Fundi's Ch. 32 Prep U

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A. to provide drainage for bile. B. to decrease dead space by decreasing drainage. C. to provide a sinus tract for drainage. D. to divert drainage to the peritoneal cavity.

A. to provide drainage for bile.

The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet? A. Vitamin A B. Zinc C. Vitamin B12 D. Magnesium

B. Zinc

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? A. laxatives B. potassium supplements C. corticosteroids D. antihypertensive drugs

C. corticosteroids

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? A. Red B. Blue-grey C. White D. Yellow

A. Red

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? A. "That is necrotic tissue, which must be removed to promote healing." B. "This is normal tissue." C. "That is old clotted blood underneath the wound" D. "That is called undermining, a type of tissue erosion."

A. "That is necrotic tissue, which must be removed to promote healing."

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A. Administer the prescribed analgesic. B. Assess the client's wound and vital signs. C. Document the pain and vital signs. D. Notify the health care provider of the pain.

B. Assess the client's wound and vital signs.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A. Green beans B. Fish C. Pasta salad D. Banana

B. Fish

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? A. Utilize the culture swab to obtain cultures from multiple sites. B. Keep the swab and the inside of the culture tube sterile prior to collecting the culture. C. Cleanse the wound after obtaining the wound culture. D. Stroke the culture swab on surrounding skin first.

B. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A. a wound left open for several days to allow edema to subside B. a surgical incision with sutured approximated edges C. a wound healing naturally that becomes infected. D. a large wound with considerable tissue loss allowed to heal naturally

B. a surgical incision with sutured approximated edges

The nurse in the postanesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after noting the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm × 3 cm of pinkish drainage along the lower edge of the dressing? A. provide oxygen via nasal cannula B. apply additional dressing, especially over the lower edge where drainage is occurring C. record full electrocardiogram (ECG) and notify health care provider D. notify health care provider of overall condition of client

B. apply additional dressing, especially over the lower edge where drainage is occurring

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed? A. surgical (sharp) debridement B. mechanical debridement C. autolytic debridement D. enzymatic debridement

B. mechanical debridement

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? A. "Be sure to take at least two showers daily to remove all microorganisms from the skin." B. "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." C. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." D. "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection."

C. "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? A. "How many meals a day do you eat?" B. "Do you use any lotions on your skin?" C. "Do you experience incontinence?" D. "Have you had any recent illnesses?"

C. "Do you experience incontinence?"

A client's risk for the development of a pressure injury is most likely due to which lab result? A. hemoglobin A1C 7% B. sodium 135 mEq/L C. albumin 2.5 mg/dL D. glucose 110 mg/dL

C. albumin 2.5 mg/dL

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? A. Allow the wound and intestinal contents to remain open to air. B. Pack the wound with gauze pads and a dry sterile dressing. C. Inform the client that this is an expected occurrence and not to worry. D. Apply saline solution-moistened gauze over the protruding area.

D. Apply saline solution-moistened gauze over the protruding area.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A. A Penrose drain promotes passive drainage into a dressing. B. A Penrose drain is a closed drainage system that is connected to an electronic suction device. C. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. D. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A. A Penrose drain promotes passive drainage into a dressing.

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? A. Apply moist saline compresses to loosen crusts before attempting to remove the staples. B. Go ahead and remove the staples as they will pop up and out of the skin. C. Apply a warm compress to the surgical staples and allow the dried blood to melt. D. Notify the health care provider of the dried blood and wait for a prescription to proceed.

A. Apply moist saline compresses to loosen crusts before attempting to remove the staples.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. A. Insert a swab into the wound. B. Tap the outside of the culture tube with the swab before placing it in the tube. C. Use the same swab for both wound sites. D. Press and rotate the swab several times over the wound surfaces. E. Touch the swab to the intact skin at the wound edges. F. Place the swab in the culture tube when done.

A. Insert a swab into the wound. D. Press and rotate the swab several times over the wound surfaces. F. Place the swab in the culture tube when done.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? A. Stage II B. Stage III C. Stage IV D. Stage I

A. Stage II

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? A. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. B. The nurse elevates the foot of the bed. C. The nurse increases the amount of time the head of the bed is elevated. D. The nurse uses a ring cushion to protect reddened areas from additional pressure.

A. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply. A. Use a new gauze for each wipe of the wound. B. Clean from the outside of the wound to the center. C. Avoid touching the wound bed, whether with gloves or forceps. D. Clean the wound from top to bottom. E. Use a sterile applicator to apply any ointment that is ordered.

A. Use a new gauze for each wipe of the wound. C. Avoid touching the wound bed, whether with gloves or forceps. D. Clean the wound from top to bottom. E. Use a sterile applicator to apply any ointment that is ordered.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? A. a client sitting in a chair who slides down B. a client who lies on wrinkled sheets C. a client who lifts himself up on the elbows D. a client who must remain on the back for long periods of time

A. a client sitting in a chair who slides down

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? A. foul-smelling drainage that is grayish in color B. small amount of drainage that appears to be mostly fresh blood C. copious drainage that is blood-tinged D. large amounts of drainage that is clear and watery and has no smell

A. foul-smelling drainage that is grayish in color

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? A. hemostasis phase B. proliferation phase C. maturation phase D. inflammatory phase

A. hemostasis phase

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? A. a newborn B. a critical care client C. an older client with arthritis D. a client with cardiovascular disease

B. a critical care client

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: A. a rash related to immobility. B. a rash related to a yeast infection. C. an allergic reaction to detergent. D. an allergic reaction to medications.

B. a rash related to a yeast infection.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? A. stage II B. stage IV C. stage I D. stage III

B. stage IV

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? A. "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." B. "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." C. "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." D. "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)."

C. "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? A. "As soon as the infection clears, your surgeon will staple the wound closed." B. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C. "Your wound will heal slowly as granulation tissue forms and fills the wound." D. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

C. "Your wound will heal slowly as granulation tissue forms and fills the wound."

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? A. A child's skin becomes less resistant to injury and infection as the child grows. B. In children younger than 2 years, the skin is thicker and stronger than in adults. C. An infant's skin and mucous membranes are easily injured and at risk for infection. D. An individual's skin changes little over the life span.

C. An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority? A. Knowledge deficit B. Acute pain C. Impaired tissue integrity D. Disturbed body image

C. Impaired tissue integrity

When applying an external heating pad, which prescription from the health care provider would the nurse question? A. Maintain the temperature between 105°F to 109°F (40.5°C to 43°C) B. Use gauze to secure the heating pad to the site of application C. Leave heating pad on for 45 minutes D. Assess site frequently during application of the heating pad

C. Leave heating pad on for 45 minutes

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? A. Monitor the client for nausea. B. Assess the coccyx area for blanching. C. Monitor intake and output. D. Assess mental status.

C. Monitor intake and output.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? A. Assure that the packing material is completely saturated when placed in the wound. B. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. C. Reduce the time interval between dressing changes. D. Use less packing material.

C. Reduce the time interval between dressing changes.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? A. If there is contamination of dirt and debris B. The event leading up to the trauma C. The status of the client's tetanus immunization D. Staging the wound for assessment

C. The status of the client's tetanus immunization

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? A. an antimicrobial dressing B. transparent film C. an alginate dressing D. a hydrogel dressing

C. an alginate dressing

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? A. alginate B. hydrogel C. hydrocolloid D. transparent film

C. hydrocolloid

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? A. place a foot board on the bed B. provide incontinent care every 4 hours as needed C. use pillows to maintain a side-lying position as needed D. elevate the head of the bed 90 degrees

C. use pillows to maintain a side-lying position as needed

Which is not considered a skin appendage? A. Eccrine sweat glands B. Sebaceous gland C. Hair D. Connective tissue

D. Connective tissue

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? A. Infection of the wound B. Herniation of the wound C. Evisceration of the viscera D. Dehiscence of the wound

D. Dehiscence of the wound

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? A. Superficial contusion accompanied by pruritus B. Superficial abscess accompanied by pruritus C. Diffuse fungal infection accompanied by pruritus D. Diffuse dermatitis accompanied by pruritus

D. Diffuse dermatitis accompanied by pruritus

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? A. Explain to the client that this is not possible because of the health care provider's prescription. B. Leave the therapy on for 10 more minutes and return to remove it after that time. C. Assist the client to get out of bed and sit up in a chair for a short while. D. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

D. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? A. Placing the client in a side-lying position with a pillow between the lower legs B. Placing the client in the supine position with a pillow under the knees C. Placing the client in a wheelchair with the back of the feet resting against the heel loops D. Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

D. Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? A. Stop removing staples and apply an abdominal pad over the incision. B. Apply adhesive wound closure strips after each staple is removed. C. Apply an occlusive pressure dressing after removing the staples. D. Stop removing staples and inform the surgeon

D. Stop removing staples and inform the surgeon

The nurse would recognize which client as being particularly susceptible to impaired wound healing? A. A client who is NPO (nothing by mouth) following bowel surgery B. a client whose breast reconstruction surgery required numerous incisions C. a man with a sedentary lifestyle and a long history of cigarette smoking D. an obese woman with a history of type 1 diabetes

D. an obese woman with a history of type 1 diabetes

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? A. assessing for impaired blood flow to the area of evisceration. B. contacting the surgeon C. monitoring for pallor and mottled appearance of the wound D. applying sterile dressings with normal saline over the protruding organs and tissue

D. applying sterile dressings with normal saline over the protruding organs and tissue

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? A. spica turn B. spiral-reverse turn C. circular turn D. figure-of-eight turn

D. figure-of-eight turn

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? A. purulent B. serous C. sanguineous D. serosanguineous

D. serosanguineous

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? A. stage I B. stage III C. stage IV D. stage II

D. stage II