Davis Advantage Chapter 50
Exam Questions and Correct
Solutions
The nurse is assigned to a patient who is preparing to go to surgery for wound debridement. The nurse
explains to the patient the purpose of the wound debridement, including which of the following? Select
all that apply.
Facilitates healing
Removal of tissue for a biopsy
Removal of necrotic tissue
Reduces the risk of infection
Reduces the risk of fluid imbalance - Correct Answers:
The nurse is explaining to the student nurse the difference between undermining and tunneling. How
should the nurse explain the two terms?
"Undermining is measuring a passageway under the skin surface and tunneling is the destruction of
tissue extending under the wound edges."
"Undermining is the measurement of the wound's length from head to toe and tunneling is the
measurement of the wound's widest point perpendicular to the length."
"Undermining is the destruction of tissue under the wound edges and tunneling is the development of a
passageway under the skin's surface."
"Undermining is the development of infection in the wound bed of the wound and tunneling is the
development of necrotic tissue over the wound." - Correct Answers: "Undermining is the destruction of
tissue under the wound edges and tunneling is the development of a passageway under the skin's
surface."
The nurse is caring for a patient at risk for skin breakdown. Which nursing interventions are appropriate
to implement to minimize the effects of injury? Select all that apply.
Keep the head of the bed less than 60 degrees.
Use a draw sheet when moving the patient.
Minimize the amount of time the patient is in one position.
, Firmly massage reddened areas noted on the back, hips, and coccyx.
Use alcohol-based skin products. - Correct Answers:
Upon admission, the nurse knows that all patients must be assessed using the Braden Scale to evaluate
the patient's risk for skin breakdown. Which of the following areas are included when assessing the
patient using the Braden Scale? Select all that apply.
Activity
Nutrition
Mobility
Body mass index
Gender - Correct Answers:
The nurse is caring for a client who has a large full-thickness burn and is going to the operating room to
have a burn excision. The nurse notes on the surgical consent that an allograft is planned. The tissue for
an allograft is from which source?
The client's own skin
The skin from a pig
The skin from a cadaver
The skin grown in the lab from a biopsy of the client's own skin - Correct Answers: The skin from a
cadaver
The nurse is caring for a client in the intensive care unit who is 36 hours post-deep partial-thickness burn
to the left lower extremity. Which nursing interventions would be in place to decrease the development
of compartment syndrome?
Monitor pulses in both burned and unburned extremities every 8 hours.
Assess pulses hourly in burned and unburned extremities.
Monitor sodium and potassium levels every 4 hours.
Maintain the head of the client's bed at 45 degrees. - Correct Answers: Assess pulses hourly in burned
and unburned extremities.
A client with a major burn injury is at great risk of burn shock. What factor causes this type of shock?
Infection
Exam Questions and Correct
Solutions
The nurse is assigned to a patient who is preparing to go to surgery for wound debridement. The nurse
explains to the patient the purpose of the wound debridement, including which of the following? Select
all that apply.
Facilitates healing
Removal of tissue for a biopsy
Removal of necrotic tissue
Reduces the risk of infection
Reduces the risk of fluid imbalance - Correct Answers:
The nurse is explaining to the student nurse the difference between undermining and tunneling. How
should the nurse explain the two terms?
"Undermining is measuring a passageway under the skin surface and tunneling is the destruction of
tissue extending under the wound edges."
"Undermining is the measurement of the wound's length from head to toe and tunneling is the
measurement of the wound's widest point perpendicular to the length."
"Undermining is the destruction of tissue under the wound edges and tunneling is the development of a
passageway under the skin's surface."
"Undermining is the development of infection in the wound bed of the wound and tunneling is the
development of necrotic tissue over the wound." - Correct Answers: "Undermining is the destruction of
tissue under the wound edges and tunneling is the development of a passageway under the skin's
surface."
The nurse is caring for a patient at risk for skin breakdown. Which nursing interventions are appropriate
to implement to minimize the effects of injury? Select all that apply.
Keep the head of the bed less than 60 degrees.
Use a draw sheet when moving the patient.
Minimize the amount of time the patient is in one position.
, Firmly massage reddened areas noted on the back, hips, and coccyx.
Use alcohol-based skin products. - Correct Answers:
Upon admission, the nurse knows that all patients must be assessed using the Braden Scale to evaluate
the patient's risk for skin breakdown. Which of the following areas are included when assessing the
patient using the Braden Scale? Select all that apply.
Activity
Nutrition
Mobility
Body mass index
Gender - Correct Answers:
The nurse is caring for a client who has a large full-thickness burn and is going to the operating room to
have a burn excision. The nurse notes on the surgical consent that an allograft is planned. The tissue for
an allograft is from which source?
The client's own skin
The skin from a pig
The skin from a cadaver
The skin grown in the lab from a biopsy of the client's own skin - Correct Answers: The skin from a
cadaver
The nurse is caring for a client in the intensive care unit who is 36 hours post-deep partial-thickness burn
to the left lower extremity. Which nursing interventions would be in place to decrease the development
of compartment syndrome?
Monitor pulses in both burned and unburned extremities every 8 hours.
Assess pulses hourly in burned and unburned extremities.
Monitor sodium and potassium levels every 4 hours.
Maintain the head of the client's bed at 45 degrees. - Correct Answers: Assess pulses hourly in burned
and unburned extremities.
A client with a major burn injury is at great risk of burn shock. What factor causes this type of shock?
Infection
