Nursing Chapter 36 Competencies Context And Environment Practice Conduct

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB

color code, which wound care should the nurse plan?

1. Red

2. Yellow

3. Black

4. A combination of all three

Question 20

Type: MCSA

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer

over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to

achieve this outcome?

1. The rubber doughnut pressure relief device was not delivered by central supply.

2. The client’s serum albumin increased over the last month.

3. Nurses did not document disinfection of the wound with alcohol with each dressing change.

4. Unlicensed assistive personnel (UAP) followed a right side–back–left side–back turning schedule.

Question 21

Type: MCSA

The nurse has applied an aquathermia pad to a client’s back. After 15 minutes of treatment, the client says that the

pack no longer is warm and asks the nurse to increase the temperature. How should the nurse evaluate this

request?

1. Because this client’s thermal tolerance is higher than normal, increasing the temperature is necessary.

2. This client may be experiencing a rebound effect from the application of moist heat.

3. Adaptation of the thermal receptors often results in the decreased sensation of warmth.

4. The aquathermia pad should be replaced with a standard hot pack.

Question 22

Type: MCMA

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this

client?

Standard Text: Select all that apply.

1. Poor skin turgor.

2. Elevated body temperature.

3. Diminished pain sensation.

4. Thin epidermis.

5. Dry skin.

Question 23

Type: MCMA

A client has a wound that is going to heal through secondary intention. When instructing the client about this

wound, the nurse would include which statements?

Standard Text: Select all that apply.

1. Minimal tissue loss.

2. Closure of the wound will occur within 5 days.

3. Healing time will be longer.

4. Potential for scarring is greater.

5. Susceptibility to infection is greater.

Question 24

Type: MCSA

A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear

red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase?

1. Inflammatory

2. Proliferative

3. Maturation

4. Remodeling

Question 25

Type: MCSA

A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes

this occurs during which phase of wound healing?

1. Exudative

2. Proliferative

3. Inflammatory

4. Maturation

Question 26

Type: MCSA

While changing a client’s dressing, the nurse notes thick yellow-green drainage on the gauze. How should the

nurse document this wound’s drainage?

1. Purulent

2. Serous

3. Sanguineous

4. Serosanguinous

Question 27

Type: MCSA

The nurse documents that a client’s postoperative wound is purosanguinous. What did the nurse assess in this

client’s wound?

1. Water and red blood cells

2. Pus and red blood cells

3. Watery drainage

4. Pus

Question 28

Type: MCSA

The nurse is assessing a client’s pressure ulcer. To determine the depth of the ulcer, the nurse should take which

action?

1. Measure the width.

2. Measure the length.

3. Insert a sterile swab into the deepest part of the wound.

4. Identify where on the face of a clock the ulcer is located.

Question 29

Type: MCSA

A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would

identify which nursing diagnosis as being appropriate?

1. Impaired Skin Integrity

2. Risk for Impaired Skin Integrity

3. Impaired Tissue Integrity

4. Risk for Infection

Question 30

Type: MCMA

A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate

for this client’s wound?

Standard Text: Select all that apply.

1. Cover it with transparent film.

2. Apply a damp-to-damp normal saline dressing.

3. Cover it with a dry dressing.

4. Irrigate the wound.

5. Apply impregnated hydrogel.

Question 31

Type: SEQ

The nurse is preparing to irrigate a client’s abdominal wound. In which order should the nurse perform this

irrigation?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Dry the area around the wound.

Choice 2. Insert the catheter into the wound until resistance is met.

Choice 3. Remove and discard clean gloves.

Choice 4. Apply clean gloves.

Choice 5. Irrigate until the solution flows clear.

Choice 6. Select a syringe with a catheter attached or with an irrigating tip.

Question 32

Type: MCMA

A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client?

Standard Text: Select all that apply.

1. The application of cold dilates blood vessels.

2. The application of cold constricts blood vessels.

3. The application of cold decreases inflammation.

4. The application of cold reduces localized pain.

5. The application of cold provides a calming, sedative effect.

Question 33

Type: MCSA

During morning care, unlicensed assistive personnel observe a client’s abdominal wound dressing become

saturated with bright red blood. What should unlicensed assistive personnel do?

1. Reinforce the wound with supplies on the client’s bedside table.

2. Document that the bath was completed, and the condition of the dressing.

3. Complete the bath, then report the change to the nurse.

4. Report the dressing changes to the nurse immediately.

Rationale 2: UAP should not document that the bath was completed before communicating the dressing changes

to the nurse.

Rationale 3: UAP should not complete the bath first.

Rationale 4: When delegating the care of the client to the UAP, the nurse should have provided direction to the

UAP to report any changes to the nurse. UAP should report the dressing changes to the nurse immediately.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for

managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health

assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15. Recognize when it is appropriate to delegate aspects of skin and wound care to unlicensed

assistive personnel.

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and

prevent complications.

Page Number: 854

Question 34

Type: MCMA

The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the

nurse use this technique when bandaging?

Standard Text: Select all that apply.

1. Finger

2. Forearm

3. Upper leg

4. Lower leg

5. Upper arm

Question 35

Type: SEQ

The nurse is preparing to apply a moist aquathermia pack to a client’s left upper leg. In which order should the

nurse prepare and apply this treatment?

Standard Text: Select all that apply.

1. Use tape or gauze ties to hold the pad in place.

2. Set the desired temperature according to the manufacturer’s instructions.

3. Apply the pad to the body part. The treatment is usually continued for 30 minutes.

4. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer.

5. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use.