pressure ulcers
A nurse assesses a patient’s sacral area and notes a shallow open ulcer with a red-pink wound bed and no slough. What stage pressure ulcer is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Rationale: A stage II pressure ulcer presents as a shallow, open wound with a red-pink bed, possibly with some blistering but no slough or necrosis.
A nurse is caring for a patient post-op who reports nausea. What is the priority action?
A. Administer antiemetic as prescribed
B. Increase IV fluids
C. Document the complaint
D. Encourage sips of water
Rationale: Nausea can lead to vomiting, increasing the risk for aspiration. Administering prescribed medication addresses the symptom directly.
A patient presents with a butterfly-shaped rash over the cheeks and nose. What condition should the nurse suspect?
A. Psoriasis
B. Eczema
C. Systemic lupus erythematosus (SLE)
D. Cellulitis
Rationale: The classic malar (butterfly) rash is a hallmark sign of SLE, an autoimmune disorder.
20. A patient scheduled for surgery has a WBC count of 18,000/mm³. What is the nurse’s next action?
A. Proceed to OR
B. Call the provider
C. Document the finding
D. Check platelet count
Rationale: An elevated WBC count may indicate infection, which could delay surgery or change the antibiotic plan.
1. A nurse is assessing a patient's wound and observes a clean cut from a sharp object. Which type of wound is this?
A) Laceration
B) Incision
C) Puncture
D) Avulsion
Answer: B) Incision
Rationale: An incision is a clean cut typically caused by a sharp object, such as a scalpel during surgery.
Which of the following is the most effective nursing intervention to prevent pressure ulcers in a bedridden patient?
A. Massaging red areas
B. Turning the patient every 4 hours
C. Using a donut-type cushion
D. Repositioning the patient every 2 hours
Rationale: Frequent repositioning relieves pressure and improves circulation, reducing the risk of skin breakdown. Every 2 hours is the evidence-based recommendation.
Which of the following should be addressed first in the PACU?
A. BP 130/85
B. RR 10
C. Pain 7/10
D. Temp 37.9°C
Rationale: Respiratory depression (RR <12) is a potential opioid side effect post-op and poses an immediate threat to life.
What is the primary goal in managing a patient with eczema?
A. Prevent scarring
B. Promote sleep
C. Maintain skin hydration
D. Encourage sun exposure
Rationale: Hydration helps reduce itching and prevents flare-ups and infections caused by scratching dry skin.
Which lab value requires immediate intervention preoperatively?
A. Hemoglobin 14 g/dL
B. Platelets 95,000/mm³
C. INR 1.0
D. Potassium 4.0 mEq/L
Rationale: A platelet count below 100,000 increases bleeding risk. Surgery may need to be postponed.
2. Which of the following diseases is associated with poor wound healing due to neuropathy and increased risk of infection?
A) Diabetes Mellitus
B) Peripheral Artery Disease
C) Venous Insufficiency
D) Hypertension
Answer: A) Diabetes Mellitus
Rationale: Diabetes Mellitus can lead to poor circulation, neuropathy, and impaired immune response, all contributing to delayed wound healing.
A patient has a stage IV pressure ulcer with exposed bone. Which interdisciplinary team member is best to consult first?
A. Physical therapist
B. Dietitian
C. Social worker
D. Speech therapist
Rationale: Proper nutrition, particularly adequate protein, is essential for wound healing. A dietitian can optimize nutritional intake to promote recovery.
patient is scheduled for surgery and takes warfarin daily. What is the priority nursing action?
A. Notify the surgeon
B. Administer vitamin K
C. Encourage early ambulation
D. Assess INR in 24 hours
Rationale: Warfarin increases bleeding risk during surgery. The surgeon must be informed to plan accordingly (delay, reverse anticoagulation, etc.).
A patient has vesicles on the lips and reports burning sensation. Which is the most likely diagnosis?
A. Impetigo
B. Herpes simplex
C. Candidiasis
D. Contact dermatitis
Rationale: Herpes simplex causes clusters of painful, fluid-filled vesicles often on the mouth or genitals.
22. Which lab result would require delaying elective surgery?
A. BUN 19 mg/dL
B. Creatinine 1.1 mg/dL
C. INR 2.8
D. Hematocrit 42%
Rationale: An INR >1.5 indicates increased bleeding risk; INR >2.5 often leads to surgery delay.
3. When measuring a wound, which of the following is the correct order?
A) Width, Depth, Length
B) Length, Width, Depth
C) Depth, Length, Width
D) Width, Length, Depth
Answer: B) Length, Width, Depth
Rationale: Wound measurements are typically taken in the order of length (head-to-toe), width (side-to-side), and depth (using a sterile cotton applicator).
A patient with a pressure ulcer has a wound culture positive for Pseudomonas aeruginosa. What is the most appropriate nursing action?
A. Apply dry sterile dressing
B. Initiate contact precautions
C. Stop all antibiotics
D. Leave the wound open to air
Rationale: Pseudomonas is a multidrug-resistant organism. Contact precautions help prevent its spread, especially in healthcare settings.
A nurse reviews the lab report of a pre-op patient and finds a potassium level of 3.0 mEq/L. What is the next best action?
A. Continue with surgery as planned
B. Call the provider
C. Document the result
D. Monitor for fluid overload
Rationale: Hypokalemia increases the risk of arrhythmias during anesthesia. Notify the provider before proceeding.
Which statement indicates correct understanding about psoriasis?
A. “It is a contagious skin condition.”
B. “It may improve with sunlight.”
C. “Antibiotics are used to treat it.”
D. “It is caused by a bacterial infection.”
Rationale: UV light can slow the growth of skin cells in psoriasis. It’s an autoimmune disease—not contagious or bacterial.
A nurse is caring for a patient with a stage II pressure ulcer on the sacrum. Which dressing is most appropriate to promote healing?
A. Dry gauze dressing
B. Hydrocolloid dressing
C. Transparent film dressing
D. Wet-to-dry dressing
Rationale: Hydrocolloid dressings maintain a moist environment, promoting wound healing for stage II pressure ulcers. Dry gauze and wet-to-dry dressings are not ideal for this stage, and transparent film dressings are more suitable for stage I ulcers.
4. A nurse is caring for a patient with a stage II pressure ulcer. Which dressing is most appropriate to promote healing?
A) Hydrocolloid dressing
B) Transparent film dressing
C) Wet-to-dry dressing
D) Dry gauze dressing
Answer: A) Hydrocolloid dressing
Rationale: Hydrocolloid dressings maintain a moist environment, promoting healing for partial-thickness wounds like stage II pressure ulcers.
The Braden Scale is used to assess risk for:
A. Deep vein thrombosis
B. Pressure ulcer development
C. Surgical site infection
D. Nutritional deficiency
Rationale: The Braden Scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear to assess pressure injury risk.
Which action is most important before obtaining informed consent?
A. Explaining the surgical procedure
B. Ensuring the patient has voided
C. Verifying understanding and witnessing signature
D. Giving the patient food and water
Rationale: The nurse ensures the patient is mentally capable of understanding the procedure and is signing voluntarily—not under duress or influence.
Which assessment finding in a patient with cellulitis should be reported immediately?
A. Erythema and warmth
B. Local pain and swelling
C. Fever of 101°F
D. Numbness in the affected area
Rationale: Numbness suggests possible nerve involvement or compartment syndrome—this is an emergency.
A nurse is caring for an elderly patient who has been bedridden for an extended period. The nurse notices a deep, open wound on the patient’s sacral area. What is the immediate nursing action?
A. Clean the wound with hydrogen peroxide
B. Apply a sterile dressing to the wound
C. Document the wound appearance and size
D. Reposition the patient to relieve pressure
Rationale: The immediate priority for an open pressure ulcer is to relieve pressure on the affected area to prevent further damage. Cleaning the wound, applying a dressing, and documenting are important but secondary actions.
Which of the following is a common sign of wound infection?
A) Clear, watery drainage
B) Foul-smelling, purulent drainage
C) Dry, black eschar
D) Pink granulation tissue
Answer: B) Foul-smelling, purulent drainage
Rationale: Purulent drainage that is foul-smelling often indicates infection and requires prompt medical attention.