QUESTIONS COMPLETE WITH 100%
VERIFIED ANSWERS
\.True or False:
Wounds that are kept moist for several days heal faster than those that are kept dry -
ANSWERS✔-True
\.True or False:
The centers for Medicare and Medicaid Services (CMS) do not reimburse an acute care facility if
a patient with intact skin develops a stage 3-4 pressure injury while hospitalized - ANSWERS✔-
true
\.True or False:
For incontinent patients, underpads and diapers with a plastic outer lining are the best supplies
- ANSWERS✔-False
\.True or False:
The usual wound care in the home environment is performed by the patient or family using
sterile technique - ANSWERS✔-False
\.True or False:
High pressure over a short time and low pressure over a long time cause skin breakdown -
ANSWERS✔-True
,\.True or False:
Povidone-iodine (betadine), Hydrogen Peroxide, and acetic acid should not be used to irrigate a
clean, granular wound - ANSWERS✔-True
\.To avoid pressure injury for an immobilized patient at home, a nurse recommends a surface to
use on the bed. A surface type that is low cost and easy to use in the home is a(n):
a. foam overlay
b. water mattress
c. air fluidized bed
d. low-air-loss surface - ANSWERS✔-a
\.For a patient in the extended care facility who has a risk for pressure injuries, a nurse will
implement:
a. massage of reddened skin areas
b. movement of the patient in the chair every 3 hours
c. maintenance of a position while in bed at 30 degrees or lower
d. placement of plastic absorptive pads directly beneath the patient - ANSWERS✔-c
\.A patient has experienced a traumatic injury that will require applications of heat. The nurse
implements the treatment based on the principle that:
a. patient response is best to minor temperature adjustments
b. the foot and palm of the hand are most sensitive to temperature
c. long exposures help the patient develop tolerance to the procedure
d. patient are more tolerant to temperature changes over a large body of surface area -
ANSWERS✔-a
,\.A severely overweight patient has returned to the unit after having major abdominal surgery.
When the nurse enters the room, it is evident that the patient has moved or coughed and the
wound has eviscerated. The nurse should immediately:
a. assess the vital signs
b. contact the doctor
c. apply light pressure on the exposed organs
d. place sterile towels soaked in saline over the area. - ANSWERS✔-d
\.A patient with a knife protruding from his upper leg is taken into the emergency department.
A nurse is waiting for the physician to arrive when a newly hired nurse comes to assist. The
nurse delegates the new staff nurse to do all of the following as soon as possible except:
a. assess vital signs
b. remove the knife to cleanse the wound
c. wrap a bandage around the knife and injured site
d. apply pressure to the surrounding area to stop the bleeding - ANSWERS✔-b
\.A nurse is planning care for a patient who has a red area over a bony prominence that
blanches when assessed. Which of the following interventions are appropriate? (Select all that
apply.)
1. Massage the area to improve the local circulation.
2. Reposition the patient off the area.
3. Reassess the area after the patient is off the area for 1 hour.
4. Request nonbleached sheets for this patient's bed.
5. Place a cold pack under the area and reassess in 1 hour. - ANSWERS✔-2, 3
\.Nursing interventions to manage a patient who is experiencing frequent fecal and urinary
incontinence include which of the following? (Select all that apply.)
, 1. Frequent perineal and sacral skin assessments
2. Using a large absorbent diaper, changing when saturated
3. Keeping the buttocks exposed to air at all times
4. Using an incontinence cleanser, followed by application of a moisture-barrier ointment
5. Offering frequent ambulation and help to the toilet - ANSWERS✔-1, 4, 5
\.Place the following steps in correct order for performing a wound irrigation.
1. Use slow continuous pressure to irrigate wound.
2. Attach 19-gauge angiocatheter to syringe.
3. Fill syringe with irrigation fluid.
4. Assess wound.
5. Position angiocatheter over wound. - ANSWERS✔-4, 3, 2, 5, 1
\.A nurse is assessing a patient's superficial wound and notices that it has very minimal tissue
loss and drainage. There are a number of dressings that may be used according to the protocol
on the unit. The nurse selects:
a. gauze
b. alginate
c. transparent film
d. negative pressure wound therapy - ANSWERS✔-c
\.A nurse is completing an assessment of the patient's skin integrity and identifies that an area
is a full-thickness loss of skin with adipose tissue, slough, and eschar visible. The nurse identifies
this stage of pressure injury as:
a. stage 1