Clients With Wounds

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Question 1
Free
Multiple Choice

The nurse predicts that the wound capable of becoming "ideally healed" is a(n)

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A

abdominal incision.

B

burn scar on the leg.

C

cancerous lesion on the inside of the cheek.

D

severe acne on the face.

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Question 2
Free
Multiple Choice

A client has a chronic, nonhealing ulcer on the lower leg. The nurse thinks the client could benefit from negative-pressure wound therapy. The most appropriate action by the nurse would be to

Choose correct answer/s
A

ask the charge nurse to discuss the matter with the physician.

B

call the physician and request an order for a negative pressure machine.

C

keep track of supplies used currently to estimate the cost of continuing the present regimen.

D

request the physician write an order to consult the wound care nurse.

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Question 3
Free
Multiple Choice

A nurse is changing a dressing over a client's abdominal surgical incision. Which action by the nurse is most important?

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A

Apply dressings using aseptic or sterile technique.

B

Irrigate the wound with copious amounts of solution.

C

Use strict sterile technique, including sterile gloves.

D

Wash the suture line carefully to remove debris.

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Question 4
Free
Multiple Choice

The edges of a client's appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client's wound record that the incision appears to be healing by

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A

granulation.

B

primary intention.

C

secondary intention.

D

tertiary intention.

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Question 5
Free
Multiple Choice

The nurse who is using an enzymatic debridement ointment will

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A

apply the ointment liberally over large areas.

B

keep the area moist after application.

C

medicate the client before applying ointment to viable tissue.

D

use the ointment cautiously on neoplastic ulcers.

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Question 6
Multiple Choice

A frail client with multiple chronic medical conditions has a chronic, infected, malodorous wound. The client begins to cry when the nurse tries to explain to the client an aggressive approach to wound care. The nurse should revise the plan to focus on

Choose correct answer/s
A
better pain control so the client can tolerate the aggressive therapy.
B
palliative care and quality of life.
C
the client's emotional barrier to the recommended treatment.
D
the possibility of eventual amputation.
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Question 7
Multiple Choice

A client must do dressing changes at home on a clean, but open, surgical wound. The nurse determines that goals for discharge instructions have been met when the client says:

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A
"I will be sure to keep the skin surrounding the wound dry."
B
"I will sit under a heat lamp for 30 minutes a day to help dry up the drainage."
C
"If I run out of saline, I can irrigate the wound with half strength peroxide."
D
"Pulling out the dried up dressings will help clean the wound out."
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Question 8
Multiple Choice

A client with an open wound develops a temperature of 99.8° F. The most appropriate action by the nurse is to

Choose correct answer/s
A
administer an antipyretic.
B
continue to monitor the client's temperature.
C
cool the client's environment.
D
keep the client warm.
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Question 9
Multiple Choice

A nurse is caring for a client with a chronic lower leg wound caused by venous insufficiency. Which action by the nurse is most appropriate?

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A
Apply ice to the surrounding tissue.
B
Elevate the leg and apply compression stockings.
C
Keep the leg in one position to avoid further injury.
D
Position the leg flat with heels elevated off the bed.
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Question 10
Multiple Choice

On removing a dressing from a client on the third postoperative day, the nurse notes thin, pink-colored drainage and documents this as

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A
serous.
B
sanguineous.
C
serosanguineous.
D
purulent.
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Question 11
Multiple Choice

When caring for a client with a wound healing by secondary intention, the nurse considers during care planning that this type of wound is

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A
healed with skin grafts.
B
prone to dehiscence.
C
sealed with sutures.
D
susceptible to infection.
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Question 12
Multiple Choice

A nurse is caring for four clients. Which client should the nurse assess first? The client with a/an

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A
eviscerated abdominal wound from surgery yesterday.
B
infected lower leg ulcer and diabetes, who needs a blood sugar measurement.
C
large open infected wound and temperature of 99.9° F.
D
operative incision covered with a clean, dry dressing from surgery 8 hours ago.
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Question 13
Multiple Choice

A client is being discharged with a large wound on the right ankle that has cellulitis. The client is obese, smokes 2 packs of cigarettes a day, and is sedentary. In the discharge instructions, which lifestyle modification would be most important for the nurse to include? The client should

Choose correct answer/s
A
drink more water.
B
lose weight.
C
start an exercise routine.
D
stop smoking.
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Question 14
Multiple Choice

To assist in the healing of a large leg ulcer, the nurse applies wet dressings to the wound to promote

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A
angiogenesis.
B
chemotaxis.
C
epithelialization.
D
wound contraction.
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Question 15
Multiple Choice

A client has a large, sacral pressure ulcer with a red wound base and no drainage. Which solution would the nurse select as the most appropriate solution for cleansing this wound?

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A
A weak iodine solution
B
Dakin's solution
C
Half-strength hydrogen peroxide
D
Normal saline
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Question 16
Multiple Choice

The nurse caring for a client receiving wet-to-dry dressings for mechanical debridement of a large wound would be aware that proper technique requires that the dressing should

Choose correct answer/s
A
be left in place about 12 hours.
B
be removed when it is totally dry.
C
cause slight bleeding when removed to be effective.
D
only be moist, not wet, when applied.
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Question 17
Multiple Choice

On a client's admission to the hospital, the nurse notes that the client has a yellow sacral decubitus ulcer. The nurse anticipates that the most appropriate wound treatment would be

Choose correct answer/s
A
applying antibiotic ointment.
B
surgical removal of eschar.
C
using wet-to-dry dressings.
D
vigorous cleansing with a Water Pik.
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Question 18
Multiple Choice

A client has a small, shallow wound with a red base that does not require debridement. The dressing the nurse would choose when covering this wound is a

Choose correct answer/s
A
dry woven gauze fastened with adhesive tape.
B
non-adhering dressing with antibiotic ointment.
C
wet nonwoven gauze.
D
wet-to-dry gauze dressing.
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Question 19
Multiple Choice

A client's dressing orders include calcium alginate (Kalistat). The nurse instructs the client that this application is appropriate for a(n)

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A
black wound.
B
draining wound.
C
infected wound.
D
red wound.
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Question 20
Multiple Choice

The nurse is aware that the process by which capillary permeability is altered to allow the large neutrophils to pass through the capillary wall and to the wound site is called

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A
banding.
B
marginating.
C
replicating.
D
segmenting.
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