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Test Bank Clinical Nursing Skills Techniques 8th Edition, Perry
Chapter 1: Using Evidence in Nursing Practice
1. Evidence-based practice is a problem-solving approach to making decisions about patient care that is grounded in:
a. the latest information found in textbooks.
b. systematically conducted research studies.
c. tradition in clinical practice.
d. quality improvement and risk management data.
2. When evidence-based practice is used, patient care will be:
a. standardized for all.
b. unhampered by patient culture.
c. variable according to the situation.
d. safe from the hazards of critical thinking.
3. When a PICOT question is developed, the letter that corresponds with the usual standard of care is:
4. A well-developed PICOT question helps the nurse:
a. search for evidence.
b. include all five elements of the sequence.
c. find as many articles as possible in a literature search.
d. accept standard clinical routines.
5. The nurse is not sure that the procedure the patient requires is the best possible for the situation. Utilizing which of the following resources would be the quickest way to review research on the topic?
d. The Cochrane Library
6. The nurse is getting ready to develop a plan of care for a patient who has a specific need. The best source for developing this plan of care would probably be:
a. The Cochrane Library.
7. The nurse has done a literature search and found 25 possible articles on the topic that she is studying. To determine which of those 25 best fit her inquiry, the nurse first should look at:
a. the abstracts.
b. literature reviews.
c. the Methods sections.
d. the narrative sections.
8. The nurse wants to determine the effects of cardiac rehabilitation program attendance on the level of postmyocardial depression for individuals who have had a myocardial infarction. The type of study that would best capture this information would be a:
a. randomized controlled trial.
b. qualitative study.
c. case control study.
d. descriptive study.
9. Six months after an early mobility protocol was implemented, the incidence of deep vein thrombosis in patients was decreased. This is an example of what stage in the EBP process?
a. Asking a clinical question
b. Applying the evidence
c. Evaluating the practice decision
d. Communicating your results
10. To use evidence-based practice appropriately, you need to collect the most relevant and best evidence and to critically appraise the evidence you gather. This process also includes: (Select all that apply.)
a. asking a clinical question.
b. applying the evidence.
c. evaluating the practice decision.
d. communicating your results.
Chapter 2: Admitting, Transfer, and Discharge
1. The patient is scheduled to go home after having coronary angioplasty. What would be the most effective way to provide discharge teaching to this patient?
a. Provide him with information on health care websites.
b. Provide him with written information on what he has to do.
c. Sit and carefully explain what is required before his follow-up.
d. Use a combination of verbal and written information.
2. While preparing for the patients discharge, the nurse uses a discharge planning checklist and notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on:
a. the patients willingness to go home.
b. the familys perceived ability to care for the patient.
c. the patients ability to live alone.
d. allowing the patient to make her own arrangements.
3. The patient arrives in the emergency department complaining of severe abdominal pain and vomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the ordered treatment, but the patient continues to refuse. What should the nurse do?
a. Summon the nurse technician to hold the arm down while the IV is inserted.
b. Use a numbing medication before inserting the IV.
c. Document the patients refusal and notify the physician.
d. Tell the patient that she will be discharged without care unless she complies.
4. An unconscious patient is admitted through the emergency department. How and when is identification of the patient made?
a. Determined only when the patient is able
b. Postponed until family members arrive
c. Given an anonymous name under the blackout procedure
d. Determined before treatment is started
5. During admission of a patient, the nurse notes that the patient speaks another language and may have difficulty understanding English. What should the nurse do to facilitate communication?
a. Use hand gestures to explain.
b. Request and wait for an interpreter.
c. Work with the family to gather information.
d. Complete as much of the admission assessment as possible using simple phrases.
6. The patient has been admitted to the emergency department after being beaten and raped. She is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her?
a. She is safe in the hospital, and she needs to provide her name.
b. She can be admitted to the hospital without anyone knowing it.
c. Her records will be used as evidence in the trial.
d. Since she has come to the hospital, she has to be examined by the doctor.
7. The patient is admitted to the ICU after having been in a motor vehicle accident. He was intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on:
a. examining the patient and treating the pain.
b. orienting the family to the ICU visitation policy.
c. making sure that the consent forms are signed.
d. informing the patient of his HIPAA rights.
8. The nurse is admitting the patient to the medical unit. The patient indicates that he has had several surgeries in the past and has been a diabetic for the past 15 years. He also earlier that morning, but the pain has finally gone since he received a pain shot in the emergency department. What does this information prompt the nurse to do next?
a. Provide the patient with an allergy arm band and document his allergies.
b. Postpone routine admission procedures immediately.
c. Ask the patient if he wants a smoking room.
d. Have all family or friends leave the room.
9. At what age is separation anxiety a common problem?
a. School-aged children
c. Middle infancy
10. The patient is being transferred from the emergency department to another institution for treatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)?
a. Helping the patient get dressed
b. Gathering IV equipment to go with the patient
c. Escorting the patient to the transport area
d. Assessing the patients respiratory status before transport
Chapter 3: Communication
1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped out of high school at age 16 and has been a laborer ever since. He never saw any need for book learning, and has lived his life my way since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of fast food while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure?
a. The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.
b. There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.
c. We have pamphlets here that can explain everything. Let me get you one.
d. Its just like a clogged pipe. All the doctor has to do is Roto-Rooter it to get it cleaned out.
2. The nurse is assessing a patient who says that she is feeling fine. The patient, however, is wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways?
a. You seem anxious today. Is there anything on your mind?
b. Im glad youre feeling better. Ill be back later to help you with your bath.
c. I can see youre upset. Let me get you some tissue.
d. It looks to me like youre in pain. Ill get you some medication.
3. Nonverbal communication incorporates messages conveyed by:
c. tone quality.
d. use of jargon.
4. The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, but he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse?
a. Explain the need for the pain medication using a slower rate of speech.
b. Explain the need for the pain medication using a simpler vocabulary.
c. Explain the need for the pain medication, but ask the patient if he would like the doctor called and the medication changed.
d. Explain in a loud manner the need for the pain medication.
5. When comparing therapeutic communication versus social communication, the professional nurse realizes that therapeutic communication:
a. allows equal opportunity for personal disclosure.
b. allows both participants to have personal needs met.
c. is goal directed and patient centered.
d. provides an opportunity to compare intimate details.
6. The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use?
a. Showing the needles and bandages in advance
b. Telling the patient exactly what discomfort to expect
c. Using dolls and stories to demonstrate what will be done
d. Asking the child to draw pictures of what he or she thinks will happen
7. The nurse is about to go over the patients preoperative teaching per hospital protocol. She finds the patient sitting in bed wringing her hands, which are sweaty, and acting slightly agitated. The patient states, Im scared that something will go wrong tomorrow. How should the nurse respond?
a. Redirect her focus to dealing with the patients anxiety.
b. Tell the patient that everything will be all right and continue teaching.
c. Tell the patient that she will return later to do the teaching.
d. Give the patient antianxiety medication.
8. The nurse is attempting to teach the patient and his family about his care after discharge. The patient and the family demonstrate signs of anxiety during the teaching session. The nurse should consider doing what?
a. Using more gestures or pictures
b. Focusing on the physical complaints
c. Getting another staff member to speak to the patient
d. Repeating information to the patient and the family at a later time
9. The patient is an elderly man who was brought to the hospital from an assisted-living community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behavior and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behavior tell the nurse?
a. The patient is exhibiting anxiety because of a change in his rituals.
b. The patient is suffering from sensory overstimulation.
c. The patient is basically an angry person.
d. The patient has to follow hospital protocol.
10. The nurse is preparing to give an intramuscular injection to the patient in room 320. The patient care technician comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond?
a. Tell the patient care technician to calm the patient down until she can get there.
b. Have the angry patients roommate moved to another location.
c. Tell the angry patient to calm down until she can get there.
d. Tell the angry patient that he has to act civilized in the hospital, and thats that.
Chapter 4: Documentation and Informatics
1. The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information?
a. The patients parents
b. The patients significant other only
c. No one in the hospital until the patient says so
d. The patients physician, significant other, and laboratory personnel
2. Which of the following is the best example of objective charting?
a. The patient states that he has been having severe chest discomfort.
b. The patient is lying in bed and seems to be in considerable pain.
c. The patient appears to be pale and diaphoretic and complains of nausea.
d. The patients skin is ashen and respiratory rate is 32 and labored.
3. Which of the following is the best example of accurate documentation?
a. Abdominal wound is 5 cm in length without redness, edema, or drainage.
b. OD to be irrigated qd with NS.
c. No complaint of abdominal pain this shift.
d. Patient watching TV entire shift.
4. Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000. At 1000, a patient complains of feeling light-headed. The nurse takes the patients vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he feels better. The nurse rechecks the blood pressure and finds that it is now back to normal. How should the nurse handle documentation for this episode?
a. Document the 1000 vital signs in the graphic record only.
b. Not report the incident because it was a transient episode.
c. Document the vital signs in the graphic and progress record.
d. Document the vital signs as 12 oclock signs.
5. The nurse manager is attempting to determine the staffing needs of the unit. One tool that she may use to determine the level of care needed would be:
a. the standardized care plan.
b. the acuity record.
c. the patient care summary.
d. flow sheets.
6. A preprinted guideline used to care for patients with similar health problems is known as the:
a. acuity record.
b. standardized care plan.
c. patient care summary.
d. flow sheet.
7. The patient is ready to go home from the hospital. What does the nurse provide to the patient and his family before he leaves the facility?
a. Discharge summary
b. Standardized care plan
c. Patient care summary
d. Flow sheet
8. Which is a delivery model that coordinates and links health care services to patients and families?
a. Critical pathways
b. Charting by exception
d. Case management
9. The patient has been in the hospital for a hip replacement. According to his critical pathway, he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of:
a. a negative variance.
b. positive case management.
c. a positive variance.
d. use of SBAR.
10. Which is a primary difference between home care and hospital care?
a. Documentation systems need to provide information for the home health nurse only.
b. Documentation no longer affects reimbursement.
c. Services are assumed and need less documentation.
d. The patient and the family witness most of the care provided.
Chapter 5: Vital Signs
1. The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patients respiratory status, the nurse should:
a. remove the patients nail polish to get a pulse oximetry reading.
b. use a forehead probe to get a pulse oximetry reading.
c. use a finger probe to get a pulse oximetry reading.
d. check the color of the patients nail polish before attempting a reading.
2. A persons core temperature is considered the most accurate since it is:
a. reflective of the surrounding environment.
b. the same for everyone.
c. controlled by the hypothalamus.
d. independent of external influences.
3. The nurse takes the patients temperature using a tympanic electronic thermometer. The temperature reading is 36.5 C (97.7 F). The nurse knows that this correlates with:
a. 37.0 C (98.6 F) rectally.
b. 37.0 C (98.6 F) orally.
c. 36.0 C (97.7 F) axillary.
d. 36.0 C (97.7 F) orally.
4. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his cigarette break. The nurse is about to take the patients temperature orally and should:
a. wait about 15 minutes before taking his temperature.
b. give him oral fluids to rinse the nicotine away before taking his temperature.
c. give him a stick of chewing gum to chew and then take his temperature.
d. take his oral temperature and record the findings.
5. When evaluating the patients temperature levels, the nurse expects the patients temperature to be lower:
a. in the morning.
b. after exercising.
c. during periods of stress.
d. during the postoperative period.
6. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should:
a. apply mild pressure to advance.
b. ask the patient to take deep breaths.
c. remove the thermometer immediately.
d. remove the thermometer and reinsert it gently.
7. An appropriate procedure for measurement of an adults temperature with a tympanic membrane sensor is:
a. pulling the ear pinna down and back.
b. moving into the ear in a figure-eight pattern.
c. fitting the probe loosely into the ear canal.
d. pointing the probe toward the mouth and chin.
8. The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is irritable and agitates easily. What should the nurse do to assess the patients temperature?
a. Take an oral temperature before doing anything else.
b. Take an axillary temperature using the upper axilla.
c. Place the child in Sims position for a rectal temperature.
d. Take a rectal temperature as the last vital sign.
9. The patient is returning from a cardiac catheterization. The puncture site is in the right femoral artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern?
a. Both pedal pulses were bounding.
b. The femoral artery could be palpated.
c. The right pedal pulse was weaker than the left.
d. The radial artery pulse was 88.
10. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his cigarette break. The nurse is about to take the patients radial pulse and should:
a. wait about 15 minutes before taking his pulse.
b. use her thumb to detect the pulse and get an accurate count.
c. press hard to detect the pulse and get an accurate count.
d. take his pulse for 15 seconds and multiply by 4.
Chapter 6: Health Assessment
1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using?
2. The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but says he still feels feverish. Before taking the patients temperature, the nurse may:
a. touch the patients skin with the dorsum of her hand.
b. touch the patients skin with the pads of her fingers.
c. palpate the skin using the bimanual method.
d. tap the patients skin using the fingertips.
3. What should the nurse do when preparing to complete an assessment for a 16-year-old patient?
a. Focus on illness behaviors.
b. Plan for a diminished energy level.
c. Treat the patient as an individual.
d. Have the parents present throughout.
4. In providing a physical assessment of an 88-year-old patient, the nurse should:
a. do it as quickly as possible to prevent fatigue.
b. assume that the patient will have disabilities.
c. prepare to perform a mental status examination.
d. always do the exam in the small exam room to prevent chills.
5. The general survey begins with a review of the patients primary health problems and an evaluation of the patients vital signs, height and weight, general behavior, and appearance. It also provides information about the patients illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel?
a. Reporting subjective signs and symptoms
b. Measuring the patients height and weight
c. Monitoring I&O
d. Obtaining initial vital signs
6. Petechiae are noted on the patient as a result of the nurse finding:
a. bluish-black patches.
c. pinpoint-sized red dots.
d. large areas of raised, irritated skin.
7. The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate?
a. Stage I pressure ulcer
b. Increased blood flow to the area
c. Localized vasodilation
8. The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient most likely will need to be in which position for the examination?
a. Sitting upright
9. Which of the following may a nursing assistant be responsible for determining?
a. Vital signs
b. Cranial nerve function
c. Neck vein distention
d. Auscultation of bowel sounds
10. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While providing cardiac education, the nurse realizes that the patient needs more education when he:
a. describes changes in his behavior that may improve cardiovascular function.
b. describes the schedule, dosage, and purpose of his medication.
c. states that he will take his medication when he has chest pain or when his heart rate is greater than 100.
d. describes the benefits of taking his medication regularly.
Chapter 7: Medical Asepsis
1. The nurse understands that the priority nursing action needed when medical asepsis is used includes:
b. surgical procedures.
c. autoclaving of instruments.
d. sterilization of equipment.
2. Handwashing with soap and water is:
a. the most effective way to reduce the number of bacteria on the nurses hands.
b. more effective than alcohol-based products for washing hands.
c. necessary for hand hygiene if hands are visibly soiled.
d. not necessary if the nurse wears artificial nails.
3. When caring for patients, the nurse understands that the single most important technique to prevent and control the transmission of infection is:
a. hand hygiene.
b. the use of disposable gloves.
c. the use of isolation precautions.
d. sterilization of equipment.
4. Which of the following measures is appropriate when a nurse is washing his or her hands?
a. Use very hot water.
b. Leave rings and watches in place.
c. Lather for at least 15 to 20 seconds.
d. Keep the fingers and hands up and the elbows down.
5. The nurse shows an understanding of the psychological implications for a patient on isolation when planning care to control the risk for:
6. An appropriate technique for the nurse to implement for the patient on isolation precautions is to:
a. double-bag all disposable items and linens.
b. put another gown over the one worn if it has become wet.
c. place specimen containers in plastic bags for transport.
d. hand items to be reused directly to a nurse standing outside the room.
7. Before entering the room of a patient on isolation where all protective barriers are required, the nurse first puts on the:
8. The patient is presenting to the hospital with a high fever and a productive cough. He says that he hasnt felt right since he returned from visiting Somalia about a month before admission. He also states that he has lost about 20 pounds in the last month and frequently wakes up in the middle of the night sweaty and clammy. What should the nurse prepare to do?
a. Place the patient on contact isolation.
b. Place the patient in a negative-pressure room.
c. Place the patient on droplet precautions.
d. Use standard precautions only.
9. For patients with which of the following conditions should the nurse implement airborne precautions?
10. The patient is admitted to the pediatric unit with severe pertussis. The nurse explains to the parents and the child that the patient will be treated with the use of:
a. airborne precautions.
b. standard precautions only.
c. droplet precautions.
d. contact isolation.
Chapter 8: Sterile Technique
1. When the following concepts are compared, which is most important in maintaining a safe environment by following aseptic principles?
a. Performing a surgical hand scrub
b. Applying a sterile gown
c. Recognizing the importance of following aseptic principles
d. Applying a mask and protective eyewear
2. The nurse is preparing to provide wound care for her patient. She realizes that the most effective way to decrease the bacterial count on her hands is to wash her hands using:
a. soap and water only.
b. a nonalcohol antiseptic alone.
c. a 50% alcohol-based antiseptic alone.
d. a 60% to 95% alcohol-based antiseptic alone.
3. The nurse is applying for a job at a local hospital. She wants to look her best for the interview and decides to wear artificial nails. She does this knowing that artificial nails:
a. are appropriate in the ICU setting as long as the nurse washes her hands frequently.
b. can lead to fungal growth under the nail.
c. can actually lower the bacterial count on the hands because they cover the natural nail.
d. are banned only in areas where patients are critically ill.
4. When removing the mask after an aseptic procedure, what should the nurse do first?
a. Remove gloves.
b. Untie top strings of mask.
c. Untie bottom strings of mask.
d. Untie top strings and let mask hang.
5. An appropriate principle of surgical asepsis is that:
a. the entirety of a sterile package is sterile once it is opened.
b. all of the draped table, top to bottom, is considered sterile.
c. an object held below the waist is considered contaminated.
d. if the sterile barrier field becomes wet, the dry areas are still sterile.
6. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to:
a. put sterile gloves on before opening sterile packages.
b. discard items that may have been in contact with the area below waist level.
c. place the povidone-iodine bottle well within the sterile field.
d. place sterile items on the very edge of the sterile drape.
7. Which patient may the nurse suspect will be at risk for a latex allergy?
a. Patient with food allergies
b. Patient with diabetes
c. Patient with arthritis
d. Patient with hypertension
8. Which of the following is an appropriate technique for the nurse to use when performing sterile gloving?
a. Put the glove on the nondominant hand first.
b. Interlock the hands after both gloves are applied.
c. Pull the cuffs down on both gloves after gloving.
d. Grasp the outside cuff of the other glove with the gloved hand.
9. The nurse is preparing to insert a urinary catheter. The package is dry but shows signs of yellowing inside the plastic wrapper, as if the package was wet at one time. What should the nurse do?
a. Use the package because it is dry at present.
b. Consider the outer package contaminated, but the inner package sterile.
c. Discard the entire package as contaminated.
d. Open the package and consider the 1-inch border as contaminated.
10. A type I hypersensitivity to latex is evident if the nurse assesses:
a. localized swelling.
b. skin redness and itching.
c. runny eyes and nose and cough.
d. tachycardia, hypotension, and wheezing.
Chapter 9: Safe Patient Handling, Transfer, and Positioning
1. A nurse should be aware of safety measures to prevent personal injury when lifting or moving patients. An appropriate principle to follow is:
a. bend at the waist for lifting.
b. tighten the stomach muscles and pelvis.
c. keep the weight to be lifted away from the body.
d. carry or hold the weight 1 to 2 feet above the waist.
2. The most prevalent and debilitating occupational health hazard among nurses is:
b. pressure ulcers.
c. musculoskeletal disorders.
3. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient may have to be turned more frequently than every 2 hours.
c. This patient may be allowed to remain in his favorite position as long as he doesnt complain of discomfort.
d. Skin breakdown is not an issue for this patient.
4. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position?
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
5. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury during transfers?
a. Diabetes mellitus
b. Myocardial infarction
c. A cerebrovascular accident
d. An upper extremity fracture
6. To assist the patient to a sitting position on the side of the bed, what should the nurse do first?
a. Raise the height of the bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patients legs over the side of the bed.
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse do?
a. Grab the patient under the axilla to lift.
b. Have the patient move forward with the weak side.
c. Have the patient put on shoes with nonskid soles.
d. Place the chair in a position 90 degrees opposite the bed.
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which would be the best technique for transferring the patient?
a. Using three nurses and a slide board
b. Using the three-person lift technique
c. Raising the head 30 degrees
d. Having the patient keeps arms to the side
9. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to:
a. lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. deep the check valve open when the patient is seated in the chair.
10. When preparing to move a patient in bed, the nurse should:
a. expect that the patients comfort level will decrease.
b. make sure that all pillows used in the previous position stay in position.
c. raise the bed to a comfortable working height.
d. plan on moving the patient herself because other nurses are busy.
Chapter 10: Exercise and Ambulation
1. The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what?
a. A normal blood pressure for this patient
b. Orthostatic hypotension
c. Orthostatic hypertension
d. Effective baroreceptor function
2. The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should:
a. tell the patient not to move his legs when dangling.
b. tell the patient to hold his breath while dangling.
c. raise the head of the bed and allow a few minutes before dangling.
d. have the patient stand without dangling.
3. An appropriate technique for the nurse to use when performing range of motion (ROM) exercises is to:
a. repeat each action five times during the exercise.
b. perform the exercises quickly and firmly.
c. support the proximal portion of the extremity being exercised.
d. continue the exercise slightly beyond the point of resistance.
4. A patient is admitted to the medical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises?
a. Flex the joint to the point of discomfort.
b. Medicate the patient after the ROM exercise session.
c. Move the joints quickly.
d. Provide support for distal joints.
5. A nurse should be concerned when observing a patient performing isometric exercises if the patient is:
a. holding his or her breath while exerting.
b. performing the exercises four times per day.
c. tightening each muscle group for 8 seconds, then relaxing.
d. repeating each exercise 8 to 10 times for each muscle group.
6. A nurse encourages a patient to prevent venous stasis by:
a. crossing the legs when sitting in a chair.
b. wearing thigh-length nylon stockings or garters.
c. elevating the legs on pillows while in bed.
d. increasing early ambulation.
7. Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to:
a. keep the skin warm and dry.
b. prevent abnormal joint flexion.
c. apply external pressure.
d. prevent bleeding.
8. When assessing the patient for risk for DVT, the nurse should consider which of the following an indicator of increased risk?
a. A positive Homans sign
b. Pallor to the distal area
c. Edema noted in the extremity
d. Fever or dehydration
9. An appropriate procedure for the nurse to use when applying an elastic stocking is to:
a. remove the stockings every 24 hours.
b. keep the tops of the stockings rolled down slightly.
c. turn the stocking inside out to apply from the toes up.
d. wash stockings daily and dry in a dryer.
10. When using an SCD, the nurse should:
a. apply powder to the patients skin if redness and itching are present.
b. leave a two-finger space between the patients leg and the compression stocking.
c. keep the patient connected to the compression device when transferring into and out of bed.
d. remove the elastic stockings before putting on the sequential pneumatic compression stockings.
Chapter 11: Orthopedic Measures
1. According to the National Association of Orthopaedic Nurses (NAON), which of the following is possibly the most effective cleansing solution for pin-site care?
a. Normal saline
b. Hydrogen peroxide
d. None of the above
2. The patient has a broken leg and needs to have a cast applied. When plaster of Paris is compared and contrasted versus the newer synthetic casts, which of the following statements is true?
a. Plaster of Paris can tolerate earlier weight bearing than synthetic casts.
b. Plaster of Paris is more expensive than synthetic casts.
c. Synthetic casts can withstand contact with water better than plaster of Paris.
d. Synthetic casts are lighter but take longer to set than plaster of Paris.
3. An expected outcome of cast application that the nurse evaluates is:
a. skin irritation at the cast edges.
b. decreased capillary refill and pallor.
c. tingling and numbness distal to the cast.
d. slight edema, soreness, and limited range of motion.
4. The patient is admitted for a fractured tibia. The nurse is preparing for cast application and expects to administer a(n) _____ to the patient minutes before the procedure.
a. oral analgesic 10
b. intramuscular (IM) analgesic 10
c. intravenous (IV) analgesic 2 to 5
d. muscle relaxant 10
5. An appropriate technique for the nurse to implement for the patient who is being casted is to:
a. apply ice to the top of the cast.
b. maintain the extremity below heart level.
c. handle the wet cast with the fingertips.
d. fold the stockinette or padding over the outer cast edges.
6. When teaching cast care, the nurse instructs the patient to:
a. blow dry the wet cast on the hot setting.
b. report changes in sensation or mobility to the area.
c. use only soft objects to slide down the cast for scratching.
d. cut away the edges of the cast if the skin becomes irritated.
7. For cast removal, which of the following instructions should the nurse provide to the patient?
a. Discomfort will be felt from the cast saw.
b. An enzyme wash may be applied to intact skin.
c. The skin will be scrubbed very well after the removal.
d. Aggressive range-of-motion exercises will be performed after removal.
8. The patient is brought into the emergency department after falling on the ice in her driveway. She is suspected of having a fractured hip. After comparing different available types of traction, she anticipates that which of the following will be used?
a. Bryants traction
b. Dunlops traction
c. Bucks extension
d. Gallows traction
9. Which type of traction does the nurse anticipate will be used for an adult patient with a fractured humerus?
a. Bryants traction
b. Dunlops traction
c. Gallows traction
d. Bucks extension
10. For a patient who is to be placed in Russells traction, the nurse prepares the:
a. occipital area.
b. arm and forearm.
c. back and abdomen.
d. lower extremities.
Chapter 12: Support Surfaces and Special Beds
1. The patient is admitted to the unit with a stage III pressure ulcer. When the different types of support surfaces are compared, which would be most therapeutic for this patient?
a. Foam mattress
b. Gel overlay
c. Air-fluidized bed
d. Air mattress
2. What is the most important factor in preventing and treating pressure ulcers?
a. Proper use of foam or air mattresses
b. Proper utilization of an air-fluidized bed
c. Frequent repositioning of the patient
d. Proper use of a low-air-loss bed
3. What is the primary purpose for the use of a support surface?
a. To reduce pressure
b. To promote patient comfort
c. To increase circulation
d. To facilitate patient movement
4. When working with a patient who is being placed on an air mattress/overlay, the nurse should:
a. apply the preinflated overlay over the standard mattress.
b. bring any plastic strips or flaps around the corners of the bed mattress.
c. administer an analgesic after the patient is moved onto the mattress.
d. keep clamps or pins attached to the sheets to keep them in place over the mattress.
5. The patient requires a support surface to help prevent pressure ulcers. He has a large open wound on his leg that is dressed daily. The nurse must choose which support surface would be most appropriate. What does the nurse realize when comparing the different types of support surfaces?
a. Water mattresses are better for patients with open wounds.
b. Air surface beds cannot be used if the patient needs CPR.
c. Water mattresses make it hard to regulate patient body temperature.
d. Air mattresses reduce shear and friction.
6. The patient is admitted with a large stage IV pressure ulcer on his coccyx. After comparing the benefits of the following support surfaces, the nurse would choose which of the following as most appropriate for this patient?
a. Water mattress
b. Gel overlay
c. Foam overlay
d. Air-fluidized bed
7. An air-suspension bed is contraindicated for the patient with:
d. respiratory insufficiency.
8. Of the following problems that may occur with the use of an air-fluidized bed, which is of greatest concern to the nurse?
c. Slight disorientation
d. Insensible fluid loss
9. The nurse is caring for a patient who is in an air-fluidized bed. She places the patient in semi-Fowlers position using foam wedges, even though she realizes that:
a. patients gain the greatest benefit from the prone position in an air-fluidized bed.
b. for resuscitation, she may have to increase the air pressure of the bed to do CPR.
c. she may have to increase the air pressure of the bed to turn the patient.
d. the foam wedges may decrease the effects of the bed.
10. A patient is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?
a. Decreasing fluid intake to ease dependent edema
b. Turning the patient every 2 hours and providing a low-air-loss mattress
c. Raising the head of the bed to maximize the patients lung inflation
d. Bathing and feeding the patient to decrease energy expenditure
Chapter 13: Safety and Quality Improvement
1. The patient is admitted to the hospital with orders for activity as tolerated. He is wheelchair-bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility. The nurse realizes that:
a. patients are not allowed to bring in an electric wheelchair.
b. electrical equipment is banned from all hospitals.
c. the charger needs to be checked by hospital engineers.
d. electrical devices are not a cause for concern.
2. Upon entering the patients room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the patient and reports the fire. What is the nurses next action?
a. Extinguish the fire.
b. Remove all other patients from the unit.
c. Close all doors of patient rooms.
d. Move the trash can into the bathroom.
3. In a long-term care facility, an elderly patient drops his burning cigarette into a trash can and starts a fire. A Type _____ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation.
4. Given the most common causes of hospital fires, which of the following choices are most appropriate in preventing patient injury?
a. Assure that all electrical devices are checked by engineering.
b. Assist patients who smoke to a safe area to smoke.
c. Prop fire doors open for easier patient access.
d. Educate patients on the importance of smoking cessation.
5. After recognizing that a patient has received an electrical shock and removing the source of the shock, what should the nurse do next?
a. Call for assistance.
b. Immediately start CPR.
c. Obtain emergency equipment.
d. Assess for the presence of a pulse.
6. The patient is an elderly gentleman who is admitted for a medical problem. While doing his admission assessment, the nurse learns that the patient gets up two to three times a night to use the restroom. The institution has only beds with four side rails. Which of the following is the appropriate rationale for leaving one of the lower side rails down?
a. Falls rarely happen in the inpatient setting.
b. Having all side rails raised increases the occurrence of falling.
c. Side rails have no bearing on whether or not a patient falls.
d. Patient falls rarely result in physical injury.
7. A patient is taking a medication that has the potential to cause orthostatic hypotension. Which of the following nursing interventions is appropriate for this patient?
a. Have the patient sit slowly and dangle.
b. Refer the patient to physical therapy.
c. Keep the side rails up at all times.
d. Obtain a walker or a cane for patient use.
8. What should the nurse do to promote patient understanding and security in the health care setting?
a. Restrain the patient as necessary.
b. Explain all procedures to the patient.
c. Allow the patient more time alone.
d. Restrict activity as much as possible.
9. As part of an attempt to implement a restraint-free environment, the nurse:
a. provides constant activity for the patient.
b. covers or camouflages tubes and drains.
c. changes caregivers as often as possible.
d. reduces visiting hours and times in therapy.
10. A patient is well known to the hospital staff from previous admissions and is prone to wandering at night. For patient safety, the physician writes an order for belt restraint prn. What should the nurse do upon reviewing this order?
a. Apply a belt restraint on the patient as needed.
b. Have the patient sign an informed consent form.
c. Inform the physician that prn restraint orders are unacceptable.
d. Obtain a signed informed consent from a family member.
Chapter 14: Disaster Preparedness
1. In addition to the Department of Homeland Security, which of the following agencies has a mission to ensure that the nation is well prepared to respond to an act of terrorism?
b. Red Cross
d. Salvation Army
2. Personal protection equipment is categorized by the level of safety provided. Standard work uniforms or work clothes offer what level of protection?
a. Level A
b. Level B
c. Level C
d. Level D
3. The most recently labeled level of protection is BioPPE. The use of BioPPE requires which of the following items?
a. Self-contained breathing apparatus
b. Respiratory protection but less skin protection
c. Chemically resistant boots and gloves
d. Standard work clothes, contact and respiratory protective devices
4. Upon arriving at a mass causality scene, health care providers using the SALT approach will initiate triage by doing which of the following first?
5. Disaster nursing differs from general nursing because when caring for patients during a disaster:
a. the focus is on caring for the sickest people first.
b. using a color tag system reduces the amount of emotional stress on the nurse.
c. the focus is no longer on airway, breathing, and circulation.
d. the focus is on caring for those most likely to survive.
6. The nurse has arrived at the scene of a natural disaster and is assigned to care for four patients. To which patient should the nurse provide care first?
a. Patient with a closed head injury with no changes in level of consciousness
b. Patient with a 3-cm laceration to the forearm
c. Patient who is breathing eight times per minute
d. Patient with a displaced wrist fracture
7. The patient is brought into the emergency department as part of an MCI. The patient has white powder on his clothes, and it is suspected that the patient has been exposed to anthrax. What should the nurse do first?
a. Cut off the patients clothing and place it in a plastic bag.
b. Have the patient remove his sweater by pulling it over his head.
c. Avoid using oxygen that could decrease the patients oxygen drive.
d. Provide the patient with appropriate antibiotics.
8. Which of the following biological agent requires the use of an antitoxin if exposure occurs?
9. The patient is admitted to the emergency department with possible smallpox exposure. The patient has never had a smallpox immunization. The nurse prepares to administer a smallpox vaccination, realizing that vaccination:
a. within 3 days of exposure will completely prevent the disease.
b. is effective only if received before exposure.
c. 4 to 7 days after exposure will completely prevent the disease.
d. within 3 days will offer only some protection from disease.
10. If a patient is receiving radiation using gamma rays, the nurse would be watching for which of the following?
a. Severe pain during administration
b. Development of an allergy to shellfish
c. Severe burns or internal injury
d. Confusion and lethargy
Chapter 15: Pain Assessment and Basic Comfort Measures
1. The nurse is caring for a patient who is a devout Orthodox Jew. The patient is on a patient-controlled analgesia (PCA) pump. What accommodations might the nurse have to make to conform to the patients cultural needs?
a. Ask the patient whether he will need alternative forms of medication for the Sabbath.
b. Ask the patient specific questions because Jews tend to be stoic regarding pain.
c. Medicate the patient around the clock instead of as needed (prn).
d. Understand that Jews believe that suffering is a consequence of actions in a previous life.
2. The patient is admitted with chronic pain. She states that nothing takes the pain away totally, but that Dilaudid works best. The fact that the patient calls the medication by name should alert the nurse to:
a. suspect that the patient is drug seeking.
b. expect that the patient may need smaller doses than normal.
c. assess the patients acceptable level of comfort.
d. accept the fact that nothing will help this patients pain.
3. The nurse frequently must assess a patient who is experiencing pain. When assessing the intensity of the pain, the nurse should:
a. ask whether there are any precipitating factors.
b. question the patient about the location of the pain.
c. offer the patient a pain scale to objectify the information.
d. use open-ended questions to find out about the sensation.
4. The nurse who is caring for a patient postoperatively notes that he is expressing discomfort and is diaphoretic. Which of the following interventions is most appropriate?
a. Straighten the bed linens.
b. Change the saturated surgical dressing.
c. Administer prescribed pain medications.
d. Check for displaced equipment underneath the patient.
5. The patients family is concerned that the patient may get too much pain medication after surgery and become addicted to the medication if he is placed on a PCA pump. They also voice concern about the effectiveness of the PCA. The nurse should instruct the family and the patient that:
a. pain relief with the PCA pump is not as good as when the nurse provides it, but it does save on nursing time.
b. pain relief is good when the medication peaks, but less so when the levels drop, and that is when the patient will know that he needs more.
c. because the device provides medication as soon as the patient needs it, he will probably use less of the medication.
d. the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate.
6. The nurse caring for a patient who has a PCA knows that it:
a. allows the family to participate in pain management for the patient.
b. prevents mistakes in medication administration.
c. can be used by all hospitalized patients.
d. provides a more constant level of medication.
7. When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult to arouse. What step should the nurse take next?
a. Insert an airway.
b. Turn patient to the side.
c. Stop the PCA.
d. Expect this as a patient outcome of the therapy.
8. The patient is scheduled for surgery late in the afternoon. His postoperative orders include PCA therapy. Which of the following nursing interventions is appropriate to perform?
a. Teach the patient about PCA after the patient comes out of recovery.
b. Teach the patient about PCA before surgery and before preoperative medication administration.
c. Tell the patient not to use PCA unless he can no longer tolerate the pain.
d. Inform the patients family to watch him carefully and to depress the PCA administration button whenever they think he needs it.
9. The nurse knows that an advantage of intraspinal analgesia is the:
a. smaller doses of epidural than intrathecal medication.
b. lack of significant patient complications.
c. systemic distribution of morphine faster than fentanyl.
d. ability to achieve appropriate analgesia with smaller dosages.
10. The patient is in the hospital undergoing major abdominal surgery. When the patient returns from the recovery room, the nurse expects that he most likely will be receiving pain medication:
a. by mouth.
c. via the epidural route.
Chapter 16: Palliative Care
1. The patient has a history of terminal cancer but is being admitted for treatment of a pressure ulcer. The patients wife has been caring for him at home and refuses to discuss admission to a nursing home. The wife looks extremely tired and is near the point of exhaustion. What could the nurse suggest?
a. A consult for hospice care
b. Continuing with the plan of care as is
c. That the doctor order the patient into a nursing home
d. That the wife stay away while the patient is hospitalized
2. The patient is being admitted to the hospital for injuries received when a hurricane destroyed her home. She is upset from the loss of her home and possessions. What type of loss is this considered?
a. Necessary loss
b. Maturational loss
c. Situational loss
d. Perceived loss
3. The nurse recognizes that anticipatory grieving can be most beneficial for a patient or family because it can:
a. be done in a private setting.
b. be discussed with other individuals.
c. promote separation of the ill patient from the family.
d. allow time for the process of grief.
4. The nurse is preparing to assist the patient at the end stage of her life. To provide comfort for the patient in response to anticipated symptom development, the nurse plans to:
a. decrease the patients fluid intake.
b. limit the use of pain medication.
c. provide larger meals with more seasoning.
d. determine patient wishes and select appropriate therapies.
5. A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill patient is to:
a. limit PO fluid intake.
b. position the patient in semi-Fowlers or Fowlers position.
c. reduce narcotic analgesic use.
d. administer bronchodilators.
6. When caring for a patient who is an appropriate candidate for organ or tissue donation, the nurse knows that requests for donation are:
a. required by state law.
b. the total responsibility of the survivors.
c. a possible inclusion in the advance directive.
d. made only by the physician.
7. The patient is on a ventilator and has a heartbeat but has been declared brain dead. The family has agreed to organ donation. The nurse realizes that which of the following organ donations would require that the patient be left on life support?
8. An appropriate technique for the nurse to implement when caring for a patients body after death is to:
a. remove the patients ID band and put a new gown on the patient.
b. cover the patient with a sheet and transfer him or her to the morgue.
c. inquire about particular cultural or spiritual practices.
d. remove tubes and lines if the patient is to be autopsied.
9. After the death of a patient and before other nursing interventions are implemented, the nurse should:
a. place the patient in a supine position and elevate the head of the bed 30 degrees.
b. wait an hour to prepare the patient for viewing.
c. place the patient in a side-lying position to allow drainage.
d. exclude the family while the body is being prepared.
10. Before allowing the family of a deceased patient to view the body, the nurse should:
a. insert the patients dentures.
b. lower the head of the bed.
c. fold the arms and hands over the chest.
d. leave all of the old dressings and tape in place.
Chapter 17: Personal Hygiene and Bed Making
1. The nurse is aware that normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing is known as:
b. the epidermis.
c. resident bacteria.
d. the dermis.
2. In relation to hygiene and the acute care setting, the nurse knows that which of the following statements is true?
a. The disposable bath is a less desirable form of bathing than the traditional basin bath.
b. The disposable bath is a more desirable form of bathing than the traditional basin bath.
c. The disposable bath is more desirable for patients who can bathe independently.
d. The disposable bath is not an acceptable form of bathing in the acute care setting.
3. The nurse is caring for a ventilated patient in the ICU who has just undergone coronary artery bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk?
a. Not provide oral hygiene because this may cause bacterial contamination of the airway.
b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth.
c. Not use chlorhexidine in oral care because it enhances the rate at which VAP develops.
d. Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP.
4. The nurse plans to give the patient a therapeutic bath. Which of the following is considered therapeutic?
a. Bed bath
b. Sponge bath at the sink
c. Sitz bath
d. Bag bath
5. What should the nurse do before starting a patients bed bath?
a. Lower the bed.
b. Offer the bedpan or urinal.
c. Partially undress the patient.
d. Place the head of the bed in high-Fowlers position.
6. The nurse is preparing to provide a complete bed bath to a patient who has a running IV. She places a bath blanket over the patient and:
a. removes the gown from the arm with the IV first.
b. removes the gown from the arm without the IV first.
c. removes the gown after the bath to keep the patient warm.
d. readjusts the IV rate before removing the gown.
7. While washing the patients face, the nurse should:
a. wash the eyes using soap and warm water.
b. wash the eyes from outer canthus to inner canthus.
c. wash the eyes with plain warm water.
d. use the same portion of the washcloth.
8. When bathing a patient, which sequence is the correct approach to use?
a. Wash the feet after the legs.
b. Wash the eyes after the face.
c. Wash the legs before the abdomen.
d. Wash the back area before the extremities.
9. What should hygienic care of the patient with dry skin include?
a. Use of moisturizers
b. Use of ultraviolet light
c. Application of antiseptic lotion
d. Lowering of bath water temperature
10. While giving the patient a bed bath, the nurse notices a reddened area on the patients coccyx. The nurse should:
a. decrease the temperature of the bath water.
b. massage the reddened area to decrease the redness.
c. apply topical moisturizing agents to the area.
d. ignore the redness because it will return to normal soon.
Chapter 18: Pressure Ulcer Care
1. The nurse is turning a patient when she notices an area with nonblanchable redness over the patients coccyx. The patient complains of pain at the site, and the site does feel cooler than the areas immediately around the site. The nurse recognizes that this patient has developed:
a. a stage I pressure.
b. a stage II pressure.
c. an unstageable pressure.
d. deep tissue injury.
2. In a patient with a stage II pressure ulcer, the nurse describes the wound as:
a. superficial blistering.
b. nonblanchable redness.
c. loss of skin without bone exposure.
d. loss of skin with exposed muscle.
3. The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer?
a. The patient who is bedridden, but who turns himself randomly
b. The patient whose Braden Scale score is 8
c. The patient who can ambulate to the bathroom independently
d. The patient whose Braden Scale score is 18
4. Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to:
5. A patient with anemia is at risk for developing pressure ulcers as a result of which of the following?
a. Increased sedation
b. Edematous tissues
c. Reduced tensile strength
d. Diminished oxygen to the tissues
6. In a long-term care facility, how often should the nurse reassess a patient for risk of a pressure ulcer?
a. Every 1 to 2 days
b. Every time the nurse sees the patient
c. Weekly for the first few weeks of stay
d. Monthly for the first 4 months of stay
7. The patient with a nasogastric (NG) tube in place may experience skin breakdown:
a. in the nose.
b. on the tongue.
c. behind the ears.
d. around the lips.
8. The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention?
a. Edema in the sacrum
b. Skin texture
c. Skin temperature
d. Pallor or mottling of the skin
9. The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound. How would the nurse classify this ulcer?
a. Stage III pressure ulcer
b. Stage IV pressure ulcer
c. Wound that cannot be staged
d. Stage II pressure ulcer
10. A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it?
a. Wound needs debride
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