NUR 1400 Week 5 Practice questions & answers
ATI Quiz Bank
1. A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the
nurse expect to heal by primary intention?
a. Partial-thickness burns
i. A partial-thickness burn heals by spontaneous re-epithelialization. Since it involves the uppermost
layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn
b. Stage III pressure ulcer
i. Stage II pressure ulcer will heal by secondary intention
c. Surgical incision
i. With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and
minimal scarring. A surgical incision is an example of wound that heals by primary intention
d. Dehisced sternal wound
i. A dehisced sternal wound can either close by secondary or tertiary intention
2. A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that,
in addition to protein, which of the following nutrients promotes wound healing?
a. Vitamin B1
i. Vitamin B1 promotes functioning of the nervous system; however, it does not specifically promote
wound healing
b. Calcium
i. Calcium aids in blood clotting and muscle contraction; however, it does not specifically promote wound
healing
c. Vitamin C
i. A diet high in protein and vitamin C is recommended because these nutrients promote wound healing
d. Potassium
i. Potassium is necessary for muscle activity and fluid balance; however, it does not specifically promote
wound healing
3. A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of
pressure ulcer formation. Which of the following instructions should the nurse include?
a. “Move between the bed and the wheelchair once every 2 hours.”
i. The nurse should instruct wheelchair-bound clients at risk for pressure ulcer formation to change
position at least once every hour
b. “Make sure that your caregiver massages your skin daily.”
i. The nurse should instruct the client and his caregiver to avoid massaging the skin, especially over bony
prominences, because it can further traumatize fragile tissues
c. “Use a rubber ring when sitting at the bedside.”
i. The nurse should instruct the client and his caregiver to avoid using a rubber ring for sitting because it
reduces circulation to the client’s skin
d. “Shift your weight in the wheelchair every 15 minutes.”
i. This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to
develop if the client does not shift position frequently to relieve pressure
,NUR 1400 Week 5 Practice questions & answers
4. A nurse in a provider’s office is assessing a client’s skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size,
elevated, and solid with very distinct borders. The nurse should document the findings as which of the following skin
lesions?
a. Papules
i. A papule. Is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in
diameter. Papules are common lesions of warts and elevated moles
b. Macules
i. A macule is flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter. A
macule is a change in the color of the skin. Freckles and the rash associated with rubella are types of
macules
c. Wheals
i. Wheals, also known as hives, are transient, elevated, irregularly shaped lesions caused by localized
edema. Wheals are common manifestations of an allergic reaction
d. Vesicles
i. A vesicle is a circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise
with herpes simplex, poison ivy, and chickenpox
5. A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the
epidermis of the client’s sacral area. The nurse should document that the client has a pressure ulcer at which of the
following stages?
a. IV
i. With a stage IV pressure ulcer, the client has full-thickness tissue loss, with destruction, tissue necrosis,
and visible damage to muscle, bone, or supporting structures. Sinus tracts, deep pockets of infection,
tunneling, and undermining can occur.
b. I
i. With a stage I pressure ulcer, the skin is intact with an area of persistent, nonblanchable redness,
usually over a bony prominence, that might feel warm or cool when touched. The tissue is swollen and
congested, and the client might report discomfort at the site. With darker skin tones, the ulcer can
appear blue or purple and different from other skin areas.
c. III
i. With a stage III pressure ulcer, there is full-thickness tissue loss with damage to or necrosis of
subcutaneous tissue. The ulcer might extend down to, but not through, underlying fascia. The ulcer
appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle
or bone. Drainage and infection are common.
d. II
i. With a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis and the
dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater.
Edema persists, and the ulcer might become infected. The client might report pain, and there might be
a small amount of drainage.
6. 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
,NUR 1400 Week 5 Practice questions & answers
i. 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
i. 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
i. 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.
d. Proteolytic enzyme
i. 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.
7. A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of
the following actions should the nurse take first?
a. Obtain the prescribed irrigation solution
i. The nurse should obtain the prescribed irrigation solution prior to performing the procedure; however,
there is another action the nurse should take first.
b. Don PPE
i. The nurse should don personal protective equipment prior to performing the procedure to prevent
exposure to blood or bodily fluids from the client’s wound; however, there is another action the nurse
should take first.
c. Check the client’s pain level
i. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize
nursing actions. Each step of the nursing process builds on the previous step, beginning with an
assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing
intervention, or notify the provider of a change in the client's status, the nurse must first collect
adequate data from the client. Assessing or collecting additional data will provide the nurse with the
knowledge to make an appropriate decision. Therefore, the nurse should determine the client’s level of
pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the
client approximately 30 minutes prior to wound care will decrease pain and increase comfort.
d. Place a waterproof pad under the client’s extremity
i. The nurse should place a waterproof pad under the client’s extremity to protect the linens from
moisture and contamination during the irrigation; however, there is another action the nurse should
take first.
8. A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following
findings of PVD is a risk factor for ulceration of the extremities?
a. Insufficient skin care
i. Insufficient skin care is not the cause of ulcers on the toes of a client who has PVD. However, poor skin
care can lead to skin infections and breakdown.
b. Dehydration
i. Dehydration is not the cause of ulcerations of the client's toes. However, dehydration can delay wound
healing.
c. Immobility
, NUR 1400 Week 5 Practice questions & answers
i. Immobility can cause pressure ulcers if the client is not turned frequently. However, ulcerations of the
client's toes are not caused by immobility. Peer Comparison A3% B1% C8% ✔D88% Difficulty level:
Moderate
d. Impaired circulation
i. Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's
toes. Severe arterial disease is identified through an assessment of the quality of the client's posterior
tibial pulses by comparing the pulses in both feet.
9. A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale,
which of the following parameters should the nurse evaluate?
a. Incontinence
i. Incontinence is a parameter on the Norton scale, not the Braden scale
b. Mental state
i. Mental state is a parameter on the Norton scale, not on the Braden scale
c. Nutrition
i. Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on
the Braden scale for determining a client's risk of developing pressure ulcers.
d. General physical condition
i. General physical condition is a parameter on the Norton scale, not on the Braden scale
10. A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of
information should the nurse include in the teaching? (SATA)
a. Use cotton balls to clean the infected areas
i. Cotton balls should not be used because the fibers can get caught in the wound and cause an infection;
therefore, gauze squares or nonwoven swabs should be used to clean the wound.
b. Cleanse the wound with tap water
i. Tap water or 0.9% sodium chloride should be used to cleanse the wound.
c. Dry the leg wound after cleaning
i. Drying the leg wound after cleaning should be avoided. The wound should be open to the air to allow
the wound to retain moisture and promote healing.
d. Microwave the cleaning solution before applying to the wound
i. The nurse should warm the cleaning solution to the client’s body temperature if possible; however,
using a microwave to warm the solution can make it too hot.
e. Discard soiled bandages in a moisture-proof bag
i. Soiled bandages and gloves should be placed in double-bagged, moisture-proof bags and not in the
regular trash. This prevents the spread of contamination to other family members within the
household.
11. A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following
adhering devices is the best choice for the nurse to use to decrease skin irritation?
a. Abdominal binder
i. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in
bed; however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is
the preferred method when applying a binder. Therefore, the nurse should use a less-restrictive
intervention first.
b. Montgomery straps
ATI Quiz Bank
1. A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the
nurse expect to heal by primary intention?
a. Partial-thickness burns
i. A partial-thickness burn heals by spontaneous re-epithelialization. Since it involves the uppermost
layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn
b. Stage III pressure ulcer
i. Stage II pressure ulcer will heal by secondary intention
c. Surgical incision
i. With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and
minimal scarring. A surgical incision is an example of wound that heals by primary intention
d. Dehisced sternal wound
i. A dehisced sternal wound can either close by secondary or tertiary intention
2. A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that,
in addition to protein, which of the following nutrients promotes wound healing?
a. Vitamin B1
i. Vitamin B1 promotes functioning of the nervous system; however, it does not specifically promote
wound healing
b. Calcium
i. Calcium aids in blood clotting and muscle contraction; however, it does not specifically promote wound
healing
c. Vitamin C
i. A diet high in protein and vitamin C is recommended because these nutrients promote wound healing
d. Potassium
i. Potassium is necessary for muscle activity and fluid balance; however, it does not specifically promote
wound healing
3. A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of
pressure ulcer formation. Which of the following instructions should the nurse include?
a. “Move between the bed and the wheelchair once every 2 hours.”
i. The nurse should instruct wheelchair-bound clients at risk for pressure ulcer formation to change
position at least once every hour
b. “Make sure that your caregiver massages your skin daily.”
i. The nurse should instruct the client and his caregiver to avoid massaging the skin, especially over bony
prominences, because it can further traumatize fragile tissues
c. “Use a rubber ring when sitting at the bedside.”
i. The nurse should instruct the client and his caregiver to avoid using a rubber ring for sitting because it
reduces circulation to the client’s skin
d. “Shift your weight in the wheelchair every 15 minutes.”
i. This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to
develop if the client does not shift position frequently to relieve pressure
,NUR 1400 Week 5 Practice questions & answers
4. A nurse in a provider’s office is assessing a client’s skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size,
elevated, and solid with very distinct borders. The nurse should document the findings as which of the following skin
lesions?
a. Papules
i. A papule. Is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in
diameter. Papules are common lesions of warts and elevated moles
b. Macules
i. A macule is flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter. A
macule is a change in the color of the skin. Freckles and the rash associated with rubella are types of
macules
c. Wheals
i. Wheals, also known as hives, are transient, elevated, irregularly shaped lesions caused by localized
edema. Wheals are common manifestations of an allergic reaction
d. Vesicles
i. A vesicle is a circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise
with herpes simplex, poison ivy, and chickenpox
5. A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the
epidermis of the client’s sacral area. The nurse should document that the client has a pressure ulcer at which of the
following stages?
a. IV
i. With a stage IV pressure ulcer, the client has full-thickness tissue loss, with destruction, tissue necrosis,
and visible damage to muscle, bone, or supporting structures. Sinus tracts, deep pockets of infection,
tunneling, and undermining can occur.
b. I
i. With a stage I pressure ulcer, the skin is intact with an area of persistent, nonblanchable redness,
usually over a bony prominence, that might feel warm or cool when touched. The tissue is swollen and
congested, and the client might report discomfort at the site. With darker skin tones, the ulcer can
appear blue or purple and different from other skin areas.
c. III
i. With a stage III pressure ulcer, there is full-thickness tissue loss with damage to or necrosis of
subcutaneous tissue. The ulcer might extend down to, but not through, underlying fascia. The ulcer
appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle
or bone. Drainage and infection are common.
d. II
i. With a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis and the
dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater.
Edema persists, and the ulcer might become infected. The client might report pain, and there might be
a small amount of drainage.
6. 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
,NUR 1400 Week 5 Practice questions & answers
i. 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
i. 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
i. 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.
d. Proteolytic enzyme
i. 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.
7. A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of
the following actions should the nurse take first?
a. Obtain the prescribed irrigation solution
i. The nurse should obtain the prescribed irrigation solution prior to performing the procedure; however,
there is another action the nurse should take first.
b. Don PPE
i. The nurse should don personal protective equipment prior to performing the procedure to prevent
exposure to blood or bodily fluids from the client’s wound; however, there is another action the nurse
should take first.
c. Check the client’s pain level
i. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize
nursing actions. Each step of the nursing process builds on the previous step, beginning with an
assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing
intervention, or notify the provider of a change in the client's status, the nurse must first collect
adequate data from the client. Assessing or collecting additional data will provide the nurse with the
knowledge to make an appropriate decision. Therefore, the nurse should determine the client’s level of
pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the
client approximately 30 minutes prior to wound care will decrease pain and increase comfort.
d. Place a waterproof pad under the client’s extremity
i. The nurse should place a waterproof pad under the client’s extremity to protect the linens from
moisture and contamination during the irrigation; however, there is another action the nurse should
take first.
8. A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following
findings of PVD is a risk factor for ulceration of the extremities?
a. Insufficient skin care
i. Insufficient skin care is not the cause of ulcers on the toes of a client who has PVD. However, poor skin
care can lead to skin infections and breakdown.
b. Dehydration
i. Dehydration is not the cause of ulcerations of the client's toes. However, dehydration can delay wound
healing.
c. Immobility
, NUR 1400 Week 5 Practice questions & answers
i. Immobility can cause pressure ulcers if the client is not turned frequently. However, ulcerations of the
client's toes are not caused by immobility. Peer Comparison A3% B1% C8% ✔D88% Difficulty level:
Moderate
d. Impaired circulation
i. Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's
toes. Severe arterial disease is identified through an assessment of the quality of the client's posterior
tibial pulses by comparing the pulses in both feet.
9. A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale,
which of the following parameters should the nurse evaluate?
a. Incontinence
i. Incontinence is a parameter on the Norton scale, not the Braden scale
b. Mental state
i. Mental state is a parameter on the Norton scale, not on the Braden scale
c. Nutrition
i. Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on
the Braden scale for determining a client's risk of developing pressure ulcers.
d. General physical condition
i. General physical condition is a parameter on the Norton scale, not on the Braden scale
10. A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of
information should the nurse include in the teaching? (SATA)
a. Use cotton balls to clean the infected areas
i. Cotton balls should not be used because the fibers can get caught in the wound and cause an infection;
therefore, gauze squares or nonwoven swabs should be used to clean the wound.
b. Cleanse the wound with tap water
i. Tap water or 0.9% sodium chloride should be used to cleanse the wound.
c. Dry the leg wound after cleaning
i. Drying the leg wound after cleaning should be avoided. The wound should be open to the air to allow
the wound to retain moisture and promote healing.
d. Microwave the cleaning solution before applying to the wound
i. The nurse should warm the cleaning solution to the client’s body temperature if possible; however,
using a microwave to warm the solution can make it too hot.
e. Discard soiled bandages in a moisture-proof bag
i. Soiled bandages and gloves should be placed in double-bagged, moisture-proof bags and not in the
regular trash. This prevents the spread of contamination to other family members within the
household.
11. A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following
adhering devices is the best choice for the nurse to use to decrease skin irritation?
a. Abdominal binder
i. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in
bed; however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is
the preferred method when applying a binder. Therefore, the nurse should use a less-restrictive
intervention first.
b. Montgomery straps
