Wounds &
Pressure Injuries
Pressure Injuries
A client has intact skin with nonblanchable redness over the heel. What stage pressure injury is this?
Stage 1 Pressure Injury
What common adverse effect should the nurse anticipate in a client receiving opioid analgesics?
Constipation
What concentration of oxygen does a nasal cannula generally provide according to the assessment?
Low to moderate
What nursing intervention can help promote sleep in a hospitalized client?
Cluster care to reduce nighttime interruptions
What is the primary goal of palliative care?
Enhance quality of life for the client and family
How often should an immobile client generally be repositioned in the scenarios tested?
Every 2 hours
What is the priority assessment for a client receiving opioid analgesics?
Respiratory Rate
Which oxygen device provides the highest oxygen concentration among the low-flow systems tested?
Nonrebreather mask
What relaxation technique was identified as helpful for anxiety and stress?
Progressive muscle relaxation
What skin change may occur as death approaches?
Mottling
A wound is left open and heals through granulation tissue. What type of healing is this?
Secondary Intention
Who is allowed to press the PCA button?
The client
A postoperative client has an oxygen saturation of 85%. What action should the nurse take first in the tested scenario?
Raised head of bed
What occurs during REM sleep?
Dreaming and memory consolidation
What communication technique is appropriate with a grieving client?
Use open-ended questions and explore feelings
A surgical wound is left open because of infection and later closed after the infection resolves. What type of healing is this?
Tertiary intention
What question best assesses pain intensity?
How would you rate your pain 0-10 scale
What should be avoided around home oxygen equipment?
Smoking and open flames
What sleep schedule should a client with insomnia try to maintain?
A consistent bedtime and wake-up time every day
A client lost a spouse 14 months ago and remains socially isolated with insomnia and hopelessness. What type of grief should the nurse suspect?
Complicated grief
A client coughs, feels a “pop,” and bowel loops protrude through the abdominal incision. What should the nurse do first?
Cover the wound with a sterile saline-moistened dressing
Name the major components of a focused pain assessment tested in the report.
Onset, location, duration, characteristics, and aggravating/relieving factors
Why is smoking near home oxygen dangerous?
Fire hazard
A client increases alcohol use to numb feelings of stress. What type of coping is this?
Maladaptive coping
What should families be taught when a client is approaching death?
Expected physical changes as death approaches