Chapter 9 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 9

Question 1

Type: MCSA

Assessment of the patients sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner?

1. Tertiary intention

2. Primary intention

3. Secondary intention

4. Recurrent surgical debridement

Correct Answer: 3

Rationale 1: Tertiary intention combines primary and secondary intention, often requiring the wound to be left open for a period of time, such as a few days.

Rationale 2: Primary intention healing occurs when the wound is closed and heals without interruption.

Rationale 3: This wound has dehisced, which means that it has not healed as expected and the suture line is opened. This may occur because of stretching of the skin, poor skin integrity, or because the wound is infection. Dehisced sternal wounds are allowed to heal by second intention.

Rationale 4: Future surgical debridement may be necessary if the wound does not heal, but this is not an expected part of the plan of care.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-2

Question 2

Type: MCSA

A patient is to receive pulsatile lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment?

1. This treatment is a form of autolytic debridement to remove dead tissue from your heel.

2. Your foot will be submersed in a whirlpool tub for this treatment.

3. This treatment will help cleanse the wound bed.

4. This treatment will inject medications into the deep crevices of your wound.

Correct Answer: 3

Rationale 1: Pulsatile lavage is not a form of autolytic debridement.

Rationale 2: Whirlpool tubs are not used for pulsatile lavage. Whirlpool treatments increase risk of cross contamination of the wound.

Rationale 3: Pulsatile lavage is used to clean materials out of the wound bed.

Rationale 4: Pulsatile lavage is not used to inject medications into the wound.

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: 9-5

Question 3

Type: MCSA

The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound?

1. Hydrocolloid dressing

2. Wet-to-dry dressing

3. Alginate dressing

4. Dry, sterile dressing

Correct Answer: 4

Rationale 1: Hydrocolloid dressings are used on moderate to heavily exudating wounds. This wound is dry.

Rationale 2: Wet-to-dry dressings are used for wounds that are healing by second intention.

Rationale 3: Alginate dressings are used to absorb secretions and form a covering for the wound bed. This wound bed is dry.

Rationale 4: The patients wound is healing by primary intention. Dry, sterile dressings are the standard for wounds healing by this method, offering protection from contamination and the absorption of the minimal amount of exudate expected.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-5

Question 4

Type: MCMA

A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patients risk of complications with wound healing?

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

Standard Text: Select all that apply.

1. The patient smokes eight cigarettes a day.

2. The patient has peripheral artery disease.

3. The patient has osteoarthritis in his knees.

4. The patients average blood sugar measurements are over 200mcg/dL.

5. The patient lost some blood during the injury but the loss was not excessive.

Correct Answer: 1,2,4

Rationale 1: Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also associated with significantly higher infection rates.

Rationale 2: Peripheral artery disease decreases oxygenation of the tissues, increasing risk of complications.

Rationale 3: The presence of osteoarthritis is related to overuse of the joint and is not a significant risk factor for problems healing.

Rationale 4: Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is a factor in healing problems.

Rationale 5: Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues, leading to difficulties with healing.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-3

Question 5

Type: MCSA

There is dead tissue throughout the patients nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal?

1. Diet analysis for protein adequacy

2. Keeping the wound covered to increase oxygen to the wound bed

3. Debridement of devitalized tissue

4. Introduction of air into the wound for drying

Correct Answer: 3

Rationale 1: The patient does need adequate protein in order for healing to occur, but this is not the most problematic issue at present.

Rationale 2: Keeping the wound covered does help to maintain oxygen levels in the wound bed, but this is not the most problematic issue present.

Rationale 3: The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is tissue that has been separated from the circulation and the bodys antimicrobial defenses. Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is essential to prevent an environment conducive to bacterial growth.

Rationale 4: The wound bed should be kept moist.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-5

Question 6

Type: MCSA

The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?

1. Encourage the patient to ingest more fluids.

2. Assess for pain and warmth.

3. Cover the wound with a sterile dry dressing.

4. Dress the wound as prescribed.

Correct Answer: 2

Rationale 1: Encouraging fluids will not reduce the inflammation that is occurring in the wound.

Rationale 2: The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patients wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected.

Rationale 3: Covering the wound with a sterile dry dressing will not address the potential for infection that exists.

Rationale 4: Simply dressing the wound according to previous order will not address the change that has occurred.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-2

Question 7

Type: MCSA

The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important?

1. Wear gloves at all times.

2. Administer antibiotics as prescribed.

3. Assess patients for infection risk upon admission.

4. Follow hand washing protocols.

Correct Answer: 4

Rationale 1: Wearing gloves at all times could increase infection rate by creating a false sense of security among staff. If other infection control methods are not used, the constant presence of gloves could increase cross-contamination.

Rationale 2: Antibiotics should be given as prescribed, but this is not the most important intervention.

Rationale 3: Knowing which patients are at highest risk for infection is helpful, but is not the most critical intervention.

Rationale 4: Correct hand washing is still considered one of the most important methods of preventing wound infections.

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: 9-6

Question 8

Type: MCMA

A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the health care provider about possible necrotizing fasciitis (NF)?

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

Standard Text: Select all that apply.

1. Blood pressure is 140/90 mm Hg.

2. The patient reports recently taking steroids for a severe ear infection.

3. The patient works in an elementary school.

4. The patient reports pain as a 9 on the 1 to 10 pain scale.

5. The patients body mass index is 31.

Correct Answer: 2,4,5

Rationale 1: If the patient is in pain this blood pressure would not be unexpected.

Rationale 2: Steroid use increases the risk for necrotizing fasciitis.

Rationale 3: Exposure to young children is not a risk factor for developing necrotizing fasciitis.

Rationale 4: Pain that is out of proportion to the physical clinical presentation is an important warning sign of NF.

Rationale 5: A body mass index (BMI) over 30 indicates obesity. Obesity is a risk factor for development of NF.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-7

Question 9

Type: MCSA

A male patient tells the nurse that he has excruciating pain in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patients perineum below the scrotal sac. What nursing intervention is priority?

1. Have the wound further evaluated for possible Fourniers gangrene.

2. Apply ice to the region.

3. Give the patient prn acetaminophen.

4. Place a scrotal support on the patient.

Correct Answer: 1

Rationale 1: The one clinical symptom of Fourniers gangrene is pain out of proportion to the wound. The other clinical symptom is that this type of disorder affects males more than females. These two pieces of information should lead the nurse to contact the patients physician for further evaluation of the wound for possible Fourniers gangrene. The patient did have an indwelling urinary catheter removed a few days ago and this type of disorder is associated with genitourinary procedures or manipulation.

Rationale 2: Applying ice to the region is not indicated.

Rationale 3: The nurse would treat the patients pain, but a different intervention is the priority.

Rationale 4: There is no indication that use of a scrotal support would relieve this patients pain or change the underlying reason for the pain.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-7

Question 10

Type: MCSA

A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patients wound?

1. Irrigating the wound twice daily before applying dry dressing

2. Caring for a split thickness skin graft

3. Applying wet-to-dry dressings

4. Caring for a suture line created by surgical closure of the wound

Correct Answer: 2

Rationale 1: Granualtion tissue should be kept moist.

Rationale 2: Once systemic manifestations of the infectious process associated with necrotizing fasciitis disappear, healthy granulation tissue appears. The next phase is to restore dermal and fascial integrity and the best way to achieve wound closure rapidly and safely is with split thickness skin grafts. Skin is taken from a donor site and placed on healthy granulation tissue to cover the defect.

Rationale 3: The wounds associated with necrotizing fasciitis are large and would not easily be treated with wet-to-dry dressings.

Rationale 4: This wound will be extensive and is not closed in the normal manner of creating a suture line.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-7

Question 11

Type: MCSA

A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)?

1. Diagnosis of type 2 diabetes mellitus

2. Daily use of NSAIDs for arthritis symptoms

3. Diagnosis of peripheral vascular disease

4. History of radiation therapy to treat colon cancer

Correct Answer: 4

Rationale 1: While diabetes mellitus can result in impaired healing, it is not a specific risk for development of ECF.

Rationale 2: There is no specific connection between use of NSAIDs and increased risk for ECF.

Rationale 3: Peripheral vascular disease can result in problems with skin integrity, but is not a specific risk for development of ECF.

Rationale 4: Radiation therapy to the abdomen increases the patients risk for development of ECF.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-7

Question 12

Type: MCSA

The patients colectomyincision is red and the skin around the sutures is taut and shiny. What nursing intervention is indicated?

1. Assess for the presence of drainage or odor.

2. Clean this healing wound and redress as ordered.

3. Collaborate with the health care provider regarding suture removal.

4. Instruct the patient to use additional splinting for deep breathing and coughing.

Correct Answer: 1

Rationale 1: Since this patients surgical wound is closed with sutures the nurse should assess for the odor of GI contents or for seepage around the sutures. If this finding is present and enterocutaneous fistula may be present.

Rationale 2: These findings do not indicate a healing wound.

Rationale 3: These findings are not those normally associated with a wound ready for suture removal.

Rationale 4: These findings do not indicate stress from coughing and they will not be changed by additional splinting.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-7

Question 13

Type: MCSA

A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care for this wound with the knowledge that it has penetrated to which skin level?

1. Epidermis

2. Hypodermis

3. Dermis

4. Cartilage

Correct Answer: 2

Rationale 1: The epidermis, the outermost layer, contains epithelial cells.

Rationale 2: The hypodermis contains blood vessels, nerves, muscle, and adipose tissue.

Rationale 3: The dermis contains connective tissue and elastic fibers, sensory and motor nerve endings, and a complex network of capillary and lymphatic vessels and muscles.

Rationale 4: Cartilage is not a layer of the skin.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-1

Question 14

Type: MCSA

The nurse measures a patients wound diameter and notes that it has reduced in size. The nurse evaluates this information to indicate the wound has entered which phase?

1. Remodeling

2. Inflammatory

3. Maturation

4. Proliferative

Correct Answer: 4

Rationale 1: The remodeling phase is the third phase of the wound healing process occurs after the wound has closed.

Rationale 2: The inflammatory phase prepares the wound environment for subsequent tissue development. This sign is recognized by the four cardinal signs of inflammation: heat, redness, swelling, and pain.

Rationale 3: The maturation stage is also known as the remodeling stage.

Rationale 4: Wound contraction occurs during the proliferative phase of wound healing.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-2

Question 15

Type: MCSA

A patient with several burn scars tells the nurse that the scars are prone to injury and dont seem as tough as the rest of his skin. Which nursing response is indicated?

1. Even when healed, the scar will only regain about 80% of the strength of normal skin.

2. Your body is still making new blood vessels for the wound.

3. Your body is trying to remove additional bacteria from the wound area.

4. Your healing process hasnt been completed.

Correct Answer: 1

Rationale 1: Remodeling/maturation is the final repair process and can last months to years. The final product of remodeling is the scar, which has covered the defect and restored the protective barrier against the external environment. Even when the wound is completely healed, only about 80% of the tensile strength of normal skin is regained and the patient is at risk for recurrent breakdown.

Rationale 2: Angiogenesis takes place in the proliferative stage of wound healing, not after scars have developed.

Rationale 3: Bacterial are normally removed from the wound during the inflammatory phase.

Rationale 4: The patients healing process may take months or years, but this is not the best answer to address the patients concerns.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-2

Question 16

Type: MCSA

The nurse is assessing a wound using the technique shown in this picture. How would the nurse document this assessment?

1. The wound is macerated.

2. The wound is tunneled.

3. The wound is deep.

4. The wound is filled with exudate.

Correct Answer: 2

Rationale 1: Maceration is a white, pale or boggy appearance or texture caused by prolonged contact with moisture.

Rationale 2: The nurse has inserted a sterile applicator under the rim of the wound and a significant distance into the surrounding tissue. This is called tunneling.

Rationale 3: The nurse is not measuring depth of wound in this picture.

Rationale 4: The nurse is not measuring amount of exudate in this picture.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-4

Question 17

Type: MCMA

A nurse documents a stage 1 pressure ulcer on a patients lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II?

Standard Text: Select all that apply.

1. The subcutaneous fat layer is exposed.

2. A fluid-filled blister is present.

3. A shallow open ulcer is present.

4. There is an area of boggy purple skin on the bony prominence.

5. There is an area of skin that does not turn white with pressure.

Correct Answer: 2,3

Rationale 1: Exposure of the subcutaneous fat layer occurs in stage III ulcers.

Rationale 2: Presence of a fluid-filled blister indicates a stage II ulcer.

Rationale 3: Shallow open ulcers are stage II ulcers.

Rationale 4: Boggy purple skin over a bony prominence is a deep-tissue injury.

Rationale 5: Nonblanchable erythema indicates a stage I ulcer.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-9

Question 18

Type: MCSA

The wound care specialist has assessed a patients pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer?

1. Stage I

2. Stage II

3. Stage III

4. Stage IV

Correct Answer: 4

Rationale 1: Stage I ulcers are treated with turning and removal of pressure.

Rationale 2: Stage II ulcers need a moist environment but not debridement.

Rationale 3: Stage III ulcers need a moist environment but not debridement.

Rationale 4: Stage IV ulcers may require debridement as well as packing to fill dead space and to absorb exudate.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-9

Question 19

Type: MCMA

During initial assessment the nurse notes that the edges of a wound are hard to palpation. The nurse would continue assessment for which conditions?

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

Standard Text: Select all that apply.

1. Infection

2. Necrosis

3. Osteomyelitis

4. Deep tissue injury

5. Maceration

Correct Answer: 1,2,4

Rationale 1: Indurated wound edges may indicate infection.

Rationale 2: Indurated edges may indicate necrosis.

Rationale 3: Osteomyelitis is considered when bone is visible or palpable.

Rationale 4: Indurated wound edges may occur when there is deep tissue injury.

Rationale 5: Maceration is softening of the skin associated with chronic exposure to moisture.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-4

Question 20

Type: MCSA

The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection. Which nursing intervention is indicated?

1. Draw peak and trough concentrations as indicated.

2. Give the medication over a 2-hour period.

3. Hold the medication if the patient experiences nausea.

4. Monitor for increase in creatinine clearance.

Correct Answer: 1

Rationale 1: Gentamicin has a narrow therapeutic range. Peak and trough concentrations should be drawn.

Rationale 2: There is no indication that it is necessary to give this medication over 2 hours.

Rationale 3: There is no indication that nausea will require interrupting therapy.

Rationale 4: Decreased creatinine clearance is the adverse effect associated with gentamicin.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-6

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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