NUR 155 Power Hour Exam 3

The nurse determines that the patient’s wound may be infected. To perform an aerobic wound culture, the nurse should

• swab the necrotic tissue area.

• collect the culture before cleansing the wound.

• obtain a culturette tube and use sterile technique.

• place the used swab in a plastic bag and send it to the laboratory.

On inspection of the patient’s wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select on the basis of the wound assessment is

• foam.

• hydrogel.

• hydrocolloid.

• transparent film.

When cleaning a wound, the nurse should do which of the following?

• Go over the wound twice and discard that swab.

• Move from the outer region of the wound toward the center.

• Start at the drainage site and move outward with circular motions.

• Use an enzymatic solution followed by a saline rinse.

You are providing wound care for a stage 1 pressure injury. Which dressing would you use

• Hydrogel

• Transparent

• Antimicrobial

• Calcium Alginate

You are documenting that your patient has a stage 2 pressure injury. Which finding would you expect to see.

• Intact skin

• Full-thickness skin loss

• Exposed bone, tendon, or muscle

• Partial-thickness skin loss with exposed dermis

The nurse is working with a patient with a moderate hearing impairment. To promote communication with this patient, the nurse should do which of the following?

• Use a louder tone of voice than normal.

• Select a public area to have a conversation.

• Approach a patient quietly from behind before speaking.

• Use visual aids such as the hands and eyes when speaking.

The nurse is working with older adult patients in an extended care facility. To enhance the patients’ gustatory sense, which action should the nurse implement?

• Mix foods together

• Assist with oral hygiene

• Make sure foods are extremely spicy

• Provide foods of similar texture and consistency

A home safety measure specific for a patient with diminished olfaction is the use of

• extra lighting in hallways.

• amplified telephone receivers.

• smoke detectors on all levels.

• mild water heater temperatures.

A recommended intervention for a lifestyle stress indicator and reduction in the incidence of heart disease is which of the following activities?

• Regular physical exercise

• Attendance at a support group

• Self-awareness skill development

• Time management

Patients undergoing stress may have periods of regression. For which of the following individuals does the nurse assess regressive behavior?

• An adult patient who exercises to the point of fatigue

• An 8-year-old child who sucks his thumb and wets the bed

• An adult patient who avoids speaking about health concerns

• An 11-year-old child who experiences stomach cramps and headaches