2021 Version:
1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a
change in the wound care procedure. Which of the following findings indicate
wound healing.
a. Erythema on the skin surrounding a client's wound
b. Deep red color on the center of the clients wound
c. Inflammation noted on the tissue edges of a client's wound
d. Increase in serosanguineous exudate from the clients wound (damaged capillaries)
Rationale: Leadership 7.0 pg
329:
- Stages of Wound Healing
- Inflammatory stage - beginning stage, also usually suggests infection
- Begins with the injury and lasts 3 to 6 days
- Effects to the wound: controlling bleeding with vasoconstriction and
retraction of blood vessels, and with clot formation. Delivering oxygen,
WBCs, nutrients to the area via blood supply. Hemostasis occurs along
with fibrin formation. Macrophages engulf microorganisms and cellular
debris (phagocytosis).
- Proliferative stage
- Lasts the next 3 to 24 days
- Effects to the wound: replacing lost tissue with connective or granulated
tissue or collagen. Contracting the wound‟s edges. Resurfacing of new
epithelial cells. Healthy granulation tissue does not bleed easily. Dark
granulation tissue can be a sign of infection, ischemia, or poor perfusion.
In the final phase of the proliferative stage of wound healing, epithelial
cells resurface the injury.
- Maturation or remodeling stage
- Occurs after day 21 and involves that strengthening of the collagen scar
and restoration of a more normal appearance. It can take more than 1 year
to complete, depending on the extent of the original wound. When scar
tissues are forming.
- Appearance:
- Note the color of open wounds.
- Red: healthy regeneration of tissue.
- Yellow: presence of purulent drainage and slough
- Black: presence of eschar that hinders healing and requires removal.
2. A nurse received change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
a. Obtain a breakfast tray for a client who received a morning dose of
, insulin aspart. - (fast-acting insulin...usually takes effect after 15 minutes)
b. Administer pain medication to a client who has rheumatoid arthritis and
received the last dose at 0400.
c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following
clients should the nurse assign to the newly licensed nurse?
, a. A client who has multiple sclerosis and ataxia - (normal finding for someone that
has multiple sclerosis = most stable - showed up on online practice tests)
b. A client who has brain tumor and is admitted for chemotherapy ←dead
c. A client who has guillain-barre syndrome and a tracheostomy -unstable
d. A client who sustained a concussion and is being monitored for complication -unstable
4. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
a. “Once I sign my living will, a family member must co-sign it”
b. “I will wait until I have a serious health problems to sign my advance directives”
c. “My doctor will need to provide approval for the decisions outlines in my living will
d. “My durable power of attorney for health care is part of my advance directives”-
durable power of will and living will are components of advance directives.
Rationale: Leadership 7.0 page 38
5. A nurse is chairing a committee about preventing infant abduction in a new birth care
center. Which of the following quality control tasks should the nurse assign to be completed
first?
a. Identify the industry standards for infant safety
b. Evaluate the selected infant safety system
c. Choose an infant safety system
d. Establish measurement criteria for infant safety systems
6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently
during meals. The nurse plans to perform dysphagia screening to determine the client's need
for a referral to which of the following providers?
a. Physical therapist
b. Respiratory therapist
c. Speech therapist
d. Occupational therapist
7. A home health nurse is assessing the home environment during an initial visit to a client who
has a history of falls. Which of the following findings should the nurse identify as increasing
the client's risk for falls (select all that apply)
- A wheeled office chair at the client's computer desk
- A raised vinyl seat on the toilet in the bathroom
- A throw rug covering some cracked vinyl flooring in the kitchen
- A folding chair without arm rests.
- A two wheeled walker used to assist the client with ambulation
8. A nurse manager is planning to assign care for four clients on a medical surgical unit.
Which of the following clients should the nurse assign to a LPN
a. An older adult who has lung cancer and has periodic episodes of severe dyspnea
b. A middle adult client who has a below the knee amputation and requires a dressing change -
stable; only needs dressing change
c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus
, d. An adolescent who is new diagnosed with DM and requires teaching regarding insulin
administration
1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a
change in the wound care procedure. Which of the following findings indicate
wound healing.
a. Erythema on the skin surrounding a client's wound
b. Deep red color on the center of the clients wound
c. Inflammation noted on the tissue edges of a client's wound
d. Increase in serosanguineous exudate from the clients wound (damaged capillaries)
Rationale: Leadership 7.0 pg
329:
- Stages of Wound Healing
- Inflammatory stage - beginning stage, also usually suggests infection
- Begins with the injury and lasts 3 to 6 days
- Effects to the wound: controlling bleeding with vasoconstriction and
retraction of blood vessels, and with clot formation. Delivering oxygen,
WBCs, nutrients to the area via blood supply. Hemostasis occurs along
with fibrin formation. Macrophages engulf microorganisms and cellular
debris (phagocytosis).
- Proliferative stage
- Lasts the next 3 to 24 days
- Effects to the wound: replacing lost tissue with connective or granulated
tissue or collagen. Contracting the wound‟s edges. Resurfacing of new
epithelial cells. Healthy granulation tissue does not bleed easily. Dark
granulation tissue can be a sign of infection, ischemia, or poor perfusion.
In the final phase of the proliferative stage of wound healing, epithelial
cells resurface the injury.
- Maturation or remodeling stage
- Occurs after day 21 and involves that strengthening of the collagen scar
and restoration of a more normal appearance. It can take more than 1 year
to complete, depending on the extent of the original wound. When scar
tissues are forming.
- Appearance:
- Note the color of open wounds.
- Red: healthy regeneration of tissue.
- Yellow: presence of purulent drainage and slough
- Black: presence of eschar that hinders healing and requires removal.
2. A nurse received change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
a. Obtain a breakfast tray for a client who received a morning dose of
, insulin aspart. - (fast-acting insulin...usually takes effect after 15 minutes)
b. Administer pain medication to a client who has rheumatoid arthritis and
received the last dose at 0400.
c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following
clients should the nurse assign to the newly licensed nurse?
, a. A client who has multiple sclerosis and ataxia - (normal finding for someone that
has multiple sclerosis = most stable - showed up on online practice tests)
b. A client who has brain tumor and is admitted for chemotherapy ←dead
c. A client who has guillain-barre syndrome and a tracheostomy -unstable
d. A client who sustained a concussion and is being monitored for complication -unstable
4. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
a. “Once I sign my living will, a family member must co-sign it”
b. “I will wait until I have a serious health problems to sign my advance directives”
c. “My doctor will need to provide approval for the decisions outlines in my living will
d. “My durable power of attorney for health care is part of my advance directives”-
durable power of will and living will are components of advance directives.
Rationale: Leadership 7.0 page 38
5. A nurse is chairing a committee about preventing infant abduction in a new birth care
center. Which of the following quality control tasks should the nurse assign to be completed
first?
a. Identify the industry standards for infant safety
b. Evaluate the selected infant safety system
c. Choose an infant safety system
d. Establish measurement criteria for infant safety systems
6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently
during meals. The nurse plans to perform dysphagia screening to determine the client's need
for a referral to which of the following providers?
a. Physical therapist
b. Respiratory therapist
c. Speech therapist
d. Occupational therapist
7. A home health nurse is assessing the home environment during an initial visit to a client who
has a history of falls. Which of the following findings should the nurse identify as increasing
the client's risk for falls (select all that apply)
- A wheeled office chair at the client's computer desk
- A raised vinyl seat on the toilet in the bathroom
- A throw rug covering some cracked vinyl flooring in the kitchen
- A folding chair without arm rests.
- A two wheeled walker used to assist the client with ambulation
8. A nurse manager is planning to assign care for four clients on a medical surgical unit.
Which of the following clients should the nurse assign to a LPN
a. An older adult who has lung cancer and has periodic episodes of severe dyspnea
b. A middle adult client who has a below the knee amputation and requires a dressing change -
stable; only needs dressing change
c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus
, d. An adolescent who is new diagnosed with DM and requires teaching regarding insulin
administration
