Practice Questions for Exam 2 NUR
340
The nurse assesses a patient's surgical wound on the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is appropriate?
a. Obtain wound cultures.
b. Notify the health care provider.
c. Document the assessment.
d. Assess the wound every 2 hours. - answerC
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a
band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
d. Redress the wound with wet-to-dry dressings. - answerA
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which
assessment finding will the nurse expect next?
a. Skin flushing
b. Rising body temperature
c. Muscle cramps
d. Decreasing blood pressure - answerB
A young adult patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which
action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - answerC
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which
assessment finding will the nurse expect next?
a. Skin flushing
b. Rising body temperature
c. Muscle cramps
d. Decreasing blood pressure - answerB
, A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse apply
to the wound?
a. Dry gauze dressing
b. Hydrocolloid dressing
c. Nonadherent dressing
d. Transparent film dressing - answerB
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - answerD
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas - answerD
A patient arrives in the emergency department with a swollen ankle after a soccer injury.
Which action by the nurse is appropriate?
a. Elevate the ankle above heart level.
b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - answerA
Which action will the nurse include in the plan of care for a patient who is being
admitted with Clostridium difficile?
a. Teach the patient about proper food storage.
b. Order a diet without dairy products for the patient.
c. Place the patient in a private room on contact isolation.
d. Teach the patient about why antibiotics will not be used. - answerC
A 74-yr-old male patient tells the nurse that growing old causes constipation so he has
been using a suppository for constipation every morning. Which action should the nurse
take first?
a. Encourage the patient to increase oral fluid intake.
b. Question the patient about risk factors for constipation.
c. Suggest that the patient increase intake of high-fiber foods.
d. Teach the patient that a daily bowel movement is unnecessary. - answerB
A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question
from the nurse will be most useful in determining the cause of the patient's symptoms?
a. "What type of foods do you eat?"
340
The nurse assesses a patient's surgical wound on the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is appropriate?
a. Obtain wound cultures.
b. Notify the health care provider.
c. Document the assessment.
d. Assess the wound every 2 hours. - answerC
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a
band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
d. Redress the wound with wet-to-dry dressings. - answerA
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which
assessment finding will the nurse expect next?
a. Skin flushing
b. Rising body temperature
c. Muscle cramps
d. Decreasing blood pressure - answerB
A young adult patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which
action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - answerC
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which
assessment finding will the nurse expect next?
a. Skin flushing
b. Rising body temperature
c. Muscle cramps
d. Decreasing blood pressure - answerB
, A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse apply
to the wound?
a. Dry gauze dressing
b. Hydrocolloid dressing
c. Nonadherent dressing
d. Transparent film dressing - answerB
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - answerD
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas - answerD
A patient arrives in the emergency department with a swollen ankle after a soccer injury.
Which action by the nurse is appropriate?
a. Elevate the ankle above heart level.
b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - answerA
Which action will the nurse include in the plan of care for a patient who is being
admitted with Clostridium difficile?
a. Teach the patient about proper food storage.
b. Order a diet without dairy products for the patient.
c. Place the patient in a private room on contact isolation.
d. Teach the patient about why antibiotics will not be used. - answerC
A 74-yr-old male patient tells the nurse that growing old causes constipation so he has
been using a suppository for constipation every morning. Which action should the nurse
take first?
a. Encourage the patient to increase oral fluid intake.
b. Question the patient about risk factors for constipation.
c. Suggest that the patient increase intake of high-fiber foods.
d. Teach the patient that a daily bowel movement is unnecessary. - answerB
A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question
from the nurse will be most useful in determining the cause of the patient's symptoms?
a. "What type of foods do you eat?"
