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    Exam Review

    1. The nurse is using the Braden scale to assess the client's risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.)
      (SATA)
      A)
      Friction and shear
      B)
      Activity
      C)
      Sensory perception
      D)
      Cognition
      E)
      Moisture
    2. The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing? (Select all that apply.)
      (SATA)
      A)
      A client who has diabetes.
      B)
      A client who is obese and sweats excessively.
      C)
      A client on bed rest who is repositioned.
      D)
      A client on long-term steroid therapy.
      E)
      A client with COPD.
    3. It is suspected that a client is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply)
      (SATA)
      A)
      White blood cell count 13,000 mm3 (elevated).
      B)
      Wound edges pink to normal skin color.
      C)
      Increased complaints of pain at wound site.
      D)
      Yellow-tinged drainage.
      E)
      Temperature 100.3° F (37.94° C).
      F)
      Foul odor noted from previous dressing.
    4. The nurse knows what goal to be appropriate for a client with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?
      A)
      Client will consume adequate nutrition to meet nutritional requirements within 1 week.
      B)
      Client will report pain management strategies and reduce pain to a tolerable level.
      C)
      Client will be able to assist with position changes using over bed trapeze within 1 week.
      D)
      Client will remain free of wound infections during the hospitalization.
    Page 1 of 4

    Exam Review

    1. The nurse may use clean gloves for changing the dressing on which of the following?
      A)
      Sterile gloves should always be used for dressing changes performed in the hospital setting.
      B)
      Sterile gloves should always be used for dressing changes performed by nurses.
      C)
      Surgical wound.
      D)
      Chronic pressure injury.
    2. Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.)
      (SATA)
      A)
      A BMI (body mass index) of 35 (elevated)
      B)
      A serum albumin of 2.9 g/dl (decreased)
      C)
      Fasting blood glucose of 215 mg/dl (elevated)
      D)
      A white blood cell count of 7000 per mm3 (normal)
      E)
      A hemoglobin of 10.0 g per dL (decreased)
    3. The nurse is caring for a post-operative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?
      A)
      Put pressure on the wound with a sterile gauze pad.
      B)
      Cover the wound with a sterile gauze pad.
      C)
      Cover the wound with a transparent dressing.
      D)
      Cover the wound with gauze soaked with normal saline.
    4. The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection?
      A)
      Two to three days after injury.
      B)
      During the first 24 to 48 hours after injury.
      C)
      Up to 5 days after injury.
      D)
      Five to seven days after injury.
    Page 2 of 4

    Exam Review

    1. The nurse is caring for a client who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the client is experiencing a complication of wound healing?
      A)
      Client reporting, "My incision is hurting."
      B)
      Approximation of the incision edges has occurred.
      C)
      Client asks, "Why has my incision started to itch?"
      D)
      The incision appears both swollen and bluish in color.
    2. How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?
      A)
      By keeping the drain lower than the insertion site.
      B)
      By turning the suction on.
      C)
      By compressing the drain reservoir.
      D)
      By "milking" the tubing.
    3. The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcome? Select all that apply
      A)
      The client's expectations are not being met.
      B)
      No injuries to the skin and tissues are evident.
      C)
      Granulation tissue is present.
      D)
      Skin is intact with no redness or swelling.
      E)
      Non-blanchable erythema is absent.
    4. The nurse is caring for a postoperative orthopedic client who has two Hemovac drains in place. Which interventions will the nurse perform? (Select all that apply)
      A)
      Recompress the device after emptying.
      B)
      Secure the device to the client's gown above the level of the wound.
      C)
      Check for kinks in the tubing.
      D)
      Label each drain and record them separately.
      E)
      Measure the amount of drainage in the device prior to emptying.
    Page 3 of 4

    Exam Review

    1. The nurse is teaching the unlicensed assistive personnel (UAP) in a nursing home about daily routine measures to reduce the incidence of pressure injuries within the agency. Which of the following should the nurse include in the teaching? (Select all that apply.)
      A)
      Positioning a client in the 30-degree lateral position.
      B)
      Decreasing clients' fluid intake to decrease incidence of incontinence.
      C)
      Rubbing reddened bony prominences.
      D)
      Using a turn sheet to reposition clients.
      E)
      Turning clients at least every 2 hours. Use of pillow bridging when needed.
    2. The nurse is performing a dressing change on a client who is postoperative from a laparotomy. The client coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?
      A)
      Apply sterile saline-soaked towels to the area.
      B)
      Instruct the client to avoid looking at the wound.
      C)
      Assess the wound to determine the extent of evisceration.
      D)
      Apply sterile gloves and push the intestines back into the wound.
    3. When the nurse is caring for a client with a Penrose drain, what care needs to be carried out?
      A)
      The suction pulls drainage away from the wound as it re-expands.
      B)
      The drain is not sutured in place so care is taken to not dislodge it.
      C)
      The drain must be connected to suction if ordered.
      D)
      The drain must be compressed after emptying to work properly.
    Page 4 of 4