Matching questions
1-35 of 35
Click a definition to match it with a term
On the fourth postoperative day, the client has a sudden coughing episode and tells
the nurse that something popped in the abdominal incision. Upon inspection, the
nurse finds that evisceration has occurred. What nursing action should be taken first?
1. Notify the clients surgeon.
2. Cover the area with a large saline-soaked dressing.
3. Position the client in bed with knees bent.
4. Pack the wound with nonadherent gauze.
Give this one a try later!
2. Cover the area with a large saline-soaked dressing.
Rationale 1: Although notifying the surgeon is important, it is not the nurses
first action.
The adult client is incontinent and wears incontinence briefs when using the
wheelchair. An irritated rash has developed in the perianal area. What care should the
nurse provide?
,1. Wash the area with soap and hot water at every brief change.
2. Apply a petroleum-based cream to the area after cleaning.
3. Wipe the skin with an alcohol-free barrier film agent after cleaning.
4. Keep the client in bed on absorbent pads until the area clears.
Give this one a try later!
3. Wipe the skin with an alcohol-free barrier film agent after cleaning.
Rationale 1: Cleansing should be done with a mild cleansing agent and
warm water.
Multiple severely injured clients have arrived in the emergency department. On rapid
assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood
spot that has soaked through the bandage. The client is otherwise stable. What action
should the nurse take?
1. Place a tourniquet above the wound.
2. Remove the dressing and place direct pressure on the wound.
3. Add an additional dressing to the wound without removing the original.
4. Remove the dressing and replace it with a new sterile dressing.
Give this one a try later!
3. Add an additional dressing to the wound without removing the original.
Rationale 1: A tourniquet should not be applied because of the risk of
interrupting arterial flow to the tissues.
The nurse is selecting dressings for a clean abdominal incision that will be allowed to
heal by secondary intention. What principles should the nurse use in choosing this
dressing?
1. Materials used in dressing this wound should keep the wound bed moist.
2. The dressing should allow good air circulation through the wound.
3. Dressings should be simple as they will be changed at least every 4 hours.
4. Absorbent material to wick exudates away and support drying should be used.
, Give this one a try later!
1. Materials used in dressing this wound should keep the wound bed moist.
Rationale 1: Wounds that are expected to heal by secondary intention heal
by granulating in. In order to support the growth of granulation tissue, the
wound bed should be kept moist and oxygen should be kept out of the
wound.
The nurse is assessing a clients 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.
Give this one a try later!
3. Insert a sterile swab into the deepest part of the wound.
Rationale 1: Measuring the width of the wound does not provide the depth
of the ulcer.
The client has a documented stage III pressure ulcer on the right hip. What NANDA
nursing diagnosis problem statement is most appropriate for use with this client?
1. Altered Tissue Perfusion
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Injury
Give this one a try later!
3. Impaired Tissue Integrity
Rationale 1:Although it is true that pressure ulcers result from altered tissue
1-35 of 35
Click a definition to match it with a term
On the fourth postoperative day, the client has a sudden coughing episode and tells
the nurse that something popped in the abdominal incision. Upon inspection, the
nurse finds that evisceration has occurred. What nursing action should be taken first?
1. Notify the clients surgeon.
2. Cover the area with a large saline-soaked dressing.
3. Position the client in bed with knees bent.
4. Pack the wound with nonadherent gauze.
Give this one a try later!
2. Cover the area with a large saline-soaked dressing.
Rationale 1: Although notifying the surgeon is important, it is not the nurses
first action.
The adult client is incontinent and wears incontinence briefs when using the
wheelchair. An irritated rash has developed in the perianal area. What care should the
nurse provide?
,1. Wash the area with soap and hot water at every brief change.
2. Apply a petroleum-based cream to the area after cleaning.
3. Wipe the skin with an alcohol-free barrier film agent after cleaning.
4. Keep the client in bed on absorbent pads until the area clears.
Give this one a try later!
3. Wipe the skin with an alcohol-free barrier film agent after cleaning.
Rationale 1: Cleansing should be done with a mild cleansing agent and
warm water.
Multiple severely injured clients have arrived in the emergency department. On rapid
assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood
spot that has soaked through the bandage. The client is otherwise stable. What action
should the nurse take?
1. Place a tourniquet above the wound.
2. Remove the dressing and place direct pressure on the wound.
3. Add an additional dressing to the wound without removing the original.
4. Remove the dressing and replace it with a new sterile dressing.
Give this one a try later!
3. Add an additional dressing to the wound without removing the original.
Rationale 1: A tourniquet should not be applied because of the risk of
interrupting arterial flow to the tissues.
The nurse is selecting dressings for a clean abdominal incision that will be allowed to
heal by secondary intention. What principles should the nurse use in choosing this
dressing?
1. Materials used in dressing this wound should keep the wound bed moist.
2. The dressing should allow good air circulation through the wound.
3. Dressings should be simple as they will be changed at least every 4 hours.
4. Absorbent material to wick exudates away and support drying should be used.
, Give this one a try later!
1. Materials used in dressing this wound should keep the wound bed moist.
Rationale 1: Wounds that are expected to heal by secondary intention heal
by granulating in. In order to support the growth of granulation tissue, the
wound bed should be kept moist and oxygen should be kept out of the
wound.
The nurse is assessing a clients 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.
Give this one a try later!
3. Insert a sterile swab into the deepest part of the wound.
Rationale 1: Measuring the width of the wound does not provide the depth
of the ulcer.
The client has a documented stage III pressure ulcer on the right hip. What NANDA
nursing diagnosis problem statement is most appropriate for use with this client?
1. Altered Tissue Perfusion
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Injury
Give this one a try later!
3. Impaired Tissue Integrity
Rationale 1:Although it is true that pressure ulcers result from altered tissue
