Exam 4 - Davis & ATI Practice Exams

What does a Kock pouch collect?

A kock pouch is an ileal reserve pouch that collects ileal drainage that is then manually emptied through a stoma.

Which type of bowel diversion allows for control over bowel elimination without the need to wear an appliance?

A sigmoid colostomy is closest to the rectum. Stool is most likely to be formed, and can often be controlled without the use of an appliance.

What type of wounds heal by primary intention?

A surgical incision would heal with primary intention. Primary intention is when the edges are well approximated and there is healing with minimal scarring.

What are the primary functions of the kidney?

Acid-base balance and water reabsorption are primary kidney functions.

Which age group experiences an increase in gastric acids?

Adolescents have increased secretion of gastric acids.

What type of dressing is best for wounds that are deep, track-like, or tunnel-like?

Alginate dressings are ideal for wounds that are tunnel-like, track-like, or deep, as they facilitate autolytic debridement.

Which procedure produces a surgical opening in the abdomen which bypassess the large intensine entirely.

An ileostomy. An ileostomy brings a portion of the ileum through a surgical opening in the abdomen, bypassing the colon completely.

Describe a stage 2 pressure injury

At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid.

Describe a stage 4 pressure injury

At stage 4, the pressure injury is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

What is the primary danger when administering oral medication to children?

Choking and aspiration is the primary danger when administering oral medications to children, as they may be unable or unwilling to swallow the medicine.

What is Clark's Rule?

Clark's Rule is adult dose x childs weight in pounds divided by average adult which , which is 150 pounds.

What is dehiscence

Dehiscence is a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing. This scenario typically occurs 5 to 8 days following surgery when healing is still in the early stages

Define diverticuLITIS

Diverticulitis is the result of diverticulosis. It is the inflammation or infection in one or more small pouches in the digestive tract

Define diverticuLOSIS

Diverticulosis is the bulging of pouches develop in the digestive tract. This occurs when the body must move highly compacted stool over time, enlarging the surrounding muscles. This causes the muscles to balloon out, and fecal material becomes trapped in the swollen areas, causing diverticulitis, the infection of the pouches.

How is dosing and calculations of medications different in the pediatric population?

Dose of medication is based on child's weight in kilograms.

Describe a stage 3 pressure injury

During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.

What is evisceration?

Evisceration is when internal organs are physically removed from the body.

What findings should a nurse expect to see if a client has impaired renal function?

High blood pressure, high heart rate, altered mental status, and fluid retention are all symptoms of kidney failure.

What type of dressing is used on a wound with significant exudate?

Hydrofibre dressings can absorb large amounts of fluid, even under pressure. Because little fluid is drawn laterally, nearby tissues do not become macerated

Which is an indication of food allergy, nausea and vomiting or intestinal bleeding?

Intestinal bleeding is often seen in true food allergies. Nausea and or vomiting may indicate food poisoning, but not an allergy

What is ischemia?

Ischemia is a condition in which the blood flow, and thus oxygen, is restricted or reduced in a part of the body

What skin condition should the nurse monitor in a client who is taking blood pressure medication?

Ischemia. Antihypertensives make it easier to stop blood flow to an area, this creates a risk for ischemia.

Which would be an appropriate technique and preparation for administration of subcutaneous injection in a person who is obese?

Method for subcutaneous injection in obese clients would include using a small, 25-27 gauge needle, injected at a 90 degree angle, with the skin pulled taut when administering.

What term describes the production of a fine spray, fog, powder , or mist from a liquid drug?

Nebulization is fine particles of a liquid medication converted to an inhaler form.

Should a patient with urinary incontinence be advised to limit fluid intake?

No, a patient with urinary incontinence would not be advised to limit fluid intake, this can lead to kidney injury, infection, and dehydration.

Are hemorrhoids contrainidcated for rectal suppository?

No, hemorrhoids are not considered a contraindication.

Is intelectual empathy a critical thinking skill?

No, intelectual empathy is a critical thinking attitude.

A nurse is teaching a newly licensed nurse about physiological changes in the digestive system that occur with aging. What should the nurse educator advise about older patients?

Older adults experience decreased peristalsis. Older adults also experience relaxation of the sphincters.

Which includes more fiber, popcorn or applesauce?

Popcorn includes more fiber than applesauce.

What is P.E.S. in a nursing plan?

Problem, Etiology, Symptom ; or P. E. S. is used to write a basic 3 part statement. This uses the phrases as evidenced by, or as manifested by.

What functions of the kidney are secondary functions?

Renin production, Vitamin D activation, Erythopoeitin secretion are all secondary kidney functions.

A wound that is healing from the inside out is healing by ________ intention.

Secondary intention, there is granulation and epithelial tissue in the wound bed.

How does smoking lead to alterations in skin integrity?

Smoking impairs circulation becuase it decreases oxygen available for the tissues. Impaired circulation can cause skin breakdown.

Describe a stage 1 pressure injury

Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears.

Which stages of pressure injury may have little to no pain?

Stages 3 and 4 pressure injury may have little or no pain due to significant tissue damage.

T or F - A food allergy may cause a rash around the anus

TRUE

When does tertiary intention healing occur?

Tertiary intention wound healing occurs when a wound is intentionally left open , such as when there is poor circulation in the wound area or infection that needs to be dealt with before the wound is closed.

What is the name of the first part of the large intestine?

The cecum , is the first portion of the large intestine.

Undigested food first enters the large intestine through which structure?

The cecum , the first portion of the large intestine.

Which part of the kidney is made up of millions of functional units called nephrons?

The cortex, the outer part of the kidney, contains millions of nephrons.

What joins the small and large intestine?

The ileum joins the small and large intestine.

Which part of the kidney contains the collecting tubules?

The medulla, the inner layer of the kidney, contains the collecting tubules.

What are the most common side effects of medications?

The most common side effects of medication are nausea, vomiting, diarrhea, dizziness, drowsiness, dry mouth , abdominal distention or distress and constipation.

What resource should a nurse access for help calculating that dose of a medication?

The nurse should contact the pharmacist. Drug handbooks, physician desk reference and medication inserts have drug information, but not dosage conversion or calculations.

When checking on a postoperative client, the nurse notices evisceration. What action should the nurse take?

The nurse should immediately cover the wound with sterile towels or dressings soaked in sterile saline solution. Then notify the surgeon.