Foundations lessons

which hypotheses would the nurse develop for a patient with post surgery for hip replacement who is receiving opioid pain meds while the spouse is in the room?

impaired mobility, risk for deep vein thrombosis, risk for constipations

For which patient hypotheses would the nurse select turning and positioning as a solution?

impaired skin integrity, risk for pressure ulcer, impaired tissue integrity, risk for impaired skin integrity

Which factor is a patient-related fall risk hazard?

incontinence

separating sick and contagious people from others

isolation

Which interpretation would the nurse make about a patient's wound culture that is positive?

it is infected

which action for skin hygiene would a nurse take for an obese immobile patient?

keep skinfolds dry

The nurse would contact the health care provider for clarification for which medication prescription?

lisinopril mg PO qd

Which characteristic is an advantage of a transdermal patch?

long term continuous administration

which patient cues would prompt the nurse to select the hypothesis impaired skin integrity?

low prealbumin levels, immobility, stage 2 pressure injury

Which steps would the nurse take to measure the dimensions of a sacral pressure injury?

measure depth with sterile cotton tip, measure width from side to side, length from up and down

Patient reluctance to share information is a major obstacle to which process?

medication reconciliation

Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)?

monitor for granulation tissue in the wound, avoid using NPWT for a cancerous wound, change to white foam if they report pain, report to the health care provider if there is an increase in drainage

Which actions apply to the administration of an intradermal injection?

monitor skin for a wheal, insert needle with bevel up, apply outward traction to skin around site

As a general rule, which information should be given to a patient when a drug is being administered?

name of drug, why its been prescribed, expected side effects

Nurse is admitting a patient who is at fall risk. which room does she assign?

nearest to nurse station

Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver?

provide written instructions

When administering an otic medication to an adult, which action would the nurse take to facilitate the spread of the medication to the entire ear canal?

pull up and back on the pinna

separate people exposed to a contagious disease

quarantine

Which action would the nurse take when caring for a patient's Jackson-Pratt drain?

reactivate the drain after emptying

An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse would observe the patient's skin for which signs of infection?

redness, swelling, drainage

loss of sensation

rehab

A nurse is providing tertiary prevention for a patient with a stroke that resulted in left-sided weakness. Which concept describes the focus of the nurse's interventions?

rehab efforts

Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder?

remove air from pack

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?

repositioning, reporting any changes in skin integrity, applying nonsterile dressing for chronic wounds

which is priority for a patient who suffered multiple fractures after motor accident?

respiratory distress

which indicates the need for additional teaching after educating on respiratory etiquette?

reusing tissues for productive cough

Which hypothesis would the nurse select for the patient w redness, warmth, and slight swelling in right lower leg from bed rest?

risk for deep vein thrombosis

which hypothesis would the nurse develop for an immobile patient who has intact skin?

risk for impaired skin integrity

which hypothesis would the nurse select for a patient who refuses to turn and lies supine most of the time

risk for impaired skin integrity

The nurse instructs a patient for whom a transdermal patch has been prescribed to rotate sites of application. For which hypothesis is this instruction an intervention?

risk for impaired tissue integrity

which actions apply to the concept of health promotion?

routine exercise, inform people of what to do to stay healthy, and assessing community assets and strengths that influence well-being

Which type of fluid would the nurse likely observe if the patient was hemorrhaging?

sanguineous

secondary intervention example

screening for HIV

A nurse is screening children for scoliosis, which type of prevention does this illustrate?

secondary

how to help venous stasis?

sequential compression devices

Which factors may impact the development of pressure injuries or nonhealing wounds?

smoking, diabetes, urinary incontinence

Which solution would the nurse select for an immobile patient who appears withdrawn and reports not having any visitors in the last week?

spiritual consult

which nursing students notes would the nurse correct?

standard precautions used during bed, bath, and mouth care. it is not necessary to document this

actions required for sterile procedure?

sterile surfaces dry, setting up sterile field, checking packaging integrity, monitoring activities in others

what to do when irrigating abdominal wound

sterile technique

Which procedure is necessary for equipment being used to enter a sterile body cavity?

sterilization

which action would the nurse take to help a patient implement a risk-reduction plan?

suggest online health education resources that help to reduce the identified risk factor

primary intervention example

teaching about safe-sex

which infection would need contact precautions?

Hepatitis A

separate people with weak immune systems

protective isolation

Which statement made by a patient who self-administers medications through a gastrointestinal (GI) tube indicates the need for further instruction about the process?

"I mix my morning medication with my morning feeding to save a bit of time before leaving for work."

Which statement by a patient who has received instructions about self-administration of medications in the home indicates a misunderstanding of information?

"If I miss a dose of any medication, I'll just double the dose when I take it the next time."

Which statement made by a nurse conducting discharge teaching indicates a review of patient education principles related to medication administration is needed?

"This pink pill is digoxin, your heart medication. You will take your pulse before you take this pill. If your pulse is less than 60 beats per minute, you will not take the pill."

A patient is to have an ophthalmic ointment applied to both eyes. Which information would the nurse provide?

"Your vision may be blurred for a while after I put the ointment in your eyes." "I'm giving you two tissues to use to wipe extra ointment off your face; use one for each eye."

The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient's activities of daily living (ADLs)?

"do you always make it to the bathroom on time?" "how often do you take a bath?" "can you bathe yourself without help?"

Patient takes many medications and nurse is worried about their ability to manage taking them. What question would the nurse ask regarding safety risk?

"do you take your meds consistently?" "do you know how to take these?" "do you know when to take your drugs?" "do you know why you are prescribed these?"

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound?

"my wound will look beefy red in 1 week"

Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools?

"norton scale is used to assess pressure injury risk" "when assessing for open woulds, I can use the characteristic instrument"

Which statements are appropriate for the nurse to make to a patient who is about to receive pain medication by intravenous push?

"you will feel effects quickly" "let me know if your arm hurts or swells" "the medication is being injected into the bloodstream"

the nurse directs a patient who needs two puffs of medication from a metered-dose inhaler to wait how many minutes between puff one and puff two

1 minute

when an infection is resolved, temperature would be below ____.

100.4

For how many minutes would a nurse monitor a patient for an immediate allergic reaction following medication administration?

20-30 minutes

elderly patient on bed rest because of hip surgery from a fall at home. has diabetes and dementia. Has an IV and a catheter. Morse fall scale deems this patient at...

75--high risk

An older, visually impaired but proudly self-sufficient adult patient has several prescribed medications to take at home. Which action would the nurse take to assist this patient in complying with the medication regimen?

Arrange for the medications to be put in a weekly pill organizer.

the nurse teaches the patient about a newly prescribed medication, specifically the name, dose, route of administration, time, frequency, and special instructions. Which method would the nurse use to evaluate the effectiveness of the teaching?

Ask the patient to explain the use of the new medication, giving its name, dose, route, frequency, expected effects, and management of side and adverse effects of the new medication.

Which statement demonstrates learning from the patient on home safety?

I checked my floorboards to make sure they are even

Nurse is educating patient on home safety. Which patient response needs further teaching?

I shave with my electric razor when I am in the tub

which PPE for body secretions

gloves

Which action would the nurse take as part of the procedure for administering a vaginal suppository?

Lubricate the applicator with a water-soluble gel.

which SMART outcomes would the nurse develop for a patient who is light-headed and fatigued and has feeble hand grip with reduced bone density?

Patient will brush teeth after breakfast with one person assisting.

purulent drainage

greenish yellow

which infection leads to airborne precautions?

Varicella zoster

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?

WOC nurse, social worker, nutritionist

which hypothesis would the nurse select for a patient who experiences increased heart rate and oxygen requirements when eating?

activity intolerance

example of tertiary intervention

administer medication to stop a disease process

which piece of clothing would the nurse remove when looking for excoriations?

adult diaper

rubeola

airborne

Which factors can place a patient at risk for a pale, dry wound?

anemia, diabetes, vascular disease, nutritional deficiencies

Which questions are answered by the medication reconciliation process?

are any of the prescribed meds duplicates? does patient currently need ever med prescribed? are there any meds that the patient needs that are not prescribed? do any interact w each other?

Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm?

ask the mother to bring her daughter to the office to be evaluated immediately

An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient's discharge from the hospital?

assist patient with community referrals

which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement?

autolytic

whihc is the first step in PPE

hand hygiene

sanguineous drainage

bloody drainage

assessment findings that indicate poor hygiene

body odor, tangled hair, excessively long and dirty nails

which primary areas injured would prompt the nurse to develop the hypothesis of impaired tissue integrity?

bone, tendon, muscle

Which cues would alert the nurse to develop a hypothesis of Risk for Impaired Skin Integrity for a patient?

braden scale of 16, inability to move,

Which evaluative cue would alert the nurse that a patient with a pressure injury is declining?

braden scale was 9 but now 8

which foods would the nurse recommend for a patient with a leg would who needs more vit A?

carrots and sweet potatos

which apsesis intervention directly protects the patient from infection?

cleaning patient bedside equipment, disposing of used needles, providing leak-proof receptacles at bedside, preventing contamination of IV sites

serous drainage

clear and watery

Herpes simplex virus

contact

The nurse looks up an unfamiliar medication when preparing to administer it. The reference indicates the medication is on the Institute for Safe Medication Practices (ISMP) high-alert list. Which action would the nurse take?

have a second nurse verify dosage

transmitted through droplets?

cough, sneeze, suctioning, talking

which are independent nursing interventions?

counseling a patient, repositioning a patient to enhance comfort, teaching a postoperative patient how to prevent surgical site infection

which cues related to skin integrity may reflect overall health issue?

cracking, tenting, pathogens identified in wound culture

which action is a breach in surgical asepsis?

health care provider reached over sterile field to pick up towel

which nursing intervention is an example of tertiary prevention?

helping the patient adjust to an incurable disease

which factors are potential causes of halitosis?

diabetes, medications, poor oral hygiene, and infection of oral cavity

which term describes excessive moisture on skin?

diaphoresis

which solution would the nurse select for a patient experiencing anorexia?

dietary measures with favorite foods

reduced basal metabolic rate

dietician

Patient is being released from SCI surgery. which question is most important at discharge?

do you have a plan of exit at home in case of emergency?

which type of injury results in a puncture wound

dog bite

rubella

droplet

which statement describes the purpose for greeting the patient and explaining the need for PPE?

eases fear and misunderstanding, creates professional relationship, builds a trusting relationship

which action can communities engage in to help reduce infections?

encouraging immunization programs

A newly admitted patient tells the nurse "I can't swallow medicines; they all need to be crushed." Based on this statement, the nurse would contact the health care provider about a prescription for which form of medication?

enteric coated tablet

Which cues would the nurse observe for a patient with an infected lateral malleolus wound?

erythema noted on superior portion of wound, purulent maladorous drainage, temperature of 102

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?

exhibit signs of healing as evidenced by presence of granulation tissue in the would within 1 week

which patient situations are of immediate concern?

experiencing shock, profuse bleeding, eviscerated wound

for an elderly patient, staying safe is most important in preventing _______.

falls

Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage?

foam

For which patient would providing a weekly medication organizer be an appropriate intervention?

forgetful patient

which type of infection would a nurse suspect when caring for a patient who has a prescription for C. diff?

gastrointestinal infections

what if a patient refused meds?

notify healthcare provider, inquire why patient is refusing, explain the consequences, document the circumstances and actions taken

Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage?

notify primary health care provider, take patient's temp, review wbc count

which actions would the nurse take for the patient receiving heat therapy?

obtain distilled water for aquathermia treatments, check on the disoriented patient more frequently, cover the container and hand when providing warm hand soaks

When reviewing a patient's chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment?

open wound over the sacrum

A patient has a prescription for 2.5 mL of a liquid medication to be administered orally. In accordance with best practice guidelines, which device would the nurse use when preparing this medication?

oral syringe calibrated in metric only

which patient findings are risk factors for the development of diabetes?

overweight, siblings have diabetes, and watches TV 5 hours a night

which parameters would the nurse monitor after applying an ankle wrap?

pain, pallor, paralysis, paresthesia, pulseness

Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected?

palpating the area for induration around the incision line

nurse identifies that patient has hard time putting on shoes and buttoning shirt. which is a goal of the plan of care?

patient will dress self within 1 month

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?

patient will eat high protein diet every meal, patient will help transfer in 24 hours

Which outcomes would the nurse develop for a patient experiencing weakness, cerebellum injury, and orthostatic hypotension?

patient will not fall during hospitalization and patient will not self injure during hospital stay

Which patient situations would prompt the nurse to question the prescription for heat therapy?

patient with local tooth abscess, patient with possible appendicitis, patient with bleeding from a small wound

which patient is likely at risk of pressure injury?

patient with unrelieved pressure who has fracture hip

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?

patients wound will exhibit granulation tissue in the wound by 1 week

CDC tells who to quarantine?

people, animals, cargo, buildings

quaternary intervention example

performing a chart audit to evaluate quality care

Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick?

personal

90 year old patient takes multiple meds and is being discharged, which members of the interprofessional team would the nurse consult with to evaluate fall risk?

pharmacist, physical therapist, and occupational therapist

Which solutions would the nurse choose for a patient experiencing dyspnea on exertion, oxygen saturation level of 86%, and pulse of 112 beats/min when grooming?

physical therapist consult, special equipment for hygiene needs, and exercises for strength

serosanguineous drainage

pink to pale red

A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider?

presence of pediculosis

which phrases describe the purpose of hand hygiene?

prevent spread of infection, breaks the chain of infection, interrupts the organism transmission

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days?

therapies consistent with guidelines for treatment, recommendations from collaborating health care professionals, agreement of patient with the plan, capability of patient to purchase supplied for home care

Which reasoning explains why a nurse measures wound size during an initial wound assessment?

to help assess the progression of wound healing

Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage?

transparent

which infections requires nurse to wear an N95 mask?

tuberculosis

Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8?

turn patient every 2 hours, pad and protect bony prominences, wash and dry the patient's skin after each liquid stool, replace soiled linens

prolonged pressure?

turning

the nurse would delegate which tasks to the unlicensed assistive personnel?

turning a patient w pressure injury cleaning incontinent patient of stool and urine

Which techniques would the nurse use to troubleshoot issues with patients' dressings?

use abdominal binder to help patient who has an abdominal would to cough, use montgomery straps for a patient who needs frequent dressing change, use a splint to help a patient deep breathe

A diagram of which injection site would be most helpful when teaching a patient how to use of an EpiPen?

vastus lateralis

when can you use an alcohol-based sanitizer?

when hands are not visibly soiled

Why is it important to gather information about the patients ADLs?

will help determine if they need any assistance at home