QUESTIONS, ANSWERS AND RATIONALES.
1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the
wound care
... [Show More] procedure. Which of the following findings indicate wound healing.
a. Erythema on the skin surrounding a client's wound
b. Deep red color on the centre of the clients wound
c. Inflammation noted on the tissue edges of a client's wound
d. Increase in serosanguineous exudate from the clients' wound (damaged capillaries)
Rationale: Leadership 7.0 pg 329:
- Stages of Wound Healing
- Inflammatory stage - beginning stage, also usually suggests infection
- Begins with the injury and lasts 3 to 6 days
- Effects to the wound: controlling bleeding with vasoconstriction and retraction of
blood vessels, and with clot formation. Delivering oxygen, WBCs, nutrients to the
area via the blood supply. Hemostasis occurs along with fibrin formation.
Macrophages engulf microorganisms and cellular debris (phagocytosis).
- Proliferative stage
- Lasts the next 3 to 24 days
- Effects to the wound: replacing lost tissue with connective or granulated tissue or
collagen. Contracting the wound’s edges. Resurfacing of new epithelial cells. Healthy
granulation tissue does not bleed easily. Dark granulation tissue can be a sign of
infection, ischemia, or poor perfusion. In the final phase of the proliferative stage of
wound healing, epithelial cells resurface the injury.
- Maturation or remodelling stage
- Occurs after day 21 and involves the strengthening of the collagen scar and
restoration of a more normal appearance. It can take more than 1 year to complete,
depending on the extent of the original wound. When scar tissues are forming.
- Appearance:
- Note the color of open wounds.
- Red: healthy regeneration of tissue.
- Yellow: the presence of purulent drainage and slough
- Black: the presence of eschar that hinders healing and requires removal.
2. A nurse received change of shift report at 0700 for four clients. Which of the following actions should the
nurse perform first?
a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart. -
(fast-acting insulin...usually takes effect after 15 minutes)
b. Administer pain medication to a client who has rheumatoid arthritis and received the last
dose at 0400.
c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should
the nurse assign to the newly licensed nurse?
a. A client who has multiple sclerosis and ataxia - (normal finding for someone that has multiple
sclerosis= most stable - showed up on online practice tests)
b. A client who has a brain tumor and is admitted for chemotherapy ← dead
c. A client who has guillain-barre syndrome and a tracheostomy -unstable
d. A client who sustained a concussion and is being monitored for complication -unstable
4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the
client indicates an understanding of the teaching?
a. “Once I sign my living will, a family member must co-sign it”
b. “I will wait until I have a serious health problems to sign my advance directives”
c. “My doctor will need to provide approval for the decisions outlines in my living will
d. “My durable power of attorney for health care is part of my advance directives”-durable power
of will and living will are components of advance directives.
Rationale: Leadership 7.0 page 38
5. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of
the following quality control tasks should the nurse assign to be completed first?
a. Identify the industry standards for infant safety
b. Evaluate the selected infant safety system
c. Choose an infant safety system
d. Establish measurement criteria for infant safety systems
6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals.
The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the
following providers?
a. Physical therapist
b. Respiratory therapist
c. Speech therapist
d. Occupational therapist
7. A home health nurse is assessing the home environment during an initial visit to a client who has a history
of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (select
all that apply)
- A wheeled office chair at the client's computer desk
- A raised vinyl seat on the toilet in the bathroom
- A throw rug covering some cracked vinyl flooring in the kitchen
- A folding chair without arm rests. - A two-wheeled walker used to assist the client with ambulation
8. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the
following clients should the nurse assign to a LPN
a. An older adult who has lung cancer and has periodic episodes of severe dyspnea
b. A middle adult client who has a below the knee amputation and requires a dressing change -
stable; only needs dressing change
c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus
d. An adolescent who is newly diagnosed with DM and requires teaching regarding insulin administration [Show Less]