N262 EXAM 2 PRACTICE QUESTIONS AND ANSWERS
WITH COMPLETE SOLUTIONS GRADED A++
Chapter 36: Skin and Wound
...
An adult client is incontinent and wears incontinence briefs when using the
wheelchair. An irritated rash has developed in the peri-anal area. What care
should the nurse provide?
a. Wash the area with soap and hot water at every brief change.
b. Apply a petroleum-based cream to the area after cleaning.
c. Wipe the skin with an alcohol-free barrier film agent after cleaning.
d. Keep the client in bed on absorbent pads until the area clears.
c. Wipe the skin with an alcohol-free barrier film agent after cleaning.
Proper technique for performing a wound culture includes which of the
following?
a. Cleansing the wound prior to obtaining the specimen
b. Swabbing for the specimen in the area with the largest
collection of drainage
c. Removing crusts or scabs with sterile forceps and then
culturing the site beneath
d. Waiting 8 hours following a dose of antibiotic to obtain the
specimen
,a. Cleansing the wound prior to obtaining the specimen
A client has a pressure injury with a shallow, partial skin
thickness, and eroded area but no necrotic areas. The nurse would treat the area
with which dressing?
a. Alginate
b. Dry gauze
c. Hydrocolloid
d. No dressing is indicated
c. Hydrocolloid
Hydrocolloid dressings protect shallow injuries and maintain an appropriate healing
environment.
Alginates --> used for wounds with significant drainage
Dry gauze (option 2) will stick to new granulation tissue, causing more damage.
A dressing is needed to protect the wound and enhance healing.
The nurse has applied an aquathermia pad to a client's back. After 15 minutes of
treatment, the client says that the pack is no longer warm and asks the nurse to
increase the temperature. How should the nurse evaluate this request?
a. Since this client's thermal tolerance is higher than normal, increasing the
temperature is necessary.
, b. This client may be experiencing a rebound effect from the application of moist
heat.
c. Adaptation of the thermal receptors often results in the decreased sensation of
warmth.
d. The aquathermia pad should be replaced with a standard hot pack.
c. Adaptation of the thermal receptors often results in the decreased sensation of
warmth.
Which statement, if made by the client or family member, would indicate the need
for further teaching?
a. "If a skin area gets red but then the red goes away after turning, I should report
it to the nurse."
b. "Putting foam pads under my heels or other bony areas can help decrease
pressure."
c. "If my father cannot turn himself in bed, I should help him change position
every 4 hours."
d. "The skin should be washed with only warm water (not hot) and lotion put on
while it is still a little wet."
c. "If my father cannot turn himself in bed, I should help him change position every 4
hours."
The nurse is writing the plan of care for a client who is confined to bed. Which
intervention should be included to help reduce the effects of shearing forces on
the client's skin?
a. Keep the head of the client's bed at 30 degrees.
WITH COMPLETE SOLUTIONS GRADED A++
Chapter 36: Skin and Wound
...
An adult client is incontinent and wears incontinence briefs when using the
wheelchair. An irritated rash has developed in the peri-anal area. What care
should the nurse provide?
a. Wash the area with soap and hot water at every brief change.
b. Apply a petroleum-based cream to the area after cleaning.
c. Wipe the skin with an alcohol-free barrier film agent after cleaning.
d. Keep the client in bed on absorbent pads until the area clears.
c. Wipe the skin with an alcohol-free barrier film agent after cleaning.
Proper technique for performing a wound culture includes which of the
following?
a. Cleansing the wound prior to obtaining the specimen
b. Swabbing for the specimen in the area with the largest
collection of drainage
c. Removing crusts or scabs with sterile forceps and then
culturing the site beneath
d. Waiting 8 hours following a dose of antibiotic to obtain the
specimen
,a. Cleansing the wound prior to obtaining the specimen
A client has a pressure injury with a shallow, partial skin
thickness, and eroded area but no necrotic areas. The nurse would treat the area
with which dressing?
a. Alginate
b. Dry gauze
c. Hydrocolloid
d. No dressing is indicated
c. Hydrocolloid
Hydrocolloid dressings protect shallow injuries and maintain an appropriate healing
environment.
Alginates --> used for wounds with significant drainage
Dry gauze (option 2) will stick to new granulation tissue, causing more damage.
A dressing is needed to protect the wound and enhance healing.
The nurse has applied an aquathermia pad to a client's back. After 15 minutes of
treatment, the client says that the pack is no longer warm and asks the nurse to
increase the temperature. How should the nurse evaluate this request?
a. Since this client's thermal tolerance is higher than normal, increasing the
temperature is necessary.
, b. This client may be experiencing a rebound effect from the application of moist
heat.
c. Adaptation of the thermal receptors often results in the decreased sensation of
warmth.
d. The aquathermia pad should be replaced with a standard hot pack.
c. Adaptation of the thermal receptors often results in the decreased sensation of
warmth.
Which statement, if made by the client or family member, would indicate the need
for further teaching?
a. "If a skin area gets red but then the red goes away after turning, I should report
it to the nurse."
b. "Putting foam pads under my heels or other bony areas can help decrease
pressure."
c. "If my father cannot turn himself in bed, I should help him change position
every 4 hours."
d. "The skin should be washed with only warm water (not hot) and lotion put on
while it is still a little wet."
c. "If my father cannot turn himself in bed, I should help him change position every 4
hours."
The nurse is writing the plan of care for a client who is confined to bed. Which
intervention should be included to help reduce the effects of shearing forces on
the client's skin?
a. Keep the head of the client's bed at 30 degrees.
