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Nursing 155 Practice Complex Next-Gen NCLEX questions ScienceMedicineNursing Jheanelle_Goodwin Save NCLEX NGN Pre-Test Questions 73 terms CamadarPreview
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66 terms Ninabear007Preview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview NCLEX Teacher Tut A nurse is assessing a client's pressure ulcer that shows signs of infection, including erythema, warmth, and purulent drainage. Which intervention is the nurse's priority in managing this wound?
a) Continuation of the current wound dressing.
b) Application of a hydrocolloid dressing.
c) Initiation of broad-spectrum antibiotics.
d) Frequent wound cleaning with hydrogen peroxide.
Answer: c) Initiation of broad-spectrum antibiotics.
Explanation: Signs of infection in a wound, such as erythema, warmth, and purulent drainage, indicate the presence of microorganisms that may require systemic treatment with antibiotics to prevent systemic spread.A client with a diabetic foot ulcer is prescribed a moist wound healing technique. Which explanation best describes the rationale behind this approach?
a) It prevents bacteria from entering the wound.
b) It promotes the formation of a scab over the wound.
c) It facilitates faster wound closure through epithelialization.
d) It reduces inflammation and pain in the wound.
Answer: c) It facilitates faster wound closure through epithelialization.
Explanation: Moist wound healing creates an optimal environment for cell migration, proliferation, and angiogenesis, which promote faster wound closure through the process of epithelialization. It also reduces the risk of scab formation and promotes better wound healing outcomes.
A nurse is caring for a client with a suspected deep tissue injury on the sacral area. What assessment finding is characteristic of this type of wound?
a) Blistering and serous drainage.
b) Sloughing and eschar formation.
c) Red, beefy granulation tissue.
d) Erythema and edema.
Answer: b) Sloughing and eschar formation.
Explanation: Deep tissue injuries typically manifest as localized areas of discolored skin, often with sloughing (dead tissue) and eschar (dry, blackened tissue) formation due to damage to underlying tissue layers.A client with a traumatic open wound is brought to the emergency department. The nurse notes that the wound has irregular, jagged edges with
tissue loss. This wound is best described as:
a) A laceration.
b) An abrasion.
c) An incision.
d) An avulsion.
Answer: a) A laceration.
Explanation: A laceration is a wound caused by a tearing of the skin and underlying tissues, often resulting in irregular, jagged wound edges.A client with a pressure ulcer is being treated with a collagenase enzyme ointment. What is the primary purpose of using this ointment in wound care?
a) To provide a barrier against moisture.
b) To break down necrotic tissue.
c) To promote granulation tissue formation.
d) To reduce inflammation and pain.
Answer: b) To break down necrotic tissue.
Explanation: Collagenase enzyme ointments are used to enzymatically debride necrotic tissue in wounds, aiding in wound healing by removing dead tissue and allowing healthy tissue to regenerate.A client with a surgical wound is being discharged with home care instructions. The nurse instructs the client to change the dressing using aseptic technique every 3 days. What is the rationale for this instruction?
a) To ensure that the wound remains dry and free from moisture.
b) To minimize the risk of infection by preventing microorganism contamination.
c) To allow for adequate air exposure and oxygenation of the wound.
d) To promote the formation of granulation tissue and epithelialization.
Answer: b) To minimize the risk of infection by preventing microorganism contamination.Explanation: Aseptic technique during dressing changes helps minimize the introduction of microorganisms into the wound, reducing the risk of infection
A client with a venous stasis ulcer is receiving compression therapy. What is the primary goal of compression therapy in this case?
a) Promoting drainage of purulent wound exudate.
b) Reducing inflammation and pain in the wound.
c) Enhancing the growth of granulation tissue.
d) Improving venous return and preventing edema.
Answer: d) Improving venous return and preventing edema.
Explanation: Compression therapy is used in venous stasis ulcers to improve venous return, decrease edema, and enhance wound healing by promoting proper circulation.A client with a large burn injury is undergoing wound care with autolytic debridement. What does autolytic debridement involve?
a) Surgical removal of necrotic tissue.
b) Application of chemical agents to dissolve dead tissue.
c) Use of enzymes to digest necrotic tissue.
d) Mechanical removal of debris from the wound.
Answer: c) Use of enzymes to digest necrotic tissue.
Explanation: Autolytic debridement involves using the body's natural enzymes to break down and liquefy necrotic tissue, facilitating its removal over time.A client with a wound healing by secondary intention asks the nurse about the appearance of the wound bed. How should the nurse accurately describe granulation tissue?
a) It is a yellowish, dry tissue that covers the wound.
b) It appears as black, leathery tissue.
c) It is beefy red tissue that fills the wound.
d) It consists of pale, waxy tissue that requires debridement.
Answer: c) It is beefy red tissue that fills the wound.
Explanation: Granulation tissue is characterized by its bright, beefy red appearance and fills in the wound as a part of the healing process.A nurse is caring for a client with a stage 4 pressure ulcer on the coccyx. The client's wound is covered with a yellowish exudate. What does this type of wound exudate indicate?
a) Infection and presence of pus.
b) Normal wound healing progression.
c) Excessive moisture in the wound.
d) Impaired blood supply to the wound.
Answer: b) Normal wound healing progression.
Explanation: Yellowish exudate is typically seen in the proliferative phase of wound healing and indicates the presence of fibrin and other components involved in tissue repair. Terms (10) Hide definitions
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