The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question?

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Skin Integrity and Wound Care Questions Questions

Question 1 of 5

The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question?

Correct Answer: B

Rationale: Dakin's solution , per the flashcards, is cytotoxic, harming clean granulation tissue, and should be questioned. Low-air-loss , hydrogel , and dietitian consults support healing. Nurses advocate for saline, making this the correct order to challenge.

Question 2 of 5

A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair?

Correct Answer: A

Rationale: Sitting over 2 hours risks ischemia on ischial tuberosities. Less than 2 hours at a time , per the flashcards, balances mobility and safety. Total daily limits or 30-minute caps are impractical. Comfort-based ignores objective risk. This standard prevents ulcers, making it the correct duration.

Question 3 of 5

The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?

Correct Answer: D

Rationale: Ice (implied Choice D), per nursing practice, reduces pain and swelling post-knee repair. Options are missing, but vital signs or pulses don't relieve pain directly. This evidence-based action, making it the correct choice.

Question 4 of 5

Which level of the cultural environment is being assessed when the nurse asks a client about family rituals and traditions?

Correct Answer: A

Rationale: Bronfenbrenner's ecological model applies here. The microsystem includes immediate settings like family, where rituals and traditions shape daily life and health beliefs, per nursing cultural assessments. Mesosystem links microsystems (e.g., family-school). Exosystem involves external settings (e.g., parent's workplace). Macrosystem is broad cultural values. Family rituals are microsystem-level, guiding care, making this the correct level.

Question 5 of 5

A nurse is caring for a client from a different cultural background who refuses a certain medication. How can understanding transcultural models and frameworks help the nurse in this situation?

Correct Answer: B

Rationale: Transcultural models (e.g., Leininger's) prioritize cultural respect. Respecting beliefs and finding alternatives aligns with this, ensuring client-centered care while addressing needs. Disregarding beliefs or overriding violates ethics. Education may help but isn't primary without respect. This approach fosters trust, making it the correct action.

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