Question 1

The client has shallow craters on the coccyx and heels. The nursing assistant has placed the client on a pressure relieving mattress. What additional action would the nursing assistant take?

Accepted Answer

A)  No additional action is needed because the mattress relieves the pressure and helps the areas to heal. 
B)  Determine whether the areas improve or get worse and chart the condition of the skin over the next several days. 
C)  Employ the turning schedule and elevate the lower leg on pillows to elevate the heels off the bed. 
D)  Change wet bed linens at least every 4 hours and cleanse skin of any incontinence as necessary. C

Question 2

What must happen for a person with a wound to remain healthy?

Accepted Answer

A)  The wound must heal so that the skin is once again intact. 
B)  The person must take an antibiotic to prevent an infection. 
C)  The wound must be cleansed daily to keep it from getting infected. 
D)  The person must drink enough water and other fluids to stay hydrated. A

Question 3

The nursing assistant is caring for a client with generalized weakness, chronic heart failure, and frequent incontinence. What action should the nursing assistant take to decrease the development of a pressure ulcer?

Accepted Answer

A)  Use the pressure-relieving seat cushion when the client sits in a chair for 1 hour. 
B)  Encourage the client to turn frequently when in bed to decrease the risk of skin breakdown. 
C)  Apply a bed protector under the bedpan and leave the client on the bedpan for 25 minutes every 2 hours. 
D)  Choose a skin barrier to apply to the coccyx to keep the client dry when the client is incontinent. A

Question 4

Which factor increases a client's risk of developing a pressure ulcer?

Accepted Answer

A)  A fungal infection of the skin 
B)  A heart problem 
C)  History of cancer 
D)  Dark skin

Question 5

What action does the nursing assistant include when turning the client with a wound drain in place?

Accepted Answer

A)  Empty the drain before turning. 
B)  Re-position the client being careful to not pull or put tension on the drain. 
C)  Report to the nurse if more drainage appears in the collection container after resident is repositioned. 
D)  Document the amount, color, odor, and texture of the drainage after repositioning.

Question 6

A nursing assistant caring for a client with a stage 3 pressure ulcer would immediately report which finding to the nurse?

Accepted Answer

A)  A foul odor to the wound 
B)  Serous drainage from the wound 
C)  Discomfort when the client lies on the coccyx 
D)  A change in appearance to a shallow crater in the area

Question 7

When bathing a resident in bed, the nursing assistant is most concerned about pressure ulcer development when finding that the resident has:

Accepted Answer

A)  been incontinent of both stool and urine. 
B)  very dry skin on the feet and elbows. 
C)  drainage on the abdominal dressing. 
D)  a pale, shiny area on the right heel.

Question 8

The main purpose of a wound drain is to:

Accepted Answer

A)  secure the wound's dressing. 
B)  protect the linen from the drainage. 
C)  allow wound drainage to leave the wound. 
D)  make it possible to observe the wound drainage.

Question 9

The nursing assistant is caring for an unconscious resident. What is the best action by the nursing assistant to prevent a pressure ulcer?

Accepted Answer

A)  Apply a pressure-relieving mattress on the resident's bed. 
B)  Employ a bed protector under the resident's skin. 
C)  Use a lift sheet to move the resident up in the bed. 
D)  Examine the linens during reposition and change as needed.

Question 10

Which is the major cause of pressure ulcers?

Accepted Answer

A)  Being elderly 
B)  Being overweight 
C)  Being immobile 
D)  Being hydrated

Question 11

The nursing assistant observes that the client's skin around the abdominal dressing is slightly irritated from previous cloth tape used during dressing changes. When preparing for the next dressing change, what is the appropriate dressing for the nursing assistant to choose?

Accepted Answer

A)  Paper tape 
B)  Kerlix gauze 
C)  Elastic bandage 
D)  Montgomery ties

Question 12

It is true that when an immobile client sits on a hard surface for too long, the biggest problem that can occur is that:

Accepted Answer

A)  a stage 1 pressure ulcer can form. 
B)  the client is likely to become uncomfortable. 
C)  the client may be incontinent of urine or stool. 
D)  a rash may develop on the client's buttocks and legs.

Question 13

The nursing assistant observes the wounds of four clients. Which client would the nursing assistant report to the nurse immediately? The client who:

Accepted Answer

A)  has a dressing dated with yesterday's date. 
B)  has a dressing saturated with bloody drainage. 
C)  has dry and intact sutures and pink skin. 
D)  needs to splint the wound when coughing.

Question 14

When a comatose resident is placed in the lateral position, the most likely place for a pressure ulcer to form is on the:

Accepted Answer

A)  breastbone. 
B)  coccyx. 
C)  shin. 
D)  hip.

Question 15

The nursing assistant is caring for a client who returned an hour ago from surgery and has an indwelling urinary catheter, an intravenous line, and a hemovac wound drain in place. What observation would the nursing assistant report immediately to the nurse?

Accepted Answer

A)  The client is drowsy and requests a blanket. 
B)  The hemovac is full of bloody drainage. 
C)  The dressing has a small area of bloody drainage present. 
D)  There is 100 mL of urine in the indwelling urine bag.

Question 16

The nursing assistant is caring for a client with a pale shiny area on their left heel. What is the appropriate action for the nursing assistant to take?

Accepted Answer

A)  Chart the observation and actions used. 
B)  Massage the area and wait 5 minutes to observe. 
C)  Apply lotion to the skin on the bottom of the feet. 
D)  Place the lower legs on pillows to elevate the heels.

Question 17

When assisting the nurse with a dressing change, which is a responsibility of the nursing assistant?

Accepted Answer

A)  Removing the soiled dressing 
B)  Handing the clean dressing to the nurse 
C)  Cutting the tape that will be used to secure the dressing 
D)  Cleaning the person's wound before the new dressing is applied

Question 18

Which item has the least effect on preventing pressure ulcers from forming?

Accepted Answer

A)  Specialty beds 
B)  Heel booties 
C)  Elbow pads 
D)  Warm socks

Question 19

A nursing assistant best helps prevent a pressure ulcer from forming by:

Accepted Answer

A)  changing the client's bed linen according to the facility's policy. 
B)  repositioning an immobile client each time the client asks. 
C)  keeping an incontinent client's skin clean and dry. 
D)  toileting the client at least every 3 hours.

Question 20

A nursing assistant caring for a client with a stage 2 pressure ulcer would immediately report which finding to the nurse?

Accepted Answer

A)  The client has been drinking water and juice between meals. 
B)  An oral temperature that is 1 degree higher than it was 4 hours ago. 
C)  The client has become incontinent of urine twice in the last 4 hours. 
D)  A request from the client to have a second serving of ice cream for dessert.

Exam 22: Preventing Pressure Ulcers and Assisting With Wound Care