Wound Care, Tissue Integrity, Sleep Comfort, Gout, Inlfammation

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Sample questions from Wound Care, Tissue Integrity, Sleep Comfort, Gout, Inlfammation

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.On a medical-surgical unit, a 72-year-old client has a chronic venous leg ulcer and a new prescription for a sterile dressing change. Which task is appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Perform the prescribed sterile dressing change
   • B.Assess the wound for changes in drainage and surrounding skin
   • C.Measure and record the client's oral temperature
   • D.Teach the client how to apply compression stockings

   Rationale: Measuring and recording a temperature is a routine task that can be delegated to a competent UAP, with the nurse responsible for interpreting and acting on the result. Wound assessment and teaching require nursing judgment, and a sterile dressing change should be performed by a licensed nurse according to the client's needs and facility policy. The exam takeaway is to delegate predictable tasks, not assessment, teaching, or procedures requiring licensed judgment.

2. 2.In the pediatric inpatient unit, an 8-year-old client being treated for a deep leg wound has a temperature increase and new wound drainage. Refer to the client's chart. Which actions should the nurse take now? Select all that apply.

   • A.Notify the provider about the change in wound findings and temperature
   • B.Apply an unprescribed topical antibiotic and reassess the wound tomorrow
   • C.Document the wound appearance, drainage, and change in vital signs
   • D.Obtain the prescribed wound culture using aseptic technique before the next antibiotic dose
   • E.Ask the UAP to assess the wound and decide whether the drainage is purulent

   Rationale: The temperature has risen from 37.2 C to 38.4 C, and the chart describes new thick drainage, so the nurse should promptly report the change, collect the prescribed culture before the next antibiotic dose when feasible, and document objective findings. Asking a UAP to assess drainage delegates nursing judgment, so that option is incorrect. Applying an unprescribed medication and delaying reassessment are not appropriate responses to possible infection.

3. 3.During a home visit, a 46-year-old client with chronic insomnia says, "I watch videos in bed until I fall asleep, but then I wake up several times." Which recommendation should the nurse make first?

   • A.Use the bed only for sleep and intimacy, and keep a consistent sleep schedule
   • B.Drink a glass of wine before bed to promote relaxation
   • C.Stay in bed longer each morning to make up for lost sleep
   • D.Take an over-the-counter sleep aid every night without consulting a clinician

   Rationale: Using the bed only for sleep and maintaining a regular sleep-wake schedule are core behavioral strategies that support sleep regulation. Extending time in bed can weaken the association between bed and sleep, while alcohol can disrupt sleep and carries safety risks. Routine use of an over-the-counter sleep aid without clinical guidance may cause adverse effects or interactions.

4. 4.In an outpatient clinic, a 59-year-old client with gout reports taking allopurinol for 2 weeks and now has a new widespread rash and a temperature of 38.1 C. Which instruction is the priority?

   • A.Take the next dose with food and report the rash at the next visit
   • B.Reduce the dose by half until the rash resolves
   • C.Continue the medication and apply a moisturizer to the rash
   • D.Stop the allopurinol and contact the prescriber immediately

   Answer and rationale are in the full material.

5. 5.At change of shift on a surgical unit, a 67-year-old client 12 hours after abdominal surgery has increasing incisional pain, temperature 38.0 C, HR 108, and a dressing saturated with fresh blood. Which action should the nurse take first?

   • A.Document the drainage and reassess the dressing in 2 hours
   • B.Reinforce the dressing, assess the client and incision, and promptly notify the surgical team
   • C.Ask the UAP to change the dressing while the nurse completes medication rounds
   • D.Remove the dressing and leave the incision open to air

   Answer and rationale are in the full material.