SOLVED

 Question 11 A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)? 1. Diagnosis of type 2 diabetes mellitus 2. Daily use of NSAIDs for arthritis symptoms 3. Diagnosis of peripheral vascular disease 4. History of radiation therapy to treat colon cancer Question 12 The patient’s colectomyincision is red and the skin around the sutures is taut and shiny. What nursing intervention is indicated? 1. Assess for the presence of drainage or odor. 2. Clean this healing wound and redress as ordered. 3. Collaborate with the health care provider regarding suture removal. 4. Instruct the patient to use additional splinting for deep breathing and coughing. Question 13 A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care for this wound with the knowledge that it has penetrated to which skin level? 1. Epidermis 2. Hypodermis 3. Dermis 4. Cartilage Question 14 The nurse measures a patient’s wound diameter and notes that it has reduced in size. The nurse evaluates this information to indicate the wound has entered which phase? 1. Remodeling 2. Inflammatory 3. Maturation 4. Proliferative Question 15 A patient with several burn scars tells the nurse that the scars are prone to injury and don’t seem as tough as the rest of his skin. Which nursing response is indicated? 1. “Even when healed, the scar will only regain about 80% of the strength of normal skin.” 2. “Your body is still making new blood vessels for the wound.” 3. “Your body is trying to remove additional bacteria from the wound area.” 4. “Your healing process hasn’t been completed.” Question 16 The nurse is assessing a wound using the technique shown in this picture. How would the nurse document this assessment? 1. The wound is macerated. 2. The wound is tunneled. 3. The wound is deep. 4. The wound is filled with exudate. Question 17 A nurse documents a stage 1 pressure ulcer on a patient’s lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II? 1. The subcutaneous fat layer is exposed. 2. A fluid-filled blister is present. 3. A shallow open ulcer is present. 4. There is an area of boggy purple skin on the bony prominence. 5. There is an area of skin that does not turn white with pressure. Question 18 The wound care specialist has assessed a patient’s pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV Question 19 During initial assessment the nurse notes that the edges of a wound are hard to palpation. The nurse would continue assessment for which conditions? 1. Infection 2. Necrosis 3. Osteomyelitis 4. Deep tissue injury 5. Maceration Question 20 The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection. Which nursing intervention is indicated? 1. Draw peak and trough concentrations as indicated. 2. Give the medication over a 2-hour period. 3. Hold the medication if the patient experiences nausea. 4. Monitor for increase in creatinine clearance.