PN 140 Test 2 NCLEX Practice Questions and Answers

PN 140 Test 2 NCLEX Practice Questions and Answers

Which of the following devices should be used to ensure the appropriate amount of irrigation pressure during a wound irrigation?

• 10 mL syringe with a 19 gauge needle
• 35 mL syringe with a 19 gauge needle
• steady flow of fluid from a height of 12 inches above the wound
• steady but gentle squirt of irrigant through a catheter irrigating system - answerB. 35 mL syringe

with a 19 gauge needle Which of the following are common sites for development of pressure ulcers? (select all that apply)

• sternum
• heels
• sacrum
• ears
• lateral malleoli
• trochanters
• tip of great toe - answerB. heels
• sacrum
• ears
• lateral maleoli
• trochanters

When educating a patient about wound healing the nurse should include what in the teaching?

• inadequate nutrition delays wound healing and increases risk of infection.
• chronic wounds heal better in a dry, open environment so leave them open to air.
• fat tissue heals more rapidly because there is less vascularization.
• long term steroid use diminishes the inflammatory response and speeds up wound healing -

answerA. inadequate nutrition delays wound healing and increases risk of infection What strategies should be included in pressure ulcer prevention (select all that apply)

• use moisture barrier ointment with incontinence

• reposition immobile patients every 4 hours
• when patient in side lying position ensure HOB <30 degrees
• place patient on pressure reducing support surface
• maintain bed at 45 degree angle
• massage reddened bony prominences
• oral nutrition supplement should be used when undernourished. - answerA. use moisture

barrier ointment with incontinence

• when patient in side lying position ensure HOB <30 degrees
• place patient on pressure reducing support surface
• oral nutrition supplement should be used when undernourished.

Why does a wound bed need to stay moist?

• to support healing by enabling granulation tissue to grow.
• to prevent excessive fluid loss from the body
• to determine if the area has reactive hyperemia
• to decrease patient discomfort - answerA. to support healing by enabling granulation tissue to

grow.What evaluation criteria are included in the Braden Risk assessment? (select all that apply)

• sensory perception
• medications
• mobility
• friction and shear
• mental status
• moisture - answerA. sensory perception
• mobility
• friction and shear
• moisture

What term refers to pale, red and watery drainage from a wound?

• serous

• sanguineous
• serosanguineous
• purulent - answerC. serosanguineous

serous - clear, watery, plasma sanguineous - bright red, active bleeding purulent - thick, yellow, green, tan or brown (pus) An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position?

• Sacral
• Patella
• Ankle
• Ear
• Elbow
• Hip
• Heel
• Shoulder - answerB. Patella
• Ankle
• Ear
• Hip
• Shoulder

The right lateral recumbent position is where the patient is positioned on their right side.Therefore, the ankle, ear, hip, knee, and shoulders are sites where a pressure injury can occur.You're working on a medical surgical floor. You have the following patients below. Select all the

patients below that are at risk for a pressure injury:

• A 19 year old female who is a quadriplegic.
• A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.
• A 55 year old female who has controlled diabetes and is ambulating three times a day.
• A 76 year old male with an elevated ammonia level and is excessively sweaty.
• A 45 year old with a Braden Scale score of 7. - answerA, B, D, and E.

The only patient not at risk for a pressure injury is the patient in option B. Remember altered sensory perception, any type of moisture issue (incontinence, sweating etc.), immobility, poor nutrition, altered mental status (high ammonia level can cause confusion and drowsiness), Braden scale score less than 9 are all risk factors for a pressure injury.The nurse is caring for clients on a medical unit. After the shift report, which client should be assessed first?

• the 34-year old client who is quadriplegic and cannot move his arms.
• the elderly client diagnosed with a CVA who is weak on the right side.
• The 78 year old client with pressure ulcers who has a temperature of 102.3
• The young adult who is unhappy with the care that was provided last shift. - answer3.

The 78 year old client with pressure ulcers who has a temperature of 102.3 A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?

• Ischemic thrombosis
• Ischemic embolism
• Hemorrhagic
• Ischemic stenosis - answerThe answer is B.

If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers.This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about

• cerebral aneurysm clipping.
• heparin intravenous infusion.
• oral low-dose aspirin therapy.
• tissue plasminogen activator (tPA). - answerC.

The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse