262 Exam 2 Test Questions with
Guaranteed Pass Solutions 2026
Updated.
An adult client is incontinent and wears incontinence briefs when using the wheelchair. An
irritated rash has developed in the perinatal area. What care should the nurse provide
- wash area with soap and hot water at every fried change
- apply petroleum-based cream to area after cleaning
- wipe skin with alcohol free barrier film agent after cleaning
- keep client in bed on absorbent pads until area clears - Answer 3: should be done with mild
cleansing agent and warm water
Proper technique for performing a wound culture includes which of the following
- cleansing wound prior to obtaining specimen
- swabbing with largest collection of drainage
- removing crusts or scabs with sterile forceps and then culturing site beneath
- waiting 8 hrs following antibiotic to obtain specimen - Answer 1: specimens should be
obtained from cleaned area of the wound
Client has pressure injury with shallow, partial skin thickness, eroded area but no necrotic areas.
Nurse treats with which dressing
- alginate
- dry gauze
- hydrocolloid
- no dressing indicated - Answer 3: protect shallow injuries and maintain appropriate healing
environment
- alginate: for wounds with lots of drainage
- dry gauze: sticks to new granulation tissue causing more damage
Nurse applied aqua thermia pad to client's back. After 15min of treatment, client says it's not
warm and asks to inc temp. How should nurse evaluate request
- since client's thermal tolerance is higher than normal, inc temp is necessary
- client may be experiencing rebound effect from application of moist heat
- adaptation of thermal receptors often results in dec sensation of warmth
, - aquathermia pad should be replaced but with standard hot pack - Answer 3: after 15min,
thermal receptors adapt to temp inc and sensation of warmth is diminished; inc temp may lead
to burns
What indicated need for further teaching
- if a skin area gets red but then goes away after turning, i should report it to nurse
- putting foam pads under my heels or bony areas can help dec pressure
- if my father can't turn himself in bed, I should help him change position every 4 hrs
- skin should be washed only with warm water (not hot) and lotion put on while still a little wet -
Answer 3: should be repositioned every 2 hrs
Nurse is writing plan of care for patient confined to bed. Which intervention should be included
to reduce effects of shearing forces on skin
- keep head of client's bed at 30 degrees
- coat client's back and butt with baby powder after bathing
- use turn sheet lifted by two staff members to move client in bed
- dust linens with cornstarch each morning to allow for easier movement - Answer 3
- bed should be less than 30 degrees, baby powder and cornstarch should not be used bc
abrasive grit damage
Nurse plans to remove client's sutures. Which action demonstrates appropriate standard of care
(SATA)
- clean technique
- grasp suture at knot with forceps
- place curved tip of suture scissors under suture as close to skin
- pull suture material that is visible beneath skin during removal
- remove alternate sutures first - Answer 1, 2, 3, 5: should not be pulled
Which are primary risk factors for pressure injuries (SATA)
- low protein diet
- insomnia
- lengthy surgical procedures
- fever
- sleeping on waterbread - Answer 1, 3, 4: protein needed for adequate skin health and
healing, fever inc skin moisture which can lead to breakdown, insomnia is restless sleeping so px
changes positions a lot
Guaranteed Pass Solutions 2026
Updated.
An adult client is incontinent and wears incontinence briefs when using the wheelchair. An
irritated rash has developed in the perinatal area. What care should the nurse provide
- wash area with soap and hot water at every fried change
- apply petroleum-based cream to area after cleaning
- wipe skin with alcohol free barrier film agent after cleaning
- keep client in bed on absorbent pads until area clears - Answer 3: should be done with mild
cleansing agent and warm water
Proper technique for performing a wound culture includes which of the following
- cleansing wound prior to obtaining specimen
- swabbing with largest collection of drainage
- removing crusts or scabs with sterile forceps and then culturing site beneath
- waiting 8 hrs following antibiotic to obtain specimen - Answer 1: specimens should be
obtained from cleaned area of the wound
Client has pressure injury with shallow, partial skin thickness, eroded area but no necrotic areas.
Nurse treats with which dressing
- alginate
- dry gauze
- hydrocolloid
- no dressing indicated - Answer 3: protect shallow injuries and maintain appropriate healing
environment
- alginate: for wounds with lots of drainage
- dry gauze: sticks to new granulation tissue causing more damage
Nurse applied aqua thermia pad to client's back. After 15min of treatment, client says it's not
warm and asks to inc temp. How should nurse evaluate request
- since client's thermal tolerance is higher than normal, inc temp is necessary
- client may be experiencing rebound effect from application of moist heat
- adaptation of thermal receptors often results in dec sensation of warmth
, - aquathermia pad should be replaced but with standard hot pack - Answer 3: after 15min,
thermal receptors adapt to temp inc and sensation of warmth is diminished; inc temp may lead
to burns
What indicated need for further teaching
- if a skin area gets red but then goes away after turning, i should report it to nurse
- putting foam pads under my heels or bony areas can help dec pressure
- if my father can't turn himself in bed, I should help him change position every 4 hrs
- skin should be washed only with warm water (not hot) and lotion put on while still a little wet -
Answer 3: should be repositioned every 2 hrs
Nurse is writing plan of care for patient confined to bed. Which intervention should be included
to reduce effects of shearing forces on skin
- keep head of client's bed at 30 degrees
- coat client's back and butt with baby powder after bathing
- use turn sheet lifted by two staff members to move client in bed
- dust linens with cornstarch each morning to allow for easier movement - Answer 3
- bed should be less than 30 degrees, baby powder and cornstarch should not be used bc
abrasive grit damage
Nurse plans to remove client's sutures. Which action demonstrates appropriate standard of care
(SATA)
- clean technique
- grasp suture at knot with forceps
- place curved tip of suture scissors under suture as close to skin
- pull suture material that is visible beneath skin during removal
- remove alternate sutures first - Answer 1, 2, 3, 5: should not be pulled
Which are primary risk factors for pressure injuries (SATA)
- low protein diet
- insomnia
- lengthy surgical procedures
- fever
- sleeping on waterbread - Answer 1, 3, 4: protein needed for adequate skin health and
healing, fever inc skin moisture which can lead to breakdown, insomnia is restless sleeping so px
changes positions a lot
