Download NS 660 EXAM 2 (2025-2026) LATEST QUESTIONS AND ANSWERS WITH EXPLANATIONS GRADED A+ and more Exams Nursing in PDF only on Docsity!
NS 660 EXAM 2 (2025-2026) LATEST QUESTIONS
AND ANSWERS WITH EXPLANATIONS
GRADED A+
Which statement would indicate the need for further teaching?
A. If skin area gets red but red goas away after turning, I should report it to the nurse
B. Putting foam pads under the heels or other bony prominences can help decrease pressure
C. If a person cannot turn himself in bed, someone should help them change position every 4 hours
D. Skin should be washed with only warm water (not hot) and lotion put on wile it is still little whet
C. If a person cannot turn himself in bed, someone should help them change position every 4 hours
EXPLANATION:
This should happen every 2 hrs.
Wound draining thick yellow material. What type of drainage?
Purulent
Client enters ED after motor cycle accident, resulting in skidding across pavement. Client wearing shorts, so large areas skin ripped off. Best describe this wound as:
A. Abrasion
B. Approximated
C. Laceration
D. Eschar
C. Laceration
Key word: Ripped
Laceration because large amounts of skin ripped off.
Although abrasion is usually related to road rash, the large amount of skin damaged is why it is considered a laceration
Nurse caring for patients with variety of wounds. Which wound will most likely heal by primary intention?
Older patient is most likely to experience which of the following changes with aging?
A. Thinning of epidermis
B. Thickening of epidermis
C. Oiliness of skin
D. Increased elasticity of skin
A. Thinning of epidermis
Age causes thinning, decreased elasticity, and increased dryness.
Caring for client and notice a superficial ulcer on left hip that appears shallow crater, red pink wound bed and no slough or eschar. Which stage would best describe the break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable
B. Stage II
Stage I = no skin loss
Minimal skin loss/shallow depth = stage II
Caring for client at high risk for developing pressure ulcers. Which of the following are intrinsic factors that increase risk of pressure ulcers? Select All that Apply:
A. Friction
B. Impaired sensation d/t spinal cord injury
C. Poor nutrition
D. Shearing
E. Edema
F. Compression
B. impaired sensation d/t spinal cord injury
C. Poor nutrition - specifically protein
C. Surgery requiring multiple incisions
D. Smoking
E. Obesity
A. Diabetes
B. Poor nutrition
D. Smoking
E. Obesity
Older adult client admitted to hospital with dehydration, and nurse has inserted peripheral IV to forearm. Which type of dressing should be applied over clients venous access site?
A. Dressing with nonadherent coating
B. Gauze dressing precut halfway to fit around IV line
C. Gauze dressing pre-medicated with antibiotics
D. Transparent film
D. Transparent film
Need to be able to clearly assess skin
Cleaning wound of gunshot victim. Which of the following is recommended guideline for this procedure?
A. Clean wound from bottom to top, outside to center
B. Clean wound top to bottom, center to outside
C. Once wound cleaned, dry area with absorbent cloth
D. use clean technique to clean the wound
B. Clean wound top to bottom, center to outside
Always want to clean wound from inside to outside to avoid introducing infectious agents into center of wound.
Often must use sterile technique rather than clean technique
Clean top to bottom to avoid dripping into wound.
Med-surge nurse is assisting wound care nurse with debridement of client's coccyx wound. What is primary goal of this action?
A. Stimulating wound bed to promote growth of granulation tissue
B. Cover exposed tissue with sterile towels moistened with sterile NSS
C. Place patient in the low Fowler's position
(1) C. Place patient in the low Fowler's position
(2) B. Cover exposed tissue with sterile towels moistened with sterile NS
(3) A. Notify physician immediately
Low Fowler's position helps to decrease abdominal pressure. Abdominal pressure would increase risk of further complications, should best to minimize first.
Important to keep wound covered, moist.
then immediately notify provider after providing immediate patient care.
Patient, 16, in MVA and sustained wound across nose and cheek. After surgery to repair wound the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?
A. Pain
B. Impaired skin integrity
C. Disturbed body image
D. Disturbed through processes
C. Disturbed body image
Patient admitted with nonhealing surgical wound. Which nursing action most effective in preventing wound infection?
A. Using a sterile dressing supply
B. Suggesting dietary supplements
C. Applying antibiotic ointment
D. Performing careful hand hygiene.
D. Performing careful hand hygiene.
All choices impact wound healing/infection, but MOST effective is hand hygiene.
Nurse who is changing dressings of postoperative patients documents various phases of wound healing on patient charts. Which statement accurately describes these stages? (select all apply)
A. Hemostasis occurs immediately after initial injury
B. Liquid called exudate formed during proliferation phase
C. Elevated Temperature
D. Pitting edema in lower extremities
B. Drop in postural BP
A and D are found in fluid volume overload
Physician orders isotonic IV solution. Which solution should nurse plan to administer?
A. 5% dextrose and normal saline solution
B. Lactated Ringer's solution
C. Half-normal saline solution
D. 10% dextrose in water
B. Lactated Ringer's solution
EXPLANATION:
D10W - hypertonic
half normal saline - hypotonic
D5W with NS - hypertonic solution
Just D5W - hypotonic (isotonic -> body digests dextrose -> becomes hypotonic)
A Patient is diagnosed with severe hyponatremia. Nurse realizes the patient will most likely need which of the following precautions implemented?
A. Seizure
B. Infection
C. Neutropenic
D. High-risk fall
A. Seizure
Looking for mental changes with changes in sodium. Fall may accompany, but seizure/mental changes more pressing concern.
Elderly patient with history of sodium retention arrives to clinic with complaint of, "heart skipping beats and leg tremors" which of the following should nurse ask patient regarding these symptoms?
A. Have you stopped taking your digoxin medication?
B. When was the last time you had a BM?
Patient receiving IV fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?
A. Fluid volume excess
B. Fluid volume deficit
C. Seizure activity
D. Liver failure
A. Fluid volume excess
Nurse planning care for Patient with fluid volume overload and hyponatremia. Which of following should be including in plan of care?
A. Restrict fluids
B. Administer IV fluids
C. Provide Kayexalate
D. Administer IV NS with furosemide
A. Restrict fluids
EXPLANATION:
More fluid than needed in body - causing dilution. -> restrict fluids to balance out fluid overload/dilution
When analyzing arterial blood gas report of a patient with COPD and respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms?
A. kidneys retain bicarbonate
B. kidneys excrete bicarbonate
C. Lungs will retain CO
D. Lungs will excrete CO
A. kidneys retain bicarbonate
Lungs can not compensate for themselves. Bicarbonate is a base, so kidneys will retain to counter acidity in lungs
Nurse is caring for patient who is anxious and dizzy following traumatic experience. AGB findings include:
Ph 7.
PaO2 110
PaCO2 25
HCO3 24
C. Assess urine
Dark yellow, concentrated, small volume urine --> sign of dehydration.
If urine is pale yellow, moderate volume --> not dehydrated.
Nurse admitting patient diagnosed with acute renal failure. Which of following electrolytes will be most affected by this disorder?
A. Calcium
B. Magnesium
C. Phosphorus
D. Potassium
D. Potassium
Potassium will be affected first.
potassium issues most often related to renal failure.
potassium = greater effects with smaller changes.
Calcium = parathyroid
Magnesium = rare, with kidney impairment but potassium changes first, medicine issues
Phosphorus = parathyroid (regulates CA, CA and P are inversely related)
A Patients ABG levels:
pH greater than 7.
Bicarb levels of 36
Nurse realizes that acid-base disorder this patient is demonstrating is which of the following?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
D. Metabolic alkalosis
Patient with metastatic bone cancer, whose calcium levels are 12.1 mg/dL. Which initial manifestations would nurse notice in patient? Select All
A. Weakness
