Matching questions
1-30 of 30
Click a definition to match it with a term
A client with poor nutrition enters the hospital for treatment of a puncture wound. An
appropriate nursing diagnosis would be _____________.
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Answer: Because a malnourished client with a wound is less able to resist
an infection, Risk for Infection is the most likely nursing diagnosis. Others
may include Pain or Imbalanced Nutrition but they are less focused on the
immediate health risk. Cognitive Level: Applying. Client Need: Safe,
Effective Care Environment. Nursing Process: Diagnosing. Learning
Outcome: 31-7.
After teaching a client and family strategies to prevent infection prevention, which
statement by the client would indicate effective learning has occurred?
1. "We will use antimicrobial soap and hot water to wash our hands at least three times
per day."
2. "We must wash or peel all raw fruits and vegetables
before eating."
,3. "A wound or sore is not infected unless we see it
draining pus."
4. "We should not share toothbrushes but it is OK to share towels and washcloths."
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Answer: 2. Rationale: Raw foods touched by human hands can carry
significant infectious organisms and must be washed or peeled.
Antimicrobial soap is not indicated for regular use and may lead to resistant
organisms. Hand hygiene should occur as needed. Hot water can dry and
harm skin, increasing the risk of infection (option 1). Clients should learn all
the signs of inflammation and infection (e.g., redness, swelling, pain, heat)
and not rely on the presence of pus to indicate this (option 3). People
should not share washcloths or towels (option 4). Cognitive Level:
Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process:
Evaluation. Learning Outcomes: 31-8; 31-5.
Which of the following are primary risk factors for pressure ulcers? Select all that
apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed
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Answer: 1, 3, and 4. Rationale: Risk factors for pressure ulcers include low-
protein diet, lengthy surgical procedures, and fever. Protein is
needed for adequate skin health and healing. During surgery, the client is
on a hard surface and may not be well protected from pressure on
bony prominences. Fever increases skin moisture, which can lead to skin
breakdown, plus the stress on the body from the cause of the fever
could impair circulation and skin integrity. Insomnia (option 5) would
generally involve restless sleeping, which transfers pressure to different
parts of the body and would reduce the chances of skin breakdown. A
waterbed (option 5) distributes pressure more evenly than a regular
mattress and, thus, actually reduces the chances of skin breakdown.
, Cognitive Level: Remembering. Client Need: Health Promotion and
Maintenance. Nursing Process: Assessment. Learning Outcome: 36-1.
An appropriate nursing diagnosis for a client with large areas of skin excoriation
resulting from scratching an allergic rash is
1. Risk for Impaired Skin Integrity.
2. Impaired Skin Integrity.
3. Impaired Tissue Integrity.
4. Risk for Infection.
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Answer: 2. Rationale: This client has an actual impairment of the integrity of
the skin due to the rash and the scratching so is no longer "at risk." Because
the damage is at the skin level, it is not impaired tissue integrity (option 3)
since that would involve deeper tissues. Surface excoriation is also not
prone to becoming infected. Cognitive Level:
Analyzing. Client Need: Physiological Integrity. Nursing Process:
Diagnosing. Learning Outcome: 36-9.
In caring for a client on contact precautions for a draining infected foot ulcer, which
action should the nurse perform?
1. Wear a mask during dressing changes.
2. Provide disposable meal trays and silverware.
3. Follow standard precautions in all interactions with the client.
4. Use surgical aseptic technique for all direct contact with the client.
Give this one a try later!
1-30 of 30
Click a definition to match it with a term
A client with poor nutrition enters the hospital for treatment of a puncture wound. An
appropriate nursing diagnosis would be _____________.
Give this one a try later!
Answer: Because a malnourished client with a wound is less able to resist
an infection, Risk for Infection is the most likely nursing diagnosis. Others
may include Pain or Imbalanced Nutrition but they are less focused on the
immediate health risk. Cognitive Level: Applying. Client Need: Safe,
Effective Care Environment. Nursing Process: Diagnosing. Learning
Outcome: 31-7.
After teaching a client and family strategies to prevent infection prevention, which
statement by the client would indicate effective learning has occurred?
1. "We will use antimicrobial soap and hot water to wash our hands at least three times
per day."
2. "We must wash or peel all raw fruits and vegetables
before eating."
,3. "A wound or sore is not infected unless we see it
draining pus."
4. "We should not share toothbrushes but it is OK to share towels and washcloths."
Give this one a try later!
Answer: 2. Rationale: Raw foods touched by human hands can carry
significant infectious organisms and must be washed or peeled.
Antimicrobial soap is not indicated for regular use and may lead to resistant
organisms. Hand hygiene should occur as needed. Hot water can dry and
harm skin, increasing the risk of infection (option 1). Clients should learn all
the signs of inflammation and infection (e.g., redness, swelling, pain, heat)
and not rely on the presence of pus to indicate this (option 3). People
should not share washcloths or towels (option 4). Cognitive Level:
Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process:
Evaluation. Learning Outcomes: 31-8; 31-5.
Which of the following are primary risk factors for pressure ulcers? Select all that
apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed
Give this one a try later!
Answer: 1, 3, and 4. Rationale: Risk factors for pressure ulcers include low-
protein diet, lengthy surgical procedures, and fever. Protein is
needed for adequate skin health and healing. During surgery, the client is
on a hard surface and may not be well protected from pressure on
bony prominences. Fever increases skin moisture, which can lead to skin
breakdown, plus the stress on the body from the cause of the fever
could impair circulation and skin integrity. Insomnia (option 5) would
generally involve restless sleeping, which transfers pressure to different
parts of the body and would reduce the chances of skin breakdown. A
waterbed (option 5) distributes pressure more evenly than a regular
mattress and, thus, actually reduces the chances of skin breakdown.
, Cognitive Level: Remembering. Client Need: Health Promotion and
Maintenance. Nursing Process: Assessment. Learning Outcome: 36-1.
An appropriate nursing diagnosis for a client with large areas of skin excoriation
resulting from scratching an allergic rash is
1. Risk for Impaired Skin Integrity.
2. Impaired Skin Integrity.
3. Impaired Tissue Integrity.
4. Risk for Infection.
Give this one a try later!
Answer: 2. Rationale: This client has an actual impairment of the integrity of
the skin due to the rash and the scratching so is no longer "at risk." Because
the damage is at the skin level, it is not impaired tissue integrity (option 3)
since that would involve deeper tissues. Surface excoriation is also not
prone to becoming infected. Cognitive Level:
Analyzing. Client Need: Physiological Integrity. Nursing Process:
Diagnosing. Learning Outcome: 36-9.
In caring for a client on contact precautions for a draining infected foot ulcer, which
action should the nurse perform?
1. Wear a mask during dressing changes.
2. Provide disposable meal trays and silverware.
3. Follow standard precautions in all interactions with the client.
4. Use surgical aseptic technique for all direct contact with the client.
Give this one a try later!
