EAQ Tissue Integrity
The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply.
"I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every two hours." "Clients fluid intake is 2000-3000ml"
A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon?
tolerance
A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets
2 tablets
A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply.
Anorexia History of Diabetes Hemiplegia Urinary incontinence
A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?
Frequent Repositioning
A nurse assesses four different clients with pressure ulcers. Which client is suspected of having an unstageable ulcer?
Full thickness in loss in tissue with base of ulcer covered in slough
Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?
Incontinence and inability to move independently
Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult?
Keep patient adequately hydrated
A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone?
RR and LOC
A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take?
Refuse to suture wounds
What information should the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply.
Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources
A 7-year-old child is brought to the emergency department with a puncture wound on the sole. It is determined that the child's history of immunizations is uncertain, and tetanus immune globulin and tetanus vaccine are prescribed and administered. What is the priority reason for using tetanus immune human globulin instead of tetanus antitoxin?
The risk for anaphylactic reaction is less
A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication?
Medication is not adequately effective
Which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised?
Fidelity
The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice?
Decreased Dermal blood flow
What is the etiology for the development of pressure ulcers in an 80-year-old client?
Decreased SubQ fat
A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply.
Empty wound drainage containers. Report changes in wound appearance.
While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client?
Erythema
A nurse withholds a prescribed opioid medication from a client requesting to be treated for intractable pain because the nurse fears the client will become addicted. In this situation, the nurse is adhering to which ethical principle?
Paternalism Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices; the client has requested to be treated with a medication that has been prescribed by the healthcare team and the nurse is refusing to give it because of unfounded personal beliefs. The client's priority is pain relief and the nurse should be working with other health team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are made. Beneficence commonly is referred to as "doing good;" it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety.
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication may be prescribed because of its major role in wound healing?
Vitamin C, (ascorbic acid)
