NCLEX Style Wound
A nurse is providing discharge instructions to a patient with a surgical incision. Which of the following statements by the patient indicates a correct understanding of how to promote optimal wound healing?
A) "I should clean my wound with hydrogen peroxide every day."
B) "I will eat a diet high in protein and vitamin C to help my wound heal."
C) "I should avoid moving around too much to prevent blood flow to the area."
D) "I will keep my wound covered with a dry dressing at all times."
Correct Answer: B) "I will eat a diet high in protein and vitamin C to help my wound heal."
Rationale:
A nurse is reviewing laboratory results for a client suspected of having malnutrition. Which of the following laboratory findings is most indicative of protein-energy malnutrition?
A) Elevated serum calcium
B) Decreased serum albumin
C) Increased blood urea nitrogen (BUN)
D) Elevated serum glucose
Correct Answer: B) Decreased serum albumin
A nurse is assessing a client who has been diagnosed with a Vitamin E deficiency. Which of the following symptoms is most likely associated with this deficiency?
A) Night blindness
B) Scurvy
C) Peripheral neuropathy
D) Rickets
Correct Answer: C) Peripheral neuropathy
diet consists of easily digestible liquids that are transparent and free of any solids or pulp.
clear liquid
The normal reference range for albumin in the blood is typically about
3.5-5.0 g/dL
A nurse is assessing a postoperative patient’s surgical incision and notes that the wound edges are not well-approximated and there is a small amount of serosanguinous drainage. Which complication of wound healing is the patient most likely experiencing?
A) Dehiscence
B) Evisceration
C) Infection
D) Hematoma
Correct Answer: A) Dehiscence
Rationale:
A nurse is reviewing the dietary intake of a client who is interested in increasing their antioxidant intake. Which of the following foods should the nurse recommend as a good source of Vitamin E?
A) Citrus fruits
B) Whole grains
C) Leafy green vegetables
D) Nuts and seeds
Correct Answer: D) Nuts and seeds
A nurse is educating a group of clients about the importance of vitamins in the diet. Which of the following statements about Vitamin A is accurate?
A) Vitamin A is primarily involved in the regulation of calcium and phosphorus metabolism.
B) Vitamin A deficiency can lead to night blindness and an increased risk of infections.
C) Vitamin A is a water-soluble vitamin that needs to be consumed daily.
D) Vitamin A is synthesized by the body when exposed to sunlight.
Correct Answer: B) Vitamin A deficiency can lead to night blindness and an increased risk of infections.
A nurse is preparing a dietary plan for a client who has been prescribed a clear fluid diet following abdominal surgery. Which of the following items is appropriate to include in the client's diet?
A) Cream of chicken soup
B) Apple juice
C) Milk
D) Orange juice with pulp
Correct Answer: B) Apple juice
The normal reference range for total bilirubin in the blood is typically about
0.1 - 1.2 mg/dL
A nurse is caring for a postoperative patient who suddenly reports feeling a "popping" sensation at the surgical incision site. Upon assessment, the nurse observes that the wound has opened, and loops of bowel are protruding. What is the nurse's immediate priority action?
A) Apply a dry sterile dressing over the wound.
B) Notify the surgeon immediately.
C) Cover the wound with sterile saline-soaked gauze.
D) Instruct the patient to avoid coughing or straining.
Correct Answer: C) Cover the wound with sterile saline-soaked gauze.
A nurse is assessing a patient with a history of incontinence and notes areas of skin breakdown on the patient's buttocks and perineal area. The skin appears red, raw, and is accompanied by superficial abrasions. Which term best describes this type of skin damage?
A) Maceration
B) Excoriation
C) Erosion
D) Ulceration
Correct Answer: B) Excoriation
Match each micronutrient with its correct function or characteristic.
Descriptions:
A) Essential for oxygen transport in the blood and energy production; found in red meat, beans, and fortified cereals.
B) Important for bone health and muscle function; found in dairy products, leafy greens, and fortified foods.
C) Necessary for nerve function, red blood cell formation, and DNA synthesis; found in animal products like meat and dairy.
D) Helps maintain fluid balance, supports nerve signals, and muscle contractions; found in bananas, potatoes, and spinach.
E) Supports immune function, wound healing, and DNA synthesis; found in meat, shellfish, and legumes.
Answers:
A nurse is caring for a client who is transitioning from a clear liquid diet to a full liquid diet following gastrointestinal surgery. Which of the following foods is appropriate to include in the client's full liquid diet?
A) Mashed potatoes
B) Chicken noodle soup
C) Vanilla yogurt
D) Scrambled eggs
Correct Answer: C) Vanilla yogurt
The normal reference range for fasting blood glucose is typically about
70-100 mg/dL
A nurse is caring for a patient with a chronic wound that has a significant amount of necrotic tissue. The healthcare provider has ordered debridement. Which type of debridement involves the use of the body's own enzymes and moisture to rehydrate, soften, and liquefy eschar and slough?
A) Surgical debridement
B) Mechanical debridement
C) Autolytic debridement
D) Enzymatic debridement
Correct Answer: C) Autolytic debridement
A nurse is providing dietary education to a client who is concerned about vitamin intake. Which of the following vitamins is fat-soluble and can be stored in the body's fatty tissues?
A) Vitamin C
B) Vitamin B6
C) Vitamin D
D) Vitamin B12
Correct Answer: C) Vitamin D
Match each macronutrient with its correct function or characteristic.
Descriptions:
A) Serve as the body's primary source of energy, especially for the brain and during physical activity; found in foods like grains, fruits, and vegetables.
B) Essential for building and repairing tissues, making enzymes and hormones; composed of amino acids and found in meat, beans, and nuts.
C) Provide a concentrated source of energy, support cell structure, and are important for hormone production; found in oils, butter, and avocados.
Answers:
Match the type of enteral feeding tube with its correct description:
Descriptions:
A) A tube inserted through the nose and passed through the esophagus into the stomach, typically used for short-term feeding.
B) A tube inserted through the abdominal wall directly into the stomach, often used for long-term feeding.
C) A tube inserted through the nose and passed through the esophagus into the small intestine, used when gastric feeding is not possible.
D) A tube inserted through the abdominal wall directly into the jejunum, used for long-term feeding when gastric feeding is not possible.
E) A type of gastrostomy tube placed endoscopically through the abdominal wall into the stomach, used for long-term feeding.
Answers:
The normal reference range for Hemoglobin A1c (HbA1c) is typically:
A nurse is preparing to irrigate a patient's wound. What is the recommended pressure range, in pounds per square inch (psi), for effective wound irrigation to ensure adequate cleaning without causing tissue damage?
A) 1-2 psi
B) 4-15 psi
C) 16-20 psi
D) 21-25 psi
Correct Answer: B) 4-15 psi
Match each type of sterile dressing with its correct description.
Descriptions:
A) A highly absorbent dressing made from seaweed, ideal for wounds with heavy exudate.
B) A dressing that provides a moist environment and is suitable for wounds with minimal to moderate exudate; it forms a gel-like covering over the wound.
C) A dressing that provides moisture to dry wounds and helps with autolytic debridement; often used for wounds with minimal exudate.
D) A versatile dressing that can be used for a variety of wounds; available in sterile and non-sterile forms, often used as a primary or secondary dressing.
E) A dressing that is highly absorbent and provides cushioning; suitable for wounds with moderate to heavy exudate.
Answers:
Match each category with its correct description.
Descriptions:
A) Essential nutrients required in large amounts that provide energy and are necessary for growth and metabolism; includes carbohydrates, proteins, and fats.
B) Nutrients needed in smaller amounts that are crucial for various bodily functions, including vitamins and minerals.
C) A non-digestible component of plant foods that aids in digestion, helps maintain bowel health, and can contribute to a feeling of fullness.
D) A vital component of the body that is necessary for maintaining hydration, regulating body temperature, and facilitating various physiological processes.
Answers:
A nurse is caring for a client who has just had a nasogastric (NG) tube inserted for enteral feeding. Which of the following methods is the most reliable for verifying the correct placement of the NG tube before initiating feeding?
A) Auscultating for air insufflation over the stomach
B) Checking the pH of the gastric aspirate
C) Observing the client for signs of respiratory distress
D) Obtaining an abdominal X-ray
Correct Answer: D) Obtaining an abdominal X-ray
Match the CBC component with its typical reference range:
Reference Ranges:
A) 4.5-11.0 x 10³/µL (4,500-11,000 cells/µL)
B) 4.7-6.1 million cells/µL (males); 4.2-5.4 million cells/µL (females)
C) 13.8-17.2 g/dL (males); 12.1-15.1 g/dL (females)
D) 40.7-50.3% (males); 36.1-44.3% (females)
E) 150,000-450,000/µL
Answers:
Match each method of debridement with its correct description.
Descriptions:
A) Involves the use of topical agents to chemically break down necrotic tissue.
B) Utilizes the body's own enzymes and moisture to naturally break down dead tissue.
C) Involves the physical removal of dead tissue using instruments like a scalpel or scissors.
D) Uses living organisms, such as maggots, to consume necrotic tissue.
E) Employs physical forces, such as wet-to-dry dressings or irrigation, to remove dead tissue.
Answers:
Match each stage of pressure ulcer with its correct description.
Descriptions:
A) Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.
B) Non-blanchable erythema of intact skin.
C) Full-thickness skin loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.
D) Partial-thickness skin loss with exposed dermis, presenting as a shallow, open sore with a red-pink wound bed.
E) Full-thickness skin or tissue loss in which the extent of damage cannot be confirmed due to obscuring by slough or eschar.
Answers:
Match each vitamin with its correct function or characteristic.
Descriptions:
A) Essential for vision, immune function, and skin health; found in foods like carrots and sweet potatoes.
B) Important for calcium absorption and bone health; can be synthesized by the body when exposed to sunlight.
C) Acts as an antioxidant, protecting cells from damage; found in nuts, seeds, and green leafy vegetables.
D) Necessary for collagen synthesis, immune support, and acts as an antioxidant; abundant in citrus fruits.
E) Crucial for blood clotting and bone metabolism; found in green leafy vegetables like spinach and kale.
Answers:
Match the type of special diet with its correct description or purpose:
Descriptions:
A) A diet that includes easily digestible foods with a soft texture, used for individuals with difficulty chewing or swallowing.
B) A diet that manages carbohydrate intake to control blood sugar levels, often used for individuals with diabetes.
C) A diet that restricts sodium intake to help manage blood pressure and fluid balance, often recommended for individuals with hypertension or heart disease.
D) A diet that limits protein, sodium, potassium, and phosphorus intake to support kidney function, often used for individuals with kidney disease.
E) A diet that reduces fat intake, often used for weight management or to lower cholesterol levels.
Answers:
Creatine kinase (CK) is an enzyme that plays a crucial role in energy production within cells, particularly in muscle tissues. Name the three CK isoenzymes and where can be primarily found.
CK-MM: mainly in skeletal muscles
CK-MB: mainly in cardiac muscles
CK-BB: mainly in brain tissues