QUESTIONS AND ANSWERS WITH
RATIONALES LATEST 2022
1. A nurse is caring for a client who has a stage II pressure ulcer. Which of the following
wound dressings should the nurse apply to the ulcer?
A. Hydrocolloid
-The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of
dressing is applied to absorb exudate and to produce a moist environment that will facilitate
healing while preventing maceration of surrounding skin.
,B. Collagen
-incorrect: The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells
into the wound, and stimulate their proliferation to facilitate healing.
C. Calcium alginate
-incorrect: The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of
dressing is used for wounds with significant exudate and must be covered with a secondary
dressing.
D. Proteolytic enzyme
-incorrect: The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. This
type of dressing is applied to facilitate debridement and to soften eschar.
2. A nurse on a medical-surgical unit observes smoke billowing from a client’s room. Which
of the following actions should the nurse take first?
A. Close the door to the client’s room
-incorrect: The nurse should close the doors and windows in the immediate vicinity to help
contain the fire; however, this is not the first action the nurse should take.
B. Evacuate the client from the room
, -The acronym RACE can help nurses remember the order of the actions to take in the event of a
fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is
rescuing or removing the client from immediate danger. The second action is activation of the
fire alarm system. The third action is confining the fire by closing doors and windows. The final
action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to
extinguish a fire could compromise the safety of clients or staff members, the nurse should await
the arrival of emergency fire personnel.
C. Sound the fire alarm
-incorrect: The nurse should sound the fire alarm to summon fire professionals to put out the fire
and ensure safety in the facility; however, this is not the first action the nurse should take.
D. Activate the fire extinguisher
-incorrect: The nurse should attempt to extinguish the fire safely if possible; however, this is not
the first action the nurse should take.
3. A. nurse is teaching a client who is recovering from gallbladder surgery how to use an
incentive spirometer. Which of the following pieces of information should the nurse include in
the teaching?
A. Exhale slowly to reach the goal volume
-incorrect: The nurse should instruct the client to inhale slowly to reach the goal volume and to