Ch22 | Complete Test Bank – Preventing Pressure Ulcers And

Test Generator Questions, Chapter 22, Preventing Pressure Ulcers and Assisting With Wound Care

Format:  Multiple Choice

Chapter Number:  22

Client Needs:  Physiological Integrity: Basic Care and Comfort

Cognitive Level:  Understand

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  490, Preventing Pressure Ulcers

1. Which is the major cause of pressure ulcers?

A) Being elderly

B) Being overweight

C) Being immobile

D) Being hydrated

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  490, Preventing Pressure Ulcers

2. The client has shallow craters on the coccyx and heels. The nursing assistant has placed the client on a pressure relieving mattress. What additional action would the nursing assistant take?

A) No additional action is needed because the mattress relieves the pressure and helps the areas to heal.

B) Determine whether the areas improve or get worse and chart the condition of the skin over the next several days.

C) Employ the turning schedule and elevate the lower leg on pillows to elevate the heels off the bed.

D) Change wet bed linens at least every 4 hours and cleanse skin of any incontinence as necessary.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  5

Page and Header:  490, Preventing Pressure Ulcers

3. A nursing assistant best helps prevent a pressure ulcer from forming by:

A) changing the client’s bed linen according to the facility’s policy.

B) repositioning an immobile client each time the client asks.

C) keeping an incontinent client’s skin clean and dry.

D) toileting the client at least every 3 hours.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  490, Preventing Pressure Ulcers

4. Which factor increases a client’s risk of developing a pressure ulcer?

A) A fungal infection of the skin

B) A heart problem

C) History of cancer

D) Dark skin

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  6

Page and Header:  490, Preventing Pressure Ulcers

5. Which item has the least effect on preventing pressure ulcers from forming?

A) Specialty beds

B) Heel booties

C) Elbow pads

D) Warm socks

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  490, Preventing Pressure Ulcers

6. When a comatose resident is placed in the lateral position, the most likely place for a pressure ulcer to form is on the:

A) breastbone.

B) coccyx.

C) shin.

D) hip.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  499, Assisting With Wound Care

7. When assisting the nurse with a dressing change, which is a responsibility of the nursing assistant?

A) Removing the soiled dressing

B) Handing the clean dressing to the nurse

C) Cutting the tape that will be used to secure the dressing

D) Cleaning the person’s wound before the new dressing is applied

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  499, Assisting With Wound Care

8. The nursing assistant observes that the client’s skin around the abdominal dressing is slightly irritated from previous cloth tape used during dressing changes. When preparing for the next dressing change, what is the appropriate dressing for the nursing assistant to choose?

A) Paper tape

B) Kerlix gauze

C) Elastic bandage

D) Montgomery ties

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  499, Assisting With Wound Care

9. The main purpose of a wound drain is to:

A) secure the wound’s dressing.

B) protect the linen from the drainage.

C) allow wound drainage to leave the wound.

D) make it possible to observe the wound drainage.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  499, Assisting With Wound Care

10. What action does the nursing assistant include when turning the client with a wound drain in place?

A) Empty the drain before turning.

B) Re-position the client being careful to not pull or put tension on the drain.

C) Report to the nurse if more drainage appears in the collection container after resident is repositioned.

D) Document the amount, color, odor, and texture of the drainage after repositioning.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  490, Preventing Pressure Ulcers

11. It is true that when an immobile client sits on a hard surface for too long, the biggest problem that can occur is that:

A) a stage 1 pressure ulcer can form.

B) the client is likely to become uncomfortable.

C) the client may be incontinent of urine or stool.

D) a rash may develop on the client’s buttocks and legs.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  490, Preventing Pressure Ulcers

12. When bathing a resident in bed, the nursing assistant is most concerned about pressure ulcer development when finding that the resident has:

A) been incontinent of both stool and urine.

B) very dry skin on the feet and elbows.

C) drainage on the abdominal dressing.

D) a pale, shiny area on the right heel.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  499, Assisting With Wound Care

13. The nursing assistant observes the wounds of four clients. Which client would the nursing assistant report to the nurse immediately? The client who:

A) has a dressing dated with yesterday’s date.

B) has a dressing saturated with bloody drainage.

C) has dry and intact sutures and pink skin.

D) needs to splint the wound when coughing.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  499, Assisting With Wound Care

14. What must happen for a person with a wound to remain healthy?

A) The wound must heal so that the skin is once again intact.

B) The person must take an antibiotic to prevent an infection.

C) The wound must be cleansed daily to keep it from getting infected.

D) The person must drink enough water and other fluids to stay hydrated.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  490, Preventing Pressure Ulcers

15. A nursing assistant caring for a client with a stage 2 pressure ulcer would immediately report which finding to the nurse?

A) The client has been drinking water and juice between meals.

B) An oral temperature that is 1 degree higher than it was 4 hours ago.

C) The client has become incontinent of urine twice in the last 4 hours.

D) A request from the client to have a second serving of ice cream for dessert.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  490, Preventing Pressure Ulcers

16. The nursing assistant is caring for a client with generalized weakness, chronic heart failure, and frequent incontinence. What action should the nursing assistant take to decrease the development of a pressure ulcer?

A) Use the pressure-relieving seat cushion when the client sits in a chair for 1 hour.

B) Encourage the client to turn frequently when in bed to decrease the risk of skin breakdown.

C) Apply a bed protector under the bedpan and leave the client on the bedpan for 25 minutes every 2 hours.

D) Choose a skin barrier to apply to the coccyx to keep the client dry when the client is incontinent.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  490, Preventing Pressure Ulcers

17. A nursing assistant caring for a client with a stage 3 pressure ulcer would immediately report which finding to the nurse?

A) A foul odor to the wound

B) Serous drainage from the wound

C) Discomfort when the client lies on the coccyx

D) A change in appearance to a shallow crater in the area

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  490, Preventing Pressure Ulcers

18. The nursing assistant is caring for a client with a pale shiny area on their left heel. What is the appropriate action for the nursing assistant to take?

A) Chart the observation and actions used.

B) Massage the area and wait 5 minutes to observe.

C) Apply lotion to the skin on the bottom of the feet.

D) Place the lower legs on pillows to elevate the heels.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  499, Assisting With Wound Care

19. The nursing assistant is caring for a client who returned an hour ago from surgery and has an indwelling urinary catheter, an intravenous line, and a hemovac wound drain in place. What observation would the nursing assistant report immediately to the nurse?

A) The client is drowsy and requests a blanket.

B) The hemovac is full of bloody drainage.

C) The dressing has a small area of bloody drainage present.

D) There is 100 mL of urine in the indwelling urine bag.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective.:  4

Page and Header:  490, Preventing Pressure Ulcers

20. The nursing assistant is caring for an unconscious resident. What is the best action by the nursing assistant to prevent a pressure ulcer?

A) Apply a pressure-relieving mattress on the resident’s bed.

B) Employ a bed protector under the resident’s skin.

C) Use a lift sheet to move the resident up in the bed.

D) Examine the linens during reposition and change as needed.