Wounds and Burns NCLEX questions (w/ rationale)

Wounds and Burns NCLEX questions (w/ rationale) Leave the first rating Students also studied Terms in this set (49) Science MedicineNursing Save Fundamentals 30 terms Mama195923Preview Nurs 120 Week 1 Questions 20 terms KSWTPreview Prioritization NCLEX questions 28 terms madisoncastello Preview FUND w 50 terms rch The nurse is working on a med-surf unit that has been participating in a research project associated w/ pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?

• decreased level of consciousness
• adequate dietary intake
• shortness of breath
• muscular pain

a The RN is caring for a pt who was involved in an automobile accident 2 weeks ago. The pt sustained a head injury and is unconscious. which priority element will the nurse consider when planning care to decrease the development of decubitus ulcer?

• resistance
• pressure
• weight
• stress

b which nursing observation will indicate the pt is at risk for pressure ulcer formation?

• the pt has fecal incontinence
• the pt ate 2/3 of breakfast
• the pt has a raised rash on the right shin
• the pt's capillary refill is less than 2 seconds

a

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?

• Stage I pressure ulcer
• Healing Stage II pressure ulcer
• Healing Stage III pressure ulcer
• Stage III pressure ulcer

c The nurse is admitting an older pt from a nursing home.During the assessment, the RN notes a shallow open reddish, pink ulcer without slough on the right heel of the pt. How will the RN stage this pressure ulcer?

• Stage I
• Stage II
• Stage III
• Stage IV

b the nurse is completing a skin assessment on a pt w/ darkly pigmented skin. Which item should the RN use FIRST to assist in staging an ulcer on this pt?

• disposable measuring tape
• cotton tipped applicator
• sterile gloves
• halogen light

d the RN is caring for a pt with a stage IV pressure ulcer.which type of healing will the RN consider when planning care for this pt?

• partial thickness wound repair
• full thickness wound repair
• primary intention
• tertiary intention

b the nurse is caring for a group of patients. which patient will the nurse see FIRST?

• pt with a stage IV pressure ulcer
• pt with a Braden scale score of 18
• pt with appendicitis using a heating pad
• pt with an incision that is approximated

c: warm applications are contraindicated with localized inflammation such as

appendicitis (can cause rupture)

the RN is caring for a pt who is experiencing a full thickness repair. Which type of tissue will the RN expect to observe when the wound is healing?

• eschar
• slough
• granulation
• purulent drainage

c the nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

• partial thickness repair
• secondary intention
• tertiary intention
• primary intention

d: clean surgical incisions have little loss of tissue and heal with primary intention the RN is caring for a pt in the burn unit. Which type of healing will the RN consider when planning care for this pt?

• partial thickness repair
• secondary intention
• tertiary intention
• primary intention

b: a wound involving loss of tissue such as a burn is left open until it becomes filled with scar tissue An RN is assessing a pt's wound. Which nursing observation will indicate the wound healed by secondary intention?

• minimal loss of tissue function
• permanent dark redness at site
• minimal scar tissue
• scarring that may be severe

d: wound is left open to form scar tissue during secondary intention, takes longer to heal and can cause infection the nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the pt is experiencing a complication of wound healing?

• the site is hurting
• the site is approximated
• the site has started to itch
• the site has a mass, bluish in color

d: a hematoma is a localized collection of blood underneath the tissue. Swelling, change in color, sensation, or warmth, all abnormal part of healing process a nurse is caring for a postoperative pt. which finding will alert the RN to a potential wound dehiscence?

• protrusion of visceral organs through a wound opening
• chronic drainage of fluid through the incision site
• report by pt that something has given way
• drainage that is odorous and purulent`

c: pt's often feel dehiscence, some drainage is normal, excess can lead to

dehiscence.

a pt has developed a pressure ulcer. which lab data will be important for the RN to check?

• vitamin E
• potassium
• albumin
• sodium

c: normal wound healing requires proper nutrition. Albumin is a protein and low

albumin can indicate improper nutrition, can reflect what the pt is intaking and also absorbing to promote wound healing an RN is caring for a pt with a wound. which assessment data will be MOST important for the RN to gather with regard for wound healing?

• muscular strength assessment
• pulse ox assessment
• sensation assessment
• sleep assessment

b: the ability to perfuse O2 to body's tissues.

the RN is caring for a pt w/ a healing stage III pressure ulcer. Upon entering the room, the RN notices an odor and observes a purulent discharge, along w/ increased redness at the wound site. What is the NEXT best step for the RN?

• complete head to toe assessment including current

treatment, vital signs, and lab results

• notify the health care provider by utilizing SBAR
• consult the wound care RN about the change in status

and the potential for infection

• check with the charge RN about the change in status

and the potential for infection

a: RN needs to gather assessment and all data before going to provider

the RN is collaborating w/ the dietitian about a pt w/ a stage III pressure ulcer. Which nutrient will the nurse most likely increase after a collaboration with the dietitian?

• fat
• protein
• vitamin E
• carbs

b the RN is completing an assessment on a pt who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the pt indicates issues w/ self concept?

• "I am so weak and tired. I want to feel better"
• "I am thinking I will be ready to go home next week"
• "I am ready for my bath and linen change right now

since this is awful"

• "I am hoping there will be something good for dinner

tonight" c