NCLEX-PN Test #13 1 Flashcards
6 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 NCLEX-PN Test #13 1 flashcards as text
A nurse assesses a pressure injury with full-thickness skin loss, visible subcutaneous fat, and no exposed bone or tendon. How should this wound be staged?
Answer: Stage III
A Stage III pressure injury involves full-thickness skin loss with visible subcutaneous fat but without exposed bone, tendon, or muscle. Stage IV would involve exposed bone, tendon, or muscle.
A nurse is performing a wet-to-dry dressing change on a wound with necrotic tissue. What is the primary purpose of this dressing technique?
Answer: Provide mechanical debridement
Wet-to-dry dressings provide mechanical debridement: the dressing is moistened, placed in the wound, and as it dries it adheres to necrotic tissue. When removed, the dead tissue is pulled away. This technique is non-selective and may also remove healthy tissue.
While performing a dressing change, a nurse observes bright red blood suddenly saturating the wound dressing. What is the priority nursing action?
Answer: Apply direct pressure and call for immediate assistance
Bright red blood indicates arterial bleeding, which is a hemorrhagic emergency. The nurse should apply direct pressure immediately to control bleeding and call for help. Removing the dressing would remove the tamponade effect and worsen bleeding.
A nurse is irrigating a deep wound with normal saline. Which action reflects proper wound irrigation technique?
Answer: Use a 35 mL syringe with an 18-gauge angiocatheter to deliver fluid at 8–15 psi
Effective wound irrigation uses a 35 mL syringe with an 18-gauge angiocatheter to deliver saline at 8–15 psi — sufficient pressure to remove debris without traumatizing wound tissue. Irrigation should proceed from the cleanest to the dirtiest area.
A patient's surgical wound edges are separated with visible subcutaneous tissue. The nurse identifies this as wound dehiscence. What is the immediate nursing action?
Answer: Cover the wound with a sterile saline-moistened dressing and notify the surgeon immediately
Wound dehiscence requires immediate intervention. The nurse should cover the wound with a sterile saline-moistened dressing to keep exposed tissue moist and prevent infection, then notify the surgeon immediately. The patient should be placed in low Fowler's position with knees slightly flexed to reduce tension on the wound.
A nurse is caring for a patient with a venous stasis ulcer on the lower leg. Which intervention is most important to include in the plan of care?
Answer: Apply compression therapy as prescribed
Compression therapy is the cornerstone of venous stasis ulcer treatment. It counteracts venous hypertension, reduces edema, and promotes venous return to facilitate healing. Leg elevation when resting also assists. Dependent positioning would worsen venous stasis.