eam 3

healing ridge (induration )

1 cm wide

CK-MB

0%

range of lymphocytes in CBC differential

20-40%

GFR range

90-120 mL/min

the medical device CARE acronym stands for

Choose appropriate size Assess skin under Reposition and reapply Evaluate daily for discontinuation

what is in a CBC? complete blood count

RBC, Hemoglobin, hematocrit, WBC count, platelets

partial thickness wound

the dermis and epidermis of the skin are broken

full thickness wound

the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved

chronic wound

a wound that does not heal easily

which color would the nurse anticipate when assessing a client's skin tears? a: red b: gray c: black d: yellow

a

which describes a fresh surgical wound that had been closed with sutures or staples making two edges of the wound meet. a: approximated b: proliferated c: debrided d: tertiary intention

a

which lab test is important for the nurse to monitor when a client is admitted with acute coronary syndrome? a: troponin b: myoglobin c: homocysteine d: creatinine kinase (CK)

a

fistula

abnormal passageway between two organs or between an internal organ and the body surface

sanguinous drainage

bloody drainage, bright red

range of hematocrit

f: 37-47% m: 42-52%

range of RBC

f: 4.2-5.4 m: 4.7-6.1

clean wound classification

no present infection and low risk of developing infection

stage 1 pressure injury

non-blanch-able erythema of intact skin: intact, non-blistered, not red

superficial wound depth

only epidermis

REEDA

redness, edema, ecchymosis, drainage, approximation

serous drainage

clear, watery plasma

range creatinine:

f: 0.5-1.1 m: 0.6-1.3

understanfint hat protein deficieny can adversly affect wound healing, whcih parameter would measure this deficiency in the patient? select all that apply a. serum albumin b. serum pre-albumin c. nitrogen balanced d. hemoglobin levels e. serum creatinine levels

a,b,c

which statement(s) indicate the patient understands the barium swallow test: a: "the doctor will be able to view my stomach and intestines during the test" b:" i should increase fluid after the test" c: "I will have to drink a contrast agent" d: "barium can cause constipation and I may need a mild laxative" e: "i will be NPO for 8 hours after test" f: "my stool may turn black for few days after"

a,b,c,d

the nurse is instructing the patient in selecting food items that contain common sources of protein in the diet. Which of the following choice can be included in the teaching as examples? a: fish b: beans c: eggs d: apples e: avocado

a,b,c,e

serosanguineous drainage

mixture of serum and red blood cells

evisceration

The total separation of the tissue layers, allowing the protrusion of visceral organs through the incision

which condition would the nurse question use a negative-pressure wound treatment device? a: chronic ulcer b: upper thigh wound c: hip wound with slight bleeding d: treated osteomyelitis within the vicinity of the wound

c

which patient is magnetic resonance imaging contraindicated? a: allergy to latex b: patient with infection c: patient with inner ear transplant d: patient with head injury

c

which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tract infection diagnosis in a client recovering from deep, partial-thickness burns who develop chills, fever, flank pain, and malaise? a: a cystoscopy and bilirubin level b: specific gravity and pH of urine c: urinalysis and urine culture and sensitivity d: creatinine clearance and albumin/globulin(A/G ratio)

c

the nurse is teaching a patient with diverticulitis about increasing fiber intake. Which of the following foods should the nurse recommend? a: white bread b: cream of wheat c: carrots d: bananas

d

a patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient's greatest risk factor for the development of pressure injuries? a: moisture from incontinence b:nutritional deficiencies c: pressure and shear d: aging

a

which action would be appropriate to implement when collecting a 24-hour urine test? a: tart time of test after discarding first voiding b: discard the last voiding in the 24 hours period for the test c: insert a urinary retention catheter to promote the collection of urine d: strain the urine after each voiding before adding the urine to the container

a

which statement made by the student nurse about precautions to take when treating a client with open burn wounds indicates the need for further teaching? a: i should use non-sterile gloves when applying ointments b: i should use non-sterile, disposable lives when removing old dressings c: i should wear PPE before caring for the client d: i should remove PPE before leaving one client to treat another

a

when a client with chronic dyspnea is scheduled for CT using contrast which assessment information would the nurse communicate to the health care provider before the procedure? select all that apply a: metformin taken today b: hematocrit 38% c: serum creatinine 2.1 mg/dL d: coronary artery disease history e: shellfish allergy f: respiratory rate 22 bpm

a,c,e

a client has a low hemoglobin level that is attributed to a nutritional deficiency. which foods should the nurse teach the client to increase in the diet? select all that apply a: liver b: apples c: carrots d: cheese e: spinach

a,e

a nursing student is listing factors that may improve the quality of life of clients in the community with chronic leg ulcers. which factor listed by the nursing student needs correction? a: offer suggestions to improve a client's level of independence b: inform clients that the cost of care may be expensive and that the level of pain may increase c: instruct clients that as their wounds heal, their capability and desire to socialize with others may increase d: understand that come clients have depression and anxiety related to the chronic nature of their wounds

b

on the initial assessment of a patient, the nurse notices an area of redness over the right trochanter that when pressed lightly, does not blanch. What does this assessment cue indicate to the nurse? a: the presence of an infection in the area b: the presence of a stage 1 pressure injury c: an allergic reaction to the sheets d: the need to apply a cold compress to reduce inflammation

b

the nurse assesses the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? a: loosening of the sutures b: sharp increase in serosanguineous drainage c: purplish color of the incision d: protrusion of organs through an open incision

b

the nurse instructs a patient with renal failure who is receiving a diet needed to be consumed. The nurse determines that the patient understands the education if the patient selects which diet. a: high in calories b: low in sodium, phosphorus and protein c: low in fiber d: high in potassium

b

which lab test provides evidence consistent with a client having renal impairment? select all that apply a: serum albumin: 4.7 g/dL b: serum creatinine: 2.0 mg/dL c: serum potassium: 5.9 mEq/L d: serum cholesterol: 120 mg/dL' e: BUN: 32 mg/dL

b,c,e

four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his abdominal wound. An increase in the amount of drainage from the wound is seen, and further examination shows that the sutures incision is now partially open, with tissues protruding from the wound. which are the priority nursing interventions? a: apply steri-strips to close the wound edges b: cover the wound with saline-moistened gauze c: apply a binder to pull the wound edges together and provide support to the edges d: notify the surgeon e: allow the area to be expected to air until all of the drainage has stopped

b,d

which action plan would the nurse take when a client who had a total hip replacement states that the plan is to go swimming at the community pool the day after discharge? a: tell the client to take a friend along for safety b: encourage participation in this activity because it provides an excellent range of motion exercise c: explain that the incision should not be immersed in water until it has healed d: let the client know that swimming can substitute for the prescribed physical therapy

c

which action would the nurse implement for a client scheduled for surgery who reports a history of MRSA in a healed surgical site from 9 months ago? a: notify the infection control officer and obtain blood cultures b: inform the operating room of the MRSA infection c: obtain an order for polymerase chain reaction (PCR) screen d: call the surgeon fr an infectious disease consultation

c

patient has a 24-hour urine specimen collection for creatine clearence. which education should be provided? a: "collect all urine from beginning to end" b: "save only a sample from each void" c: "clean perineal area three times before beginning" d: "discard first void and collect until end of time"

d

which condition would the nurse instruct a client to report immediately to the health care provider? a: pelvic pain immediately after colonoscopy b: rectal bleeding for 48 hours after prostate biopsy c: light vaginial bleeding for 24 hours after a hysterosalpingogram d: a body temperature of 102 degrees F( 38.9 C) after cervical biopsy

d

which principle would be considered when caring for a client with a closed wound drainage system? a: gravity causes fluid to flow down a pressure gradient b: fluid flow rate is determined by the diameter of the lumen c: siphoning causes fluid to flow from one level to a lower level d: fluids flow from an area of higher pressure to one of lower pressure

d

range of aspartate aminotransferase (AST)

0-35 units/L

range of basophils in CBC differential

0.5-1%

range of albumin

3.5-5

while apatient recieves vacuum-assisted therapy (VAP) to treat a diabetic ulcer, the equipment alarm suddenly starts beeping. the nurse would troubleshoot the system to which possible cause of the alarm. a. the canister is empty b. there is an air leak in the dressing c. the canister is tipped at 35 degrees d. the irrigating solution has reached 90* F

b

what are appropriate post-procedure interventions for cerebrospinal fluid specimens? a: position patient with head at 90 degrees for 4 hours b: assess puncture for drainage and bleeding c: encourage oral fluids d: maintain NPO until gag reflex returns e: encourage ambulation immediately after test is complete

b,c

which statement describes negative wound pressure wound therapy? a: suction pump is being used b: necrotizing infections are treated c: oxygen is administered under high pressure d:L a low-voltage current is applied to a wound area e: chronic ulcers are reduced by removing fluids from the wound

a,d

what is included in a liver function blood test?

albumin, pre-albumin, bilirubin, alanine aminotransferase (ALT), alkaline phosphate (ALP), aspartate aminotransferase (AST)

a client is hospitalized with pressure injuries. which tasks could be delegated to an UAP- select all that apply a: empty wound drainage b: report changes in wound appearence c: apply prescribed dressings and medications d: assess and record data about wound appearence e:choosing dressings and therapies for wound treatment

a,b

the nurse is caring for a patient who is scheduled for iodine contrast studies. to ensure patient saftey, which question would the nurse ask the patient before performing the test? select all that apply a."do you have an allergy to kale?" b. "do you have an allergy to egg-white" c. "do you have an allergy to cabbage" d. "do you have an allergy to shellfish?" e. "do you have an allergy to vegetable oil?"

a,c,d

which specimen should be collected by nursing using a sterile technique in a sterile container? a: clean-catch urine b: stool for occult blood c: wound drainage d: sputum e: urine from a folley catheter

a,c,d,e

a primary health care provider schedules a bone scan for a client with osteoporosis. Which nursing action I beneficial for the client? select all that apply a: placing the client in the supine position b: verifying presence or absence of a shellfish allergy c: ensuring the client does not have metal on their clothing d: instructing the client to empty their bladder before the scan e: informing the client that the postprocedure headache resolves in 2 days

a,d

which nursing action would be included in the plan of care when a client is admitted with thrombocytopenia? select all that apply a: avoid intramuscular injections b: institute neurotropic precautions c: monitor the WBC count d: administer prescribes anticoagulants e: examine the skin for ecchymotic areas

a,e

which physiological activity is associated with the proliferative phase of normal wound healing? a: white blood cells migrate into the wound b: epithelial cells grow over granulation tissue c: scar tissue gradually becomes thinner and pale d: vasodilation occurs with increased capillary permeability

b

male patient w/ heart disease asks the nurse about recommended lipid levels. which of the following is a recommended level? a: total cholesterol- >200 mg/dL b: LDL: >100 mg/dL c: HDL: >45 mg/dL d: triglycerides: >60 mg/dL

c

which blood test would the nurse expect to be elevated in patients with chronic renal failure? a: creatinine kinase b: triglycerides c: creatinine d: alkaline phosphatatse

c

which purpose is served by a cystoscopy ordered for a client experiencing decreased and difficult urination? a: to ascertain the size of kidneys b: to ascertain the protein content in urine c: to ascertain the presence of urethral wall of abnormalities d: to ascertain the total amount of catecholamines excreted

c

which features are characteristic of a closed drainage system, such as a Jackson-Pratt (JP) drain? a: works by gravity b: provides for early discharge c: usually is inserted in surgery d: reduces the amount of antibiotics required e: allows for accurate measurement of wound drainage

c, e

how would the nruse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? a: red b: black c: green d: yellow

d

which client finding would the nurse document as a pulse deficit? a: BP of 130/70 mmHg indicating pulse deficit of 60 b: capillary refill greater than 3 seconds indicating pulse deficit c: apical pulse 86 and radial pulse deficit of 8 d: radial pulse and pedal pulse 70 indicating pulse deficits of 10

c

which patient is at risk for impaired wound healing? a: a 22-year-old with a pelvic fracture incurred in a motor vehicle accident b: a 49-year-old with a history of smoking two packs a day who just had abdominal surgery c: a 72-year-old with diabetes and cardiovascular disease who had a surgical repair of a broken hip d: a 90-year-old with no chronic health conditions with a small blistered burn on the hand

c

range of billirubin

0.3-1 mg/dL

upon review of four clients' urinalysis reports which client's results support the nurse's suspicion that the client may be developing kidney disease? A: serum creatinine- 1.1 mg/dL B: BUN- 18 mg/dL C: serum creatinine: 2.5 mg/dL D: BUN 20 mg/dL

C

Alanine aminotransferase (ALT)

4-36 units/L

range of neutrophils in CBC differential

55-70%

range of troponin I

<0.03

range of troponin T

<0.1

range of LDL

<130 mg/dL

range of total cholesterol

<200 mg/dL

range of myoglobin

<90

range of eosinophils in CBC differential

1-4%

range blood urea nitrogen(BUN)

10-20

range of prealbumin

15-36

range of platelets in CBC

150,000-400,000

which of the following actions should be taken by the nurse when caring for a patient receiving total parenteral nutrition (hyperalimentation)? a: change the IV tubing every 24 hours according to facility protocol b: monitor patient blood glucose levels every 6 hours c: weigh patient weekly d: administer through a peripheral IV line e: use an infusion pump for administration f: use routinely with intact GI tract

a,b,e

a client is scheduled for a kiney ultrasound. which instructions would be given by the nurse? select all that apply a: drink plenty of fluids b: eat foods rich in fiber c: do not urinate before the exam d: lie flat and perfectly still during the test e: a urinary catheter may be needed temporarily for the test

a,c,d

a client reported a loss of 20 pounds (9kg) in 3 months and black, tarry stools. a colonoscopy is scheduled. which instructions would the nurse give to prepare the client for this test? a: the nurse instructs the client that a bland diet will be prescribed for the night before the test b: the nurse tells the client not to eat or drink anything the morning of the test c: the nurse administers an oil-retention enema just before the test d: the nurse explains that the pretest laxative will cause diarrhea after the test

b

a complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which reply by the nurse is best? a: "don't worry these tets are routine" b: "they are done to identify other health risks" c: "they determine whether surgery will be safe" d: "i don't know; your health care provider prescribed them"

b

a patient is prescribed furosemide and is at risk of hypokalemia. Which food choice would be beneficial to manage this potential side effect? a: applesauce b: oranges c: cauliflower d: blueberries

b

the nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first does of intravenous antibiotics? a: RBC count b: wound culture c: knee -ray d: urinalysis

b

which intervention could result in further tissue necrosis when the RN delegates the tasks of caring for a client with pressure ulcers? a: cleaning of the wound performed by the RN b: performing irrigation of the wound by the PCA c: administering of oral analgesics by the LPN d: repositioning the client every 1 to 2 hours by the LPN

b

which information about common expected responses to computed tomography (CT) scan contrast material would the nurse include in the pre-procedure teaching? a: visual disturbances b: flushing of the face c: sensation of warmth d: lemony taste in the mouth e: small petechiae on the arms

b,c

when performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which locations would the nurse examine? select all that apply a: sclera b: nail beds c: conjunctiva d: palms of hands e: bony prominences

b,c,d

which of the following should be immediately reported to the primary care provider? a: hemoglobin: 15.6 g/dL b: hematocrit: 31% c: RBC: 5.3x10^6/uL d: WBC: 2000 cells/mm3 e: platelets: 230,000 cells/mm3

b,d

clean-contaminated wound

because the surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater.

a patient has stage 3 pressure injury on the coccyx. which food will be the most beneficial in improving the healing process? a: food high in vitamin d b: whole grain carbohydrates c: high-calorie, high-protein drink d: food high in fat and water content

c

five days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. which clinical findings support that the client is experiencing wound dehiscence? a: increased bowel sounds b: loosening of intact sutures c: sudden increase in serosanguineous drainage d: purplish color of the incision

c

the nurse evaluates that nutritional education for a patient on a clear liquid diet is effective when the patient selects which food item to comply with this order. a: pudding b: ice cream c: chicken broth d: rice

c

the nurse has placed a nasogastric tube for a patient requiring enteral feeding. The nurse validates placement through pH measurement and using clinical standards should be used to confirm placement prior to using the tube. a: auscultation b: the presence of bowel sounds c: x-ray d: patient affirmation

c

the patient tells the nurse that she has been on a high-protein, low-carbohydrate diet for the past 6 months. Which blood test results could be influenced by her diet? a. bilirubin b. creatinine c. blood urea nitrogen d. creatinine kinase

c

what is included in a kidney function blood test?

creatinine, blood urea nitrogen (BUN), GFR

a client has a large, open abdominal wound. the health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover it with abdominal pads, and secure it with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? a: use two square gauze pads to cleanse the wound, one for each half of the wound b: apply new Montgomery straps each time the dressing is changed c: hold the wet gauze with the tips of the forceps higher than the wrist d: cleanse the wound with wet, sterile gauze from the center of the wound outward

d

in which position would the nurse place a patient when preparing for a thoracentesis? a. prone position with arms resting on a pillow b. side-lying position with the knees pulled up c. high fowlers position with the feet on the floor d. sitting position with the arms resting on the over-the-bed table

d

which technique is used to collect an aerobic culture specimen from a wound? a: collect the specimen immediately after removing the old dressing b: apply sterile gloves, then open the culture tube c: always be sure to culture any necrotic tissue d: irrigate the wound before collecting the culture material

d

while caring for a client with a portable wound drainage system, the nurse observes that the collection container is half full. the nurse empties the container. which nursing intervention would the nurse do next? a: circle the drainage on the dressing b: irrigate the suction tube with sterile saline c: clean the drainage port with an alcohol wipe d: compress the container before closing the port

d

during the follow-up visit after an appendectomy, the patient reports a popping sensation at the surgical suture line. The nurse identifies excessive drainage from the surgical wound. which action would the nurse take for this? select all that apply a. use lactated ringer's solution to clean the wound b. apply heat to the incision for 15 mins every 4 hours c. instruct the patient to couch deep breathe to reduce anxiety d. moisten the gauze with sterile norma; saline and cover the wound e. notify the primary health care provider about the patients condition

d,e

infected wounds

evidence of infection, such as purulent drainage, necrotic tissue, or bacterial counts above 100,000 organisms per gram of tissue

range of hemoglobin

f: 12-16 m: 14-18 g/dL

range of total creatinine kinase

f: 30-135 m: 55-170

range of triglyceride

f: 35-135 m: 40-160

range of HDL

f: >55 m: >45

stage 3 pressure injury

full thickness skin loss: extended to subcutaneous and no further - undermining present - tunneling may be present

stage 4 pressure injury

full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.

wound healing phases are

inflammatory, proliferative, maturation

what is included in a lipid profile?

low density lipoprotein, high density lipoprotein, total cholesterol, triglyceride

what are the components of a CBC differential

neutrophils, lymphocytes, monocytes, eosinophils, basophils

dehiscence

partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

stage 2 pressure injury

partial thickness skin loss with exposed dermis: shallow, pink, intact/ruptured blister

P's of circulation

pian pallor pulselessness paraesthesia paralysis

masceration

softening or dissolution of tissue after lengthy exposure to fluid

purulent drainage

thick green, yellow, or brown drainage usually indicates infection

a postoperative client has been placed on a clear liquid diet. the nurse should provide the client with which item that are allowed to be consumed on this diet. a. broth b. coffee c. gelatin d. pudding e. vegetable juice f. pureed vegetables

a,b,c

range of monocytes in CBC differential

2-8%

range of alkaline phosphate (ALP)

30-120

colonized wound

A wound that has one or more organisms present on the surface, but when a swab culture is obtained there is no overt sign of an infection in the tissue below the surface

contaminated wound classification

An open traumatic wound; a surgical wound with a major break in sterile technique; or a surgical wound into contaminated areas such as the colon or inflamed/contaminated skin.

which change would the nurse assess for in a client who sustained skin injuries 3 days ago? a: local edema b: erythema c: pale color of scar tissue d: formation of scar tissue e: red colored granulation tissue

a,b

put in order the steps for obtaining a capillary blood glucose a: cleanse site with alcohol and allow to dry b: ensure hands are washed c: select site, put on gloves d: quickly puncture skin w/ lancet e: cover test strip w/ full blood sample f: wipe away first drop w/ gauze

a, b, c, d, f, e

what are the cardiac markers?

Troponin I, Troponin T, CK-MB (creatine kinase MB), and myoglobin, total creatinine kinase

A patient is newly diagnosed diabetic. the nurse prioritizes education focused on which of the following nutritional choices? a: limiting carbohydrates b: increasing simples sugars c: maintaining 2500 calorie diet d: limiting sodium intake

a

Mr. Grant has just had a lumbar puncture. Which of the following notes would be important to document on his plan of care? a. He is to lie flat for at least 4 hours. b. He should remain NPO for at least 4 hours. c. The nurse should assess for signs of postprocedure hypertension. d. The nurse should hold all sedatives and narcotics for at least 4 hours.

a

which prescribes action would the nurse perform first when caring for a client with hemodynamically stable sepsis who complains of abdominal pain? a: draw peripheral blood cultures from two different sites b: administer levofloxacin 500 mg intravenously over 30 mins c: administer 1 L intravenous bolus of ringer's lactate over 30 mins d: take the client to x-ray for an abdominal CT scan

a

which response would the nurse give when a client is admitted with chest pain and a family member asks about the purpose of the prescribed 12-lead electrocardiogram(ECG)? a: indicated whether a heart attack is occurring b: detects changes in the structures in the heart c: shows whether the heart muscle is pumping d: evaluates for prognosis after heart attack

a

a client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. which action would the nurse take? a: instruct the client to splint the wound with a pillow when coughing b: place the client in the supine position and inspect the site of the incision c: assess the intensity of the pain and administer the prescribed analgesic d: notify the health care provider immediately and then check for wound dehiscence

a

mr. brown is admitted with advanced liver disease. which of the following lab results would you expect to see? a. albumin 2.6 g/dL b. BUN 18 mg/dL c. homocysteine 2.4 mg/L d. billirubin 0.7 mg/dL

a

which of the following nutrients is most helpful in preventing birth defects and should be taken by women of childbearing age? a: folic acid b: magnesium c: calcium d: selenium

a

a patient is taking an anticoagulant (warfarin). which lab result should be recognized as most clinically significant? a: platelets- 400,000 cells/mm3 b: INR: 5.9 c: activated partial thromboplastin time: 30 sec d: fibrinogen: 350 mg/dL

b

which rationale is correct for the nurse to empty a hemovac wound suction device when it is half full? a: emptying the unit is safer when it is half full b: accurate measurement of drainage is facilitated c: negative pressure in the unit lessens as fluid accumulates, interfering with further drainage d: fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound

c

which term would the nurse use to describe the exudate characteristic of a serosanguineous wound? a: greenish-blue pus b: creamy yellow exudate c: blood-tinged amber fluid d: beige pus with a fishy ordor

c

a client with hypertension has been told to maintain a diet low in sodium. the nurse who is teachig this client about foods that are allowed shoud include which food items in a list provided to the client? a. tomato soup b. boiled shrimp c. instant oatmeal d. summer squash

d

a patients lab reports indicate that the red blood cell count is 3.8 cells/mm3. the nurse finds that the patient's anemia is due to hemolysis. Which lab finding is consistent with the nurse's conclusion? a. increased ketone levels b. increase gluten levels c. increased creatinine levels d. icnreased urobilinogen levels

d

ms Jackson is a 58-year-old woman with no family history of colorectal cancer. which of the following screening guidelines would you recommend? a. fecal occult blood testing every 5 years b. sigmoidoscopy every 10 years c. cystoscopy every 5 years d. colonoscopy every 10 years

d

which action would the nurse take after having difficulty in palpating the pedal pulse if a client with venous insufficiency? a: count the pulse at another site b: notify the primary health care provider c: lower the legs to increase blood flow d: verify the pule by using a doppler

d

which class of medications does the nurse suspect the patient is consuming when a 19-year-old with megaloblastic anemia is on folic acid therapy but still has reduced red blood cell count and low folate levels? a. laxatives b. diuretics c. analgesics d. oral contraception

d

unstagable pressure injury

the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

range WBC count in CBC

5000-10,000

which statement by the student nurse about the use of a suction pump in negative-pressure wound therapy indicates the need for further teaching? a: the wound site should be monitored at least every 2 hours b: this treatment is used mostly for areas of skin cancer c: the foam dressing should be changed every 48-72 hours d: a continuous low-negative pressure should be maintained"

b

which dressing would the nurse view as beneficial for the recovery of a client's red-colored wound that was caused by pressure? select all that apply a: absorptive dressings b: hydrocolloid dressings c: transport film dressings d: moist gauze dressings with antibiotics e: non-adhering dressings with antibiotic ointment

b,c,e

when a 37-year old patient comes to the clinic after sustaining an abrasion while gardening, which wound characteristic would the nurse likely identify? select all the apply a. superficial b. full-thickness c. appears weepy d. bleeds profusely e. associated with the risk of internal bleeding and infection

a, c

Which topic will the nurse include when teaching a group of clients about risk factors for heart disease? select all that apply a: obesity b: hypertension c: diabetes insipidus d: asian-american ancestry e: increased high density lipoprotein (HDL)

a,b