Chapter 60 My Nursing Test Banks

Osborn,_2e
Chapter 60

Question 1

Type: MCSA

A patient injured in an accident has a large open leg wound that will require hospitalization for several days. The patient states he has just completed a course of steroid therapy. The nurse will include additional monitoring for which condition in the plan of care?

1. Delayed wound healing

2. Increased risk of thromboembolism

3. Increased tendency to bleed excessively

4. Increased pain at the wound site

Correct Answer: 1

Rationale 1: Steroids suppress the inflammatory phase and thus contribute to a delay in wound healing. Chronic use of steroids results in decreased production of histamines, which are needed for the inflammatory response.

Rationale 2: There is no increase in the risk of thromboembolism specifically associated with the use of steroids.

Rationale 3: There is no increase in bleeding specifically associated with the use of steroids.

Rationale 4: Steroid use does not increase pain from wounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 60-1

Question 2

Type: MCMA

The nurse would assess that granulation tissue is developing in a wound when noting which characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Beefy red color

2. Blue-gray tinge to the wound bed

3. Small, round nodules in the wound bed

4. Pearly-appearing wound margins

5. Moist tissue

Correct Answer: 1,3,5

Rationale 1: Granulation tissue appears beefy red.

Rationale 2: Granulation tissue should not have a blue-gray tinge.

Rationale 3: Granulation tissue, so named for its characteristic tiny, round, granule-like nodules, is a highly vascular connective tissue that contains newly formed capillaries, proliferating fibroblasts, and residual inflammatory cells.

Rationale 4: Pearl-like wound margins indicate that epithelialization is occurring.

Rationale 5: Granulation tissue is moist.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-1

Question 3

Type: MCSA

The nurse caring for a patient with an extensive wound would expect angiogenesis to begin during which phase of healing?

1. Remodeling

2. Inflammatory phase

3. Maturation

4. Proliferation

Correct Answer: 4

Rationale 1: Remodeling is the final stage of wound healing and occurs after the phase that includes angiogenesis.

Rationale 2: The purpose of the inflammatory phase is to prepare the wound for the growth of new tissue.

Rationale 3: The maturation phase, also known as the remodeling phase, is the final phase of wound healing.

Rationale 4: During proliferation, growth factors originating from injured vessels stimulate the formation of vascular buds and regrowth of vascular loops. Stimulated endothelial cells multiply and form tubular structures differentiating into arterioles or venules, a process referred to as angiogenesis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-1

Question 4

Type: MCSA

A nurse assesses that the periwound area of a patients large abdominal wound is macerated. What change in nursing management will be required because of the maceration?

1. Apply a petroleum-based product to the periwound area.

2. Keep the moist dressing off the periwound area.

3. No new measures are necessary, as this is a normal finding.

4. Apply a separate moist dressing to the periwound area.

Correct Answer: 2

Rationale 1: It is not necessary to introduce another product into the care of this wound.

Rationale 2: Maceration occurs when excessive moisture destroys the skins integrity. Periwound skin becomes macerated when the wet dressing from the wound extends to the skin around the wound. The most appropriate nursing measure is to keep the skin around the wound dry.

Rationale 3: Maceration is not a normal finding and requires nursing intervention.

Rationale 4: Applying moist dressings to the periwound area would worsen the maceration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-5

Question 5

Type: MCMA

The nurse is caring for a patient with a large open wound. While changing the dressing, the nurse notes purulent drainage. What additional assessments are necessary for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Wound odor

2. Blood urea nitrogen (BUN)

3. Fever

4. Wound bleeding

5. White blood cell count

Correct Answer: 1,3,5

Rationale 1: The presence of an odor can be one of the first signs of impending infection.

Rationale 2: BUN is an indicator of renal function, not wound infection.

Rationale 3: Fever is an indicator of infection.

Rationale 4: Bleeding is not an indicator of infection.

Rationale 5: Purulent drainage indicates infection, which requires the nurse to assess for other indicators of infection. Increased WBC is a positive indicator of infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-4

Question 6

Type: MCSA

The nurse is caring for an 84-year-old patient who was just admitted with a large sacral ulcer. When assessing the wound, the nurse notes small areas of both black and white tissue in the wound bed. Which dressing protocol would the nurse expect to follow with this wound?

1. Wet-to-dry with normal saline every 6 hours

2. Dry dressing twice per day

3. Wet-to-wet with Dankins solution once per day

4. Petroleum-based antiseptic dressing once per day

Correct Answer: 1

Rationale 1: The black and white tissue must be debrided from the wound area before healing can occur. Wet-to-dry dressing provides a means of debridement.

Rationale 2: The black and white tissue must be debrided from the wound area before healing can occur. Dry dressings cover the wound but do not provide the needed debridement.

Rationale 3: The black and white tissue must be debrided from the wound area before healing can occur. Wet-to-wet dressings do not adhere to the wound; therefore, no debridement is provided.

Rationale 4: The black and white tissue must be debrided from the wound area before healing can occur. Petroleum-based products would not provide debridement.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-5

Question 7

Type: MCMA

The nurse would increase surveillance and prevention for pressure ulcer development in which at-risk patients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A 70-year-old patient who has been living at home and has limited ability to obtain groceries

2. A 68-year-old patient whose assessment reveals a low body mass index

3. A 50-year-old patient who has developed urinary incontinence after hospitalization for cholecystectomy.

4. A 35-year-old patient who has diabetic neuropathy

5. A 29-year-old patient hospitalized for treatment of pregnancy-induced hypertension

Correct Answer: 1,2,3,4

Rationale 1: Patients with poor nutrition are more susceptible to pressure ulcer development. Good nutrition supports skin health.

Rationale 2: Being very thin reduces the amount of subcutaneous padding and increases pressure on bony prominences.

Rationale 3: Patients who have urinary or fecal incontinence or are exposed to other types of moisture such as perspiration, wound drainage, or emesis are more prone to ulcers.

Rationale 4: Reduced sensation prevents the patient from feeling the pain associated with the development of a pressure ulcer, which increases the risk of development and progression.

Rationale 5: A young patient with pregnancy-induced hypertension is probably well hydrated. There is no indication of any other standard risk factors.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-3

Question 8

Type: MCMA

The nurse is developing unit assessment protocols for the risk of pressure ulcer development. What factors would the nurse include in this document?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Presence of moisture

2. Potential for friction and shear

3. Adequacy of nutrition

4. Mobility status

5. Presence of confusion

Correct Answer: 1,2,3,4

Rationale 1: Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development.

Rationale 2: Friction and shear potentially remove layers of tissue, thereby increasing the risk for loss of skin integrity, which can progress to necrosis of the skin with pressure.

Rationale 3: Nutrition supplementation is an essential intervention against pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization.

Rationale 4: Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area.

Rationale 5: There is no indication that a patient who is confused is at greater risk for developing pressure ulcers.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-3

Question 9

Type: MCMA

The nurse understands that to prevent pressure ulcers, pressure must be removed from high-risk areas of the body. What nursing interventions are essential to accomplish this goal?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pull the patient up in bed every 2 hours or less.

2. Turn the patient at least every 2 hours.

3. Encourage the patient to be out of bed.

4. Position articles the patient uses just out of reach to encourage movement.

5. Float the heels off the bed with pillows beneath the ankles.

Correct Answer: 2,3,5

Rationale 1: Pulling patients up in bed increases friction and shear but does not prevent pressure. Increasing friction and shear may increase the risk of pressure ulcers.

Rationale 2: Turning takes prolonged pressure off a single area.

Rationale 3: Bed rest increases the risk for pressure ulcer development.

Rationale 4: The patient may move more to reach for these articles, but this technique would increase the risk for falls. The nurse must consider the patient holistically when planning care.

Rationale 5: Placing pillows under the ankles floats the heels off the bed, thereby offloading pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-3

Question 10

Type: MCMA

The nurse is caring for a frail, elderly patient who has a chronic pressure ulcer on the ankle. The nurse plans care to reverse which factors that impair healing in the wound?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Repeated prolonged insults to the tissue

2. Patients lack of concern about the wound

3. An inadequate blood supply in the tissue

4. Newly diagnosed urinary tract infection that may have been present for some time

5. Recent laceration on the other leg

Correct Answer: 1,3,4

Rationale 1: Wounds generally become chronic because of repeated prolonged insults to the tissue.

Rationale 2: The patients lack of concern about the wound is not directly related to healing.

Rationale 3: Wounds generally become chronic because of inadequate blood supply in the tissue.

Rationale 4: Chronic infection may affect the ability to heal from chronic wounds and represents a disruptive underlying pathologic process.

Rationale 5: Recent trauma is associated with acute traumatic wounds and would not affect the status of the chronic wound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-2

Question 11

Type: MCMA

A nurse who works in a diabetes clinic is providing education regarding foot care to a group of patients and families. The nurse would make which statements to explain why these patients are at risk for foot ulcers?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You may not be able to feel injury to your feet.

2. Changes in your blood vessels decrease circulation to your feet.

3. Diabetes makes you clumsier.

4. Your body responds to infection more slowly than do those without diabetes.

5. Swelling associated with diabetes tends to make shoes and socks fit more tightly.

Correct Answer: 1,2,4

Rationale 1: Patients with diabetic neuropathy have reduced sensation in the feet.

Rationale 2: Macrovascular and microvascular changes decrease circulation.

Rationale 3: There is no indication that the patient with diabetes is any clumsier than other patients of the same age.

Rationale 4: The reason for the diabetics slow response to a wound or infection is not understood.

Rationale 5: There is no evidence that diabetes results in swelling of the feet.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-2

Question 12

Type: MCSA

The nurse is caring for a patient with a large wound on the right hip. What nursing measure is the most essential for the patient?

1. Keep the patient on continuous bed rest.

2. Encourage the patient to sit up in a chair as much as possible through the day.

3. Turn the patient from side to side every 2 hours.

4. Keep the patients weight off the right side.

Correct Answer: 4

Rationale 1: Unless a compromising factor exists, a large hip wound would not require complete bed rest.

Rationale 2: Prolonged chair sitting can be detrimental to wound healing, depending on where pressure is applied relative to the wound.

Rationale 3: Turning the patient from side to side is inappropriate; the patient would be lying on the wound half the time, creating pressure that would diminish the blood supply.

Rationale 4: Keeping pressure off the right hip is the essential nursing measure because pressure would decrease blood flow to the area. Blood flow is needed to get oxygen and nutrients to the area and heal the wound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-5

Question 13

Type: MCMA

The nurse is caring for a patient with a deep wound that has tunneling. Following the dressing change, what factors are essential for the nurse to document?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Amount of irrigation poured into the tunnel

2. Type of drainage coming from the wound

3. Size and shape of the tunnel

4. Direction and number of tunnels

5. Length of dressing needed to pack wound

Correct Answer: 2,3,4,5

Rationale 1: Irrigation fluid would not be poured into the tunnel during dressing changes.

Rationale 2: It is essential to document the type of drainage in order to assess for the presence of infection.

Rationale 3: The size and shape of the tunnel must be documented so the next person changing the dressing has that information as a guide.

Rationale 4: The number of tunnels and their direction must be documented so that the next person changing the dressing has that information as a guide.

Rationale 5: It is essential to document the length of dressing to provide information about the depth of the tunnel.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-4

Question 14

Type: MCMA

The nurse routinely uses a tracing graph of transparent film to assess the dimensions of wounds. What rationales would the nurse offer for this decision?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Using this film helps to document the shape of the wound.

2. Placement of this film helps to prevent infection from iatrogenic causes.

3. Having a visual representation of the wound offers a psychological boost to the patient.

4. These films help keep the wound dry.

5. These tracings show the progress of the wound surface contracture.

Correct Answer: 1,3,5

Rationale 1: Tracing graphs of transparent film, such as the E-Z Graph System of wound assessment, enable health care providers to outline the shape of the wound.

Rationale 2: Tracings are not left in place to prevent infection.

Rationale 3: For patients whose wounds are healing by millimeters, these tracings demonstrate the progress in wound healing and offer a great psychological boost

Rationale 4: Tracings are not used to keep wounds dry.

Rationale 5: Tracing graphs of transparent film, such as the E-Z Graph System of wound assessment, enable health care providers to track the progress of the wound surface contracture.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-4

Question 15

Type: MCMA

The nurse manager of a long-term care facility would institute which policies to be in compliance with federal tag 314?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Periodic resident care plan revisions

2. Transfer of resident with pressure ulcers to an acute care facility

3. Documentation of a plan to reduce the development of pressure ulcers

4. A plan to assess residents for their risk of pressure ulcers

5. A method of documenting adherence to facility pressure ulcer policies and procedures

Correct Answer: 1,3,4,5

Rationale 1: If a resident develops a pressure ulcer, F-tag 314 mandates periodic care plan revisions to reflect added interventions to treat the ulcer.

Rationale 2: There is no federal mandate that requires the resident be transferred to acute care if a pressure ulcer develops.

Rationale 3: Each long-term care facility must have documented prevention strategies to reduce the development of pressure ulcers.

Rationale 4: The long-term care facility must have a plan in place to assess residents for the risk of developing pressure ulcers.

Rationale 5: It is not enough to simply have plans in place. F-tag 314 requires a method to document adherence to those plans.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-6

Question 16

Type: MCSA

The nurse is caring for a young patient with a large wound on the arm from necrotizing fasciitis. Which statement should the nurse make to support the patients psychological adjustment to the wound?

1. I think this wound makes you look dashing.

2. What is the best time for you to have your dressing changed?

3. I told your mother that she probably shouldnt look at the wound yet.

4. Lets let your family participate in the next dressing change.

Correct Answer: 2

Rationale 1: The nurse should offer frank information about the appearance of the wound. This statement dismisses the patients concerns.

Rationale 2: Allowing the patient to set the time for the dressing change gives the patient some control over the situation.

Rationale 3: The patient should decide when others can look at the wound. The nurses statement suggests there is something about the wound that should be hidden.

Rationale 4: The nurse should provide privacy during dressing changes until the patient is ready to reveal the injury to others.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-6

Question 17

Type: MCSA

The nurse who is current on wound care research would consider which product to be antimicrobial when used in wound dressings?

1. Normal saline

2. Tap water

3. Topical gold

4. Topical silver

Correct Answer: 4

Rationale 1: Normal saline is used to cleanse wounds but is not antimicrobial.

Rationale 2: Tap water can be used to cleanse some wounds but is not antimicrobial.

Rationale 3: Gold is not a wound care product.

Rationale 4: Silver is a product that has come into wide use as a local antimicrobial agent. Its use continues to be a topic of research.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-7

Question 18

Type: MCSA

Wound breakdown after healing continues to be an issue with burn victims. Research into which topic would offer the most comprehensive interventions to help diminish this problem?

1. Techniques to reduce wound infection

2. Techniques to increase tensile strength

3. Methods to increase family participation in wound care

4. Methods to increase patient compliance with exercise routines

Correct Answer: 2

Rationale 1: Techniques to reduce wound infection would not offer the most comprehensive ways to reduce this problem.

Rationale 2: Wound breakdown is related to the tensile strength of the scar. Techniques to increase tensile strength would reduce wound breakdown.

Rationale 3: Family participation has no direct bearing on wound strength.

Rationale 4: Exercise routines may help with healing, but research into this area would not produce the most comprehensive interventions to help reduce wound breakdown.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-7

Question 19

Type: MCMA

A patient with a severe laceration was malnourished before the injury. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Encourage intake of vitamin Ccontaining foods.

2. Ensure that the patient consumes probiotic-enhanced dairy products.

3. Administer appropriate medications with a canned nutritional drink.

4. Restrict fluids that contain sodium.

5. Limit the fats in the patients diet.

Correct Answer: 1,3

Rationale 1: Water-soluble vitamins such as C and the B family are needed for wound healing.

Rationale 2: There is no indication that this patient requires probiotics.

Rationale 3: As long as there is no drugfood interaction, the nurse could offer a canned nutritional supplement drink when the patient takes oral medications.

Rationale 4: There is no specific reason to limit sodium-containing fluids.

Rationale 5: The patient must have fats to absorb fat-soluble vitamins.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-5

Question 20

Type: MCMA

A patient has a large scar on the leg from a laceration. What information would the nurse provide about these scars?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. This scar tissue is just as strong as any other skin on your body.

2. You need to protect this scar from trauma for about 3 or 4 months.

3. Do not expose the scar to intense sunlight.

4. It may take up to 2 years for this area to get as strong as it is going to.

5. Once the scar is present, epithelialization will begin.

Correct Answer: 3,4

Rationale 1: Scar tissue does not recover its full preinjury strength.

Rationale 2: Scar tissue should be protected from injury forever.

Rationale 3: Scar tissue should be protected from overexposure to the sun.

Rationale 4: The remodeling phase may take up to 2 full years.

Rationale 5: Epithelialization is the process by which the wound in closed. This forms a scar, which then undergoes additional maturation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-1

Question 21

Type: MCSA

A patient is admitted with an ulcer on the right great toe. The nurse determines that the blood pressure in the patients right arm is 138 systolic, the left arm is 136 systolic, the right ankle is 65 systolic, and the left ankle is 66 systolic. How does the nurse evaluate these readings?

1. The wound will require debridement.

2. The patient is getting adequate circulation to the feet.

3. This ulcer is not likely to heal.

4. The patient needs intravenous fluids to support intravascular volume.

Correct Answer: 3

Rationale 1: The need for debridement is determined by the appearance of the wound, not by blood pressure measurements.

Rationale 2: The right ankle-brachial index (ABI) is 0.47 and the left ABI is 0.49. Neither reading supports an evaluation of adequate circulation.

Rationale 3: An ankle-brachial index (ABI) of less than 0.5 indicates poor prognosis for healing. The patients right ABI is 0.47.

Rationale 4: The described assessment does not offer enough information to determine if IV fluids are needed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-2

Question 22

Type: MCSA

Assessment reveals that a female patient has 4+ pitting edema in both lower extremities. Both legs are reddened, with shiny spots, and the skin is dry and flaky. Which assessment finding would the nurse interpret as the best indicator of venous insufficiency?

1. Dry skin

2. Reddened color

3. Flaking skin

4. Shiny skin

Correct Answer: 2

Rationale 1: Dry skin can be caused by a variety of factors. This is not the best evidence of venous insufficiency.

Rationale 2: This reddened color is called hemosiderin stain and is a simple, noninvasive clue to venous insufficiency.

Rationale 3: Flaking skin can be caused by a variety of factors. This is not the best evidence of venous insufficiency.

Rationale 4: Shininess is related to the edema. This is not the best evidence of venous insufficiency.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-2

Question 23

Type: MCMA

A patient who has a slowly healing wound from a traumatic injury is prescribed an arginine supplement. What information would the nurse provide about this supplement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Arginine helps to build collagen for wound healing.

2. Arginine will help build blood supply to the injured area.

3. Arginine helps support the immune system.

4. Arginine is essential for coagulation.

5. Arginine decreases bacterial proliferation.

Correct Answer: 1,2,3

Rationale 1: Arginine is an amino acid that is essential for collagen accumulation.

Rationale 2: Arginine is an amino acid that produces nitric oxide, which is essential for angiogenesis.

Rationale 3: Arginine is an amino acid that supports immunity.

Rationale 4: Arginine does not contribute to clotting.

Rationale 5: Arginine does not affect bacterial proliferation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-2

Question 24

Type: FIB

A patient with diabetes presents with an ulcer on the end of the great toe. Assessment reveals gangrene extending to the base of the toe. The nurse would evaluate this ulcer as matching criteria for grade ____ on the Wagner Ulcer Grade Classification System.

Standard Text:

Correct Answer: 4

Rationale : Because there is gangrene in a portion of the forefoot, the ulcer is grade 4. If gangrene extended to involve more of the foot, the grade would be 5.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-2

Question 25

Type: MCMA

A patient has been admitted with a lower leg ulcer. Which findings would suggest to the nurse that care specific to a venous ulcer should be planned?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The area around the ulcer is crusted and edematous.

2. There is copious drainage from the wound.

3. The ulcer area has a punched-out appearance with defined margins.

4. The area around the wound is spongy.

5. The patient reports working in an occupation that requires lots of sitting.

Correct Answer: 1,2,4

Rationale 1: Crusting and edema are findings associated with venous ulcers.

Rationale 2: Venous ulcers tend to produce large amounts of drainage.

Rationale 3: Venous ulcers typically have margins that are not well defined.

Rationale 4: Maceration of the periwound tissue is common due to drainage.

Rationale 5: These ulcers are more common in people who have a history of standing for long periods.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 60-2

Question 26

Type: MCSA

A patient with very thin, fragile skin has just been resuscitated in the emergency department. During the resuscitation efforts, a dressing was taped over an IV site. How should the nurse remove this dressing?

1. Grasp the tape and pull sharply and quickly.

2. Rub the sides of the tape until it loosens.

3. Hold the skin down and gently pull the tape off.

4. Allow the tape to loosen over several days and remove it in sections.

Correct Answer: 3

Rationale 1: This action in a patient with thin and fragile skin will likely result in a skin tear.

Rationale 2: Rubbing the skin and tape will probably damage the skin.

Rationale 3: The nurse should brace the skin while removing the tape as gently as possible.

Rationale 4: Allowing the dressing to remain in place for several days increases the risk of infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-2

Question 27

Type: MCSA

A patient has a pressure ulcer on the ear where an oxygen cannula has been in place. The ulcer is shallow and long and has a black wound bed. How would the nurse stage this ulcer?

1. Stage II

2. Stage III

3. Stage IV

4. Unstageable

Correct Answer: 4

Rationale 1: Stage II is partial-thickness loss of dermis with a pink or red wound bed.

Rationale 2: Stage III is full-thickness tissue loss. Slough may be present, but the wound bed is visible.

Rationale 3: Stage IV is full-thickness loss with exposed bone, tendon, or muscle. The wound bed is visible.

Rationale 4: This wound in unstageable because the wound bed is covered in eschar. When eschar is removed, the wound will be stageable.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-3

Question 28

Type: FIB

The nurse has used the Braden Risk Assessment Scale to assess three newly admitted patients. The scores are 11, 15, and 17. The nurse prioritizes pressure ulcer prevention for the patient whose score is ________.

Standard Text:

Correct Answer: 11

Rationale : A Braden score of 11 indicates a high risk for pressure ulcer development. A score of 15 indicates low risk, and a score above 16 is very low to no risk.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-3

Question 29

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