Pressure Ulcer Staging

Question 1 of 8

The ED nurse is assessing a machinist who sustained an injury to his left hand when his ring finger became caught in a baling machine. The patient sustained multiple lacerations about the wrist and hand as well as significant loss of the skin, soft tissue, and tendons underlying the area. The skin torn from the patient’s finger was transported to the ED in a plastic bag. The patient is right-handed. All of the following initial nursing actions would be appropriate except:

Mechanically removing large pieces of debris from the wound

Assessing the patient's distal neurovascular status

Soaking the injured finger in povidone-iodine solution

Wrapping the injured finger in sterile gauze

Question 2 of 8

When suturing the patient’s lacerations, the nurse practitioner orders lidocaine with epinephrine. However, when anesthetizing the nose wound, the NP requests lidocaine without epinephrine because:

Administering epinephrine so close to the respiratory tract may cause bronchospasms

Epinephrine is a vasodilator and will cause further bleeding

Epinephrine will cause further nasal discharge and contaminate the wound

Epinephrine is a vasoconstrictor and may cause tissue ischemia

Question 3 of 8

A 22-year-old man is bleeding profusely from a facial laceration when brought to the emergency department (ED). A part of his nose is missing. As the patient screams for help, he shows the nurse the missing nose part in his hand. The priority nursing intervention at this time would be to:

Question the patient about cause of the trauma

Evaluate the amputated nose part for possible reimplantation

Obtain arterial blood gas measurements to assess airway patency

Apply direct digital pressure to the bleeding vessels

Question 4 of 8

The ED nurse is assessing a machinist who sustained an injury to his left hand when his ring finger became caught in a baling machine. The patient sustained multiple lacerations about the wrist and hand as well as significant loss of the skin, soft tissue, and tendons underlying the area. The skin torn from the patient’s finger was transported to the ED in a plastic bag. The patient is right-handed. All of the following initial nursing actions would be appropriate except:

Soaking the injured finger in povidone-iodine solution

Wrapping the injured finger in sterile gauze

Assessing the patient's distal neurovascular status

Mechanically removing large pieces of debris from the wound

Question 5 of 8

After a patient’s lacerations are sutured, the nurse questions the patient and learns he received a tetanus booster 8 months ago. Based on this information, the nurse would:

Suggest that the patient have two tetanus booster shots 3 months apart

Administer half the usual dose of tetanus toxoid

Administer 0.5 mL of absorbed tetanus toxoid

Not administer a tetanus prophylaxis because it is unnecessary

Question 6 of 8

One of a patient’s lacerations extends through his left eyebrow. The nurse responds appropriately by:

Assessing for injury to the first cranial nerve

Leaving the eyebrow intact

Shaving the eyebrow

Applying adhesive skin closures

Question 7 of 8

A 22-year-old man is bleeding profusely from a facial laceration when brought to the emergency department (ED). A part of his nose is missing. As the patient screams for help, he shows the nurse the missing nose part in his hand. The priority nursing intervention at this time would be to:

Question the patient about cause of the trauma

Obtain arterial blood gas measurements to assess airway patency

Apply direct digital pressure to the bleeding vessels

Evaluate the amputated nose part for possible reimplantation

Question 8 of 8

Before a patient’s facial lacerations are treated, the nurse should:

Apply an aerosol anesthetic

Irrigate the wounds

Scrub the wounds vigorously

Provide a mirror for the patient to assess the injury

Pressure Ulcer Staging

300,000+ Students Use These Cheatsheets To Pass NCLEX

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Pressure Ulcer Staging

300,000+ Students Use These Cheatsheets To Pass NCLEX

What email should we send your results to?

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