Online Practice Test 36

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 36 > NCLEX® Review Date/Time Submitted: July 24, 2012 at 7:44 AM (UTC/GMT)

Summary of Results 40% Correct of 10 Scored items: 4 Correct:  40% 6 Incorrect:  60% More information about scoring

1.		Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? Your Answer: Using a heating pad Correct Answer: Sitting in Fowler's position
		Objective: Describe factors affecting skin integrity. Rationale: None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The client at greatest risk for postoperative wound infection is: Your Answer: A 32-year-old diabetic postoperative from an appendectomy Correct Answer: An 18-year-old drug user postoperative from removal of a bullet in the leg
		Objective: Describe the three phases of wound healing. Rationale: All are at risk for infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is at great risk for immune deficiency. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		Why is a client with fever often predisposed to pressure ulcers? Your Answer: The client may be too weak to change position. Correct Answer: Increased metabolism causes increased oxygen needs that cannot be met.
		Objective: Identify assessment data pertinent to skin integrity, pressure sites, and wounds. Rationale: Increased metabolism causes increased oxygen needs that cannot be met; therefore, a client with a fever is predisposed to pressure ulcers. Answers 1 and 2 are false statements. Answer 3 may be a cause of pressure ulcers and may occur in clients with fever, but it is not directly related. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		Black wounds are treated with debridement. Which type of debridement is most selective and least damaging? Your Answer: Debridement with wet to dry dressings Correct Answer: Chemical debridement
		Objective: Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. Rationale: Chemical debridement is either done with enzyme agents or autolytic agents. Answer 1 is a type of sharp debridement. Answers 2 and 3 are mechanical and less precise than chemical. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: Your Answer: Purulent
		Objective: Identify three major types of wound exudates. Rationale: Drainage is described as purulent. Sanguineous and Serous-sanguineous contain blood. Serous is clear and watery. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
6.		The nurse cares for a client with a wound in the late regeneration phase of tissue repair. The wound may be protected by applying a:  Your Answer: Transparent film
		Objective: Identify purposes of commonly used wound dressing materials and binders. Rationale: Wounds in the regeneration phase of healing need to be protected as new tissue grows. Answers 2, 3, and 4 are dressings used to remove nonviable tissue. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		A client has a diabetic stasis ulcer on the lower leg. The nurse uses a hydrocolloid dressing to cover it. The procedure for application includes: Your Answer: Holding in place for one minute to allow it to adhere
		Objective: Identify essential steps of obtaining wound specimens, applying dressings, and irrigating a wound. Rationale: The skin is cleansed with normal saline or a mild cleanser. Residue of old dressings will dissolve. The dressing size is to be 3-4 cm (1.5 inches) larger than the size of the wound. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		A home health nurse visits a client who twisted an ankle in the morning. The client has an ice bag on the ankle. Which one of the client's chronic conditions contraindicates the use of ice? Your Answer: Osteoporosis Correct Answer: Diabetes
		Objective: Identify physiologic responses to and purposes of heat and cold. Rationale: Diabetes contradicts the use for ice. Clients with neurological or circulatory impairment are at risk for injury with ice use. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as: Your Answer: Laceration
		Objective: Identify assessment data pertinent to skin integrity, pressure sites, and wounds. Rationale: Laceration best describes the wound, because skin is ripped off. An abrasion is a scrape.Unapproximated is a general term for a wound that is not closed. Eschar is a scab-like covering over a wound. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		What physiological conditions are contraindicated for using heat as a therapy? (Select all that apply.) Your Answer: Active hemorrhage  Noninflammatory edema Localized malignant tumor Correct Answers: The first 24 hours of injury Active hemorrhage  Noninflammatory edema Localized malignant tumor
		Objective: Identify physiologic responses to heat and cold and purposes of heat and cold. Rationale: Heat causes vasodilatation and increases blood flow to the affected area bringing oxygen, nutrients, antibodies, and leukocytes. A possible disadvantage of heat is that it increases capillary permeability, which allows extracellular fluid and substances to pass through the capillary walls and may result in edema or an increase in preexisting edema. Contraindications include: the first 24 hours of injury, active hemorrhage, noninflammatory edema, localized malignant tumor, and skin disorder that causes redness or blisters. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge of physiological changes with application of cold and heat.