Week 3 practice questions
A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight redness at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make?
a. The patient has a normal inflammatory response.
b. The abdominal incision shows signs of an infection.
c. The abdominal incision shows signs of impending dehiscence.
d. The patient’s health care provider must be notified about their condition.
The nurse assessing a patient with a chronic leg wound finds redness and edema. The patient reports pain at the wound site. What would the nurse expect to be ordered to assess the patient’s systemic response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of the center of the wound
d. Culture and sensitivity of the wound
A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature?
a. Using a cooling blanket while the patient is febrile
b. Giving antipyretics on an around-the-clock schedule
c. Providing increased fluids and have the AP give sponge baths
d. Giving prescribed antibiotics and placing warm blankets for comfort
A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist gauze dressings. How would the nurse expect healing to occur?
a. Cell regeneration
b. Tertiary intention
c. Secondary intention
d. Remodeling of tissues
Which patient has the greatest risk for delayed wound healing?
a. A 65-year-old woman with stress incontinence
b. A 52-year-old obese woman with type 2 diabetes
c. A 78-year-old man who has a history of hypertension
d. A 30-year-old man who drinks 2 alcoholic beverages per day
Which order should a nurse question in the plan of care for an older adult, immobile stroke patient with a pink, clean stage 3 pressure injury?
a. Pack the wound with foam dressing.
b. Turn and position the patient every hour.
c. Clean the wound daily with a cytotoxic solution.
d. Assess for pain and medicate before dressing change.
An 85-year-old patient has a score of 16 on the Braden Scale. What should the nurse include in the plan of care?
a. Implementing a 1-hour turning schedule with skin assessment.
b. Elevating the head of the bed 90 degrees when the patient is supine.
c. Continuing with weekly skin assessments with no special precautions.
d. Placing a silicone foam dressing on the patient’s sacrum to prevent breakdown.
Which patients are at most risk for pressure injuries? (select all that apply)
a. A patient with right sided-paralysis and fecal incontinence
b. An older adult who is alert and needs assistance to ambulate
c. A young adult patient with paraplegia after a gunshot wound
d. A morbidly obese patient who has an open abdominal wound
e. An ambulatory patient who has occasional stress incontinence
f. A young adult with a tibial fracture from a motor vehicle accident
An 82-year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 × 2 × 0.8 cm, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?
a. stage 1
b. stage 2
c. stage 3
d. stage 4
The nurse provides diligent skincare because the primary function of the skin is
a. insulation.
b. protection.
c. sensation.
d. absorption.
Age-related assessment findings of the hair and nails include (select all that apply)
a. oily scalp.
b. scaly scalp.
c. thinner nails.
d. thicker, brittle nails
e. longitudinal nail ridging.
When assessing the nutritional-metabolic pattern in relation to the skin, the nurse asks the patient about
a. joint pain.
b. the use of moisturizing shampoo.
c. recent changes in wound healing.
d. self-care habits related to daily hygiene.
The nurse assessed a patient’s skin lesions as firm, edematous, and irregularly shaped with a variable diameter. They would be called
a. wheals.
b. papules.
c. fissures.
d. plaques.
During the physical assessment of a patient’s skin, the nurse would
a. use a flashlight in a poorly lit room.
b. note cool, moist skin as a normal finding.
c. pinch up a fold of skin to assess for turgor.
d. perform a lesion-specific assessment and then a general inspection.
Patients with dark skin are more likely to develop
a. keloids.
b. wrinkles.
c. skin rashes.
d. skin cancer.
On inspection of a patient’s dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called
a. vitiligo.
b. intertrigo.
c. Nevus of Ota.
d. telangiectasia.
Diagnostic testing is recommended for skin lesions when
a. a health history cannot be obtained.
b. a more definitive diagnosis is needed.
c. percussion reveals an abnormal finding.
d. treatment with prescribed medication has failed.
Which safe sun practices would the nurse include in a teaching plan for a patient with photosensitivity? (select all that apply)
a. Wear protective clothing
b. Apply sunscreen liberally and often.
c. Emphasize the short-term use of a tanning booth.
d. Avoid exposure to the sun, especially during midday
e. Wear any sunscreen that is available from the drugstore
When teaching a patient with melanoma, the nurse recognizes that the patient’s prognosis is most dependent on
a. the thickness of the lesion.
b. the degree of asymmetry in the lesion.
c. the amount of ulceration in the surrounding skin.
d. how much color variation is present in the lesion.
The nurse determines that a patient with which disorder is most at risk for spreading the disease?
a. Tinea pedis
b. Impetigo on the face
c. Candidiasis of the nails
d. Psoriasis on the palms and soles
A mother and her children have been diagnosed with pediculosis corporis at a health care center. An appropriate treatment is
a. applying pyrethrins to the body.
b. topical application of griseofulvin
c. moist compresses applied frequently.
d. administration of systemic antibiotics.
A common site for the lesions caused by atopic dermatitis is the
a. buttocks.
b. temporal area.
c. antecubital space.
d. plantar surface of the feet.
During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient’s knees and elbows. You would describe this finding as
a. lentigo.
b. psoriasis.
c. actinic keratosis
d. seborrheic keratosis.
In teaching a patient who is using topical corticosteroids to treat acute dermatitis, the nurse should tell the patient that (select all that apply)
a. the cream form is the most efficient system of delivery.
b. short-term topical corticosteroid use usually does not cause systemic side effects
c. use a glove to apply a large amount of topical ointment to prevent further infection.
d. abruptly stopping the use of topical corticosteroids may cause the dermatitis to reappear.
e. systemic side effects from topical corticosteroids are likely if the patient is malnourished.
Important patient teaching after a chemical peel includes
a. avoidance of sun exposure.
b. application of firm bandages.
c. limitation of vigorous exercise.
d. use of moist heat to relieve discomfort.
Which instruction would the nurse provide to prevent burn injuries?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended.
Which wound description indicates a need for excision and grafting? (select all that apply)
a. Red, painful blisters
b. Leathery, brown, exposed tendon
c. Pearly white color, insensitive to pain, dry
d. Charred eschar, visible thrombosed blood vessels
e. Large, fluid-filled vesicles, moderate edema, moist, red
Estimate the total body surface area burn injury using the rule of 9’s. Burns involve the entire right arm and upper back. _____%
18%
23%
42%
55%
A patient is hospitalized with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. The respiratory therapist applied a non-rebreather mask. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Respiratory rate is 6/min. Oxygen saturation decreases to 88%. The patient is unresponsive. What is the priority nursing intervention?
a. Notify the HCP and get ready for intubation.
b. Encourage the patient to cough and auscultate the lungs again.
c. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.
d. Document the findings and continue to monitor the patient’s breathing.
Which lab result supports the need for additional IV fluid to treat burn shock?
a. Hematocrit 52%
b. Sodium 137 mEq/L
c. WBC 12.5 × 109/L
d. Potassium 3.4 mmol/L
What nutrition intervention may promote wound healing for a patient with a 10% burn injury?
a. Eat a high-protein, high-carbohydrate diet
b. Increase normal caloric intake by about 4 times
c. Eat at least 1500 calories/day in small, frequent meals
d. Eat a lactose-free diet to reduce the potential for diarrhea
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. What is the most important nursing intervention following surgery?
a. Wash the wound with soap and water 3 times a day.
b. Medicate for pain relief in between dressing changes.
c. Reapply a new dressing without disturbing the wound bed.
d. Assess the wound for signs of infection during dressing changes.
What nursing interventions can be used to manage burn pain? (select all that apply)
a. Suggest pain management options.
b. Use a pain-rating tool to monitor the patient’s level of pain.
c. Delay painful dressing changes until the patient’s pain is completely relieved.
d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics).
e. Provide nonpharmacologic therapies (e.g., music therapy, distraction) to replace opioids in the acute phase of a burn injury.
What intervention prevents hypertrophic scarring during the rehabilitation phase of burn recovery?
a. Applying pressure garments
b. Repositioning the patient every 2 hours
c. Performing active ROM at least every 4 hours
d. Applying a water-based moisturizer to healed skin
A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse would take when meeting with the patient would be to
a. arrange a return-to-clinic appointment and prescription for pain medications.
b. give the patient written information and websites resources for burn survivors.
c. teach the patient and the caregiver proper wound care to be performed at home.
d. review the patient’s current health care status and readiness for discharge to home.
The bone cells that function in the formation of new bone tissue after a patient sustains a fracture are called
a. osteoids.
b. osteocytes.
c. osteoclasts.
d. osteoblasts.
When performing passive range of motion for a patient, the nurse puts the elbow joint through the movements of (select all that apply)
a. flexion and extension.
b. inversion and eversion.
c. pronation and supination.
d. flexion, extension, abduction, and adduction.
e. pronation, supination, rotation, and circumduction.
A patient with a torn ligament in the knee asks what the ligament does. The nurse would respond that ligaments
a. connect bone to bone.
b. provide strength to muscle.
c. lubricate joints with synovial fluid.
d. relieve friction between moving parts.
The increased risk for falls in the older adult is likely due to (select all that apply)
a. changes in balance.
b. decrease in bone mass.
c. loss of ligament elasticity
d. erosion of articular cartilage.
e. decrease in muscle mass and strength.
The nurse obtained a health history of a patient with a fracture. Which problem, if reported by the patient, would most concern the nurse?
a. Diabetes
b. Hypertension
c. Chronic bronchitis
d. Nephrotic syndrome
When grading muscle strength, the nurse records a score of 3/5, which indicates
a. no detection of muscular contraction.
b. a barely detectable flicker of contraction.
c. active movement against full resistance without fatigue.
d. active movement against gravity but not against resistance. *
An abnormal assessment finding of the musculoskeletal system is
a. equal leg length bilaterally.
b. ulnar deviation and subluxation.
c. full range of motion in all joints.
d. muscle strength of 5/5 in all muscles.
A patient is scheduled for a bone scan. The nurse explains that this diagnostic test involves
a. incision or puncture of the joint capsule.
b. insertion of small needles into certain muscles.
c. administration of a radioisotope before the procedure.
d. placement of skin electrodes to record muscle activity.
The nurse in urgent care suspects an ankle sprain when a patient describes
a. being hit by another soccer player during a game.
b. having ankle pain after sprinting around the track.
c. dropping a 10-lb weight on his lower leg at the health club.
d. twisting his ankle while running bases during a baseball game.
A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by
a. formation of callus
b. complete bony union
c. hematoma at the fracture site.
d. presence of granulation tissue.
A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when
a. the patient cannot tolerate prolonged immobilization.
b. the patient cannot tolerate the surgery for a closed reduction.
c. other nonsurgical methods cannot achieve adequate alignment
d. a temporary cast would be too unstable to provide normal mobility.
The nurse suspects a neurovascular problem based on assessment of
a. exaggerated strength with movement.
b. increased redness and heat below the injury.
c. decreased sensation distal to the fracture site.
d. purulent drainage at the site of an open fracture.
A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects early compartment syndrome when the patient has
a. increasing edema of the limb.
b. muscle spasms of the lower arm.
c. bounding pulse at the fracture site.
d. pain when passively extending the fingers.
The nurse would monitor a patient with a pelvic fracture for
a. changes in urine output.
b. petechiae on the abdomen
c. a palpable lump in the buttock.
d. sudden increase in blood pressure.
The nurse teaches the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes
a. hip flexion contracture.
b. clot formation at the incision.
c. skin irritation and breakdown.
d. increased risk for wound dehiscence.
A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid
a. lifting heavy objects
b. sleeping on the back.
c. abduction exercises of the affected ankle.
d. bearing weight on the affected leg for 6 weeks
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