person is more prone to impaired skin integrity because of decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis.

Rationale 2: Elevated body temperature does impact a persons skin integrity, but this could occur at any age, and not just in an older client.

Rationale 3: The older person is more prone to impaired skin integrity because of diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch.

Rationale 4: The older person is more prone to impaired skin integrity because of generalized thinning of the epidermis.

Rationale 5: The older person is more prone to impaired skin integrity because of increased dryness due to a decrease in the amount of oil produced by the sebaceous glands.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe factors affecting skin integrity.

MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity.

Page Number: 837

Question 23

Type: MCMA

A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements?

Standard Text: Select all that apply.

1. Minimal tissue loss.

2. Closure of the wound will occur within 5 days.

3. Healing time will be longer.

4. Potential for scarring is greater.

5. Susceptibility to infection is greater.

Correct Answer: 3, 4, 5

Rationale 1: In primary intention healing, there is minimal tissue loss.

Rationale 2: In tertiary intention healing, the closure of the wound will occur within 5 days.

Rationale 3: In secondary intention healing, the repair time is longer.

Rationale 4: In secondary intention healing, the scarring is greater.

Rationale 5: In secondary intention healing, the susceptibility to infection is greater.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Differentiate primary and secondary wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 834

Question 24

Type: MCSA

A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase?

1. Inflammatory

2. Proliferative

3. Maturation

4. Remodeling

Correct Answer: 1

Rationale 1: The inflammatory phase is initiated immediately after injury, and lasts 36 days.

Rationale 2: The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post-injury.

Rationale 3: The maturation phase begins on about day 21 and can extend 1 or 2 years after the injury.

Rationale 4: Remodeling is another name for the maturation phase.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe the three phases of wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 835

Question 25

Type: MCSA

A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing?

1. Exudative

2. Proliferative

3. Inflammatory

4. Maturation

Correct Answer: 4

Rationale 1: Exudative is not a phase of wound healing.

Rationale 2: Keloid formation does not occur during the proliferative phase of wound healing.

Rationale 3: Keloid formation does not occur during the inflammatory phase of wound healing.

Rationale 4: Dark, thick scars, or keloids, are caused by an abnormal amount of collagen during the maturation phase of healing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe the three phases of wound healing.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 835

Question 26

Type: MCSA

While changing a clients dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wounds drainage?

1. Purulent

2. Serous

3. Sanguineous

4. Serosanguinous

Correct Answer: 1

Rationale 1: Purulent exudate is thick, and can vary in color, including green and yellow.

Rationale 2: Serous drainage appears watery.

Rationale 3: Sanguineous drainage is red because of the high number of red blood cells.

Rationale 4: Serosanguinous drainage is watery with red blood cells.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three major types of wound exudate; 16. Demonstrate appropriate documentation and reporting of skin integrity and wound care.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 836

Question 27

Type: MCSA

The nurse documents that a clients postoperative wound is purosanguinous. What did the nurse assess in this clients wound?

1. Water and red blood cells

2. Pus and red blood cells

3. Watery drainage

4. Pus

Correct Answer: 2

Rationale 1: Water and red blood cells would be considered serosanguinous drainage.

Rationale 2: Purosanguinous drainage consists of purulent drainage and red blood cells.

Rationale 3: Watery drainage would be considered serous drainage.

Rationale 4: Pus would be considered purulent drainage.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three major types of wound exudate.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 836

Question 28

Type: MCSA

The nurse is assessing a clients pressure ulcer. To determine the depth of the ulcer, the nurse should take which action?

1. Measure the width.

2. Measure the length.

3. Insert a sterile swab into the deepest part of the wound.

4. Identify where on the face of a clock the ulcer is located.

Correct Answer: 3

Rationale 1: Measuring the width of the wound does not provide the depth of the ulcer.

Rationale 2: Measuring the length of the wound does not provide the depth of the ulcer.

Rationale 3: To measure the depth of a wound, the nurse should insert a sterile swab into the deepest part of the wound and then measure the length of the swab that was inserted.

Rationale 4: Identifying locations on the face of a clock determines the presence of undermining or sinus tracts.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe the four stages of pressure ulcer development.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 838

Question 29

Type: MCSA

A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate?

1. Impaired Skin Integrity

2. Risk for Impaired Skin Integrity

3. Impaired Tissue Integrity

4. Risk for Infection

Correct Answer: 2

Rationale 1: Impaired Skin Integrity is appropriate if the client has an alteration in the epidermis or dermis.

Rationale 2: Because the client is experiencing episodes of incontinence without any current changes in skin integrity, the client is at Risk for Impaired Skin Integrity.

Rationale 3: Impaired Tissue Integrity is appropriate if the client has damage to mucous membranes, integument, or subcutaneous tissues.

Rationale 4: Risk for Infection would be appropriate if the client has severe skin impairment, the client is immunosuppressed, or the wound is caused by trauma.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9. Identify nursing diagnoses associated with impaired skin integrity.

MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care.

Page Number: 842

Question 30

Type: MCMA

A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this clients wound?

Standard Text: Select all that apply.

1. Cover it with transparent film.

2. Apply a damp-to-damp normal saline dressing.

3. Cover it with a dry dressing.

4. Irrigate the wound.

5. Apply impregnated hydrogel.

Correct Answer: 2, 4, 5

Rationale 1: Covering with a transparent film is not appropriate for a yellow wound.

Rationale 2: A damp-to-damp normal saline dressing will remove nonviable tissue from the wound, and is appropriate for a yellow wound.

Rationale 3: Covering with a dry dressing is not appropriate for a yellow wound.

Rationale 4: Irrigating the wound is appropriate for a yellow wound.

Rationale 5: Applying impregnated hydrogel is appropriate for a yellow wound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12. Identify purposes of commonly used wound dressing materials and binders.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 846

Question 31

Type: SEQ

The nurse is preparing to irrigate a clients abdominal wound. In which order should the nurse perform this irrigation?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Dry the area around the wound.

Choice 2. Insert the catheter into the wound until resistance is met.

Choice 3. Remove and discard clean gloves.

Choice 4. Apply clean gloves.

Choice 5. Irrigate until the solution flows clear.

Choice 6. Select a syringe with a catheter attached or with an irrigating tip.

Correct Answer: 4, 6, 2, 5, 1, 3

Rationale 1: After irrigating, the nurse should dry the area around the wound.

Rationale 2: The nurse should then insert the catheter into the wound until resistance is met.

Rationale 3: The nurse should then remove and discard the clean gloves.

Rationale 4: The nurse first should apply clean gloves.

Rationale 5: The nurse should then irrigate the wound until the solution flows clear.

Rationale 6: The nurse should then select a syringe with a catheter attached or with an irrigating tip.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Verbalize the steps used in: b. Irrigating a wound.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 850

Question 32

Type: MCMA

A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client?

Standard Text: Select all that apply.

1. The application of cold dilates blood vessels.

2. The application of cold constricts blood vessels.

3. The application of cold decreases inflammation.

4. The application of cold reduces localized pain.

5. The application of cold provides a calming, sedative effect.

Correct Answer: 2, 3, 4

Rationale 1: The application of heat, not cold, dilates blood vessels.

Rationale 2: The application of cold does constrict blood vessels.

Rationale 3: The application of cold does decrease inflammation.

Rationale 4: The application of cold does reduce localized pain.

Rationale 5: The application of heat, not cold, provides a calming, sedative effect.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 856

Question 33

Type: MCSA

During morning care, unlicensed assistive personnel observe a clients abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel do?

1. Reinforce the wound with supplies on the clients bedside table.

2. Document that the bath was completed, and the condition of the dressing.

3. Complete the bath, then report the change to the nurse.

4. Report the dressing changes to the nurse immediately.

Correct Answer: 4

Rationale 1: UAP are not trained to reinforce dressings. This should not be done.

Rationale 2: UAP should not document that the bath was completed before communicating the dressing changes to the nurse.

Rationale 3: UAP should not complete the bath first.

Rationale 4: When delegating the care of the client to the UAP, the nurse should have provided direction to the UAP to report any changes to the nurse. UAP should report the dressing changes to the nurse immediately.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15. Recognize when it is appropriate to delegate aspects of skin and wound care to unlicensed assistive personnel.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 854

Question 34

Type: MCMA

The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging?

Standard Text: Select all that apply.

1. Finger

2. Forearm

3. Upper leg

4. Lower leg

5. Upper arm

Correct Answer: 2, 4

Rationale 1: Recurrent turns are used to cover distal parts of the body, for example, the end of a finger.

Rationale 2: Spiral reverse turns are used to bandage cylindrical parts of the body that are not uniform in circumference, for example, the forearm.

Rationale 3: Spiral turns are used to bandage parts of the body that are fairly uniform in circumference, for example, the upper leg.

Rationale 4: Spiral reverse turns are used to bandage cylindrical parts of the body that are not uniform in circumference, for example, the lower leg.

Rationale 5: Spiral turns are used to bandage parts of the body that are fairly uniform in circumference, for example, the upper arm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Verbalize the steps used in: c. Applying dressings.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 854


Question 35

Type: SEQ

The nurse is preparing to apply a moist aquathermia pack to a clients left upper leg. In which order should the nurse prepare and apply this treatment?

Standard Text: Select all that apply.

1. Use tape or gauze ties to hold the pad in place.

2. Set the desired temperature according to the manufacturers instructions.

3. Apply the pad to the body part. The treatment is usually continued for 30 minutes.

4. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer.

5. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use.

Correct Answer: 4, 2, 5, 3, 1

Rationale 1: The last step is to apply tape or gauze to hold the pad in place.

Rationale 2: Second, set the temperature according to the manufacturers instructions.

Rationale 3: The fourth step is to apply the pad to the body part being treated and expect to keep the pad in place for 30 minutes.

Rationale 4: First, the reservoir of the unit should be filled two-thirds full with water.

Rationale 5: The third step is to cover the pad and plug in the unit, making sure the pad is checked for leaks or malfunctions before use.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Verbalize the steps used in: d. Applying dry and moist heat and cold.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications.

Page Number: 858

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