Nokea
A client is post-operative day 1 and reports a sudden increase in blood-tinged
liquid draining from his incision after feeling a popping sensation. What is the
nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct Answer: B
Rationale:
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A client recently had an above the knee amputation and complains of pain
distal to the amputation. What type of pain is the client experiencing?
- A. Nociceptive
- B. Neuropathic
- C. Visceral
- D. Cutaneous
Correct Answer: A
Rationale:
A client is immobile and requires mechanical ventilation with a tracheostomy.
She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse
observes bone and tendon at the base of the wound. How would the nurse
document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct Answer: D
Rationale:
What phase of wound healing occurs at the time of injury and lasts about 3-5
days?
- A. Maturation
- B. Intentional
- C. Inflammatory
- D. Proliferative
Correct Answer: C
Rationale:
What level of Maslow's Hierarchy of needs does shelter belong to?
- A. Love and belonging
- B. Physiological
- C. Safety and security
- D. Esteem
Correct Answer: C
Rationale:
Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct Answer: C
Rationale: