HESI NUR112 STUDY GUIDE

The nurse is caring for a 70-year-old client who reports seeing a number of different health care providers. Which follow-up assessment question will the nurse ask?

"Do you get all of your medications filled at the same pharmacy?" Explanation: Polypharmacy is a concern in the older adult population. The nurse should ask if medications are filled at the same pharmacy. Pharmacists can often note discrepancies in medications prescribed or identify duplicate orders written by different providers. The other questions posed are not helpful.

The nurse is discussing epidural analgesia with the nursing student. Which of statement by the nursing student indicates a need for additional education?

"Epidural analgesia is always administered in a continuous infusion to prevent or treat pain." Explanation: The infusion can be set on a continuous rate (basal mode) or an intermittent mode controlled by the client (patient-controlled epidural analgesia [PCEA]). It is commonly used in labor and discontinued after delivery.

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.

An older adult client who is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply.

"It may take you longer to heal than someone younger." "Eat nourishing foods after surgery to promote healing." "Wound healing can take longer if you have been exposed often to the sun." "Monitor your moods after surgery. Depression after surgery is not normal." Explanation: Wound healing can be delayed in older adult clients, especially those with long-term sun exposure. Eating healthy foods can speed healing. A home health aide can assist with caregiving to reduce stress. Depression, which is abnormal after surgery, can affect wound healing. It is not advisable to encourage the client to do everything alone at home to build strength, as this could be dangerous if the client is not physically capable.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

Which statements made by the nurse indicate how insulin pens simplify self-administered insulin for clients? Select all that apply.

"The cylinder of the insulin pen contains a prefilled reservoir of insulin." "The dose of insulin in an insulin pen is displayed in a window of the syringe." "The insulin pen automatically resets the dose window to zero, following the injection." Explanation: The cylinder of an insulin pen contains a prefilled reservoir of insulin because insulin comes prepared. The dose of insulin in an insulin pen is displayed in a window of the syringe, making it easier for the client see the remaining dose. Insulin pens automatically reset the dose window to zero following the injection; this minimizes client error. The cylinder of the insulin pen is made out of hard plastic, not soft plastic, to allow the client to grasp it like a pen. Insulin pens are more expensive, not less expensive, than insulin vials

The nurse is preparing to administer meperidine as an intramuscular injection in an adult client's deltoid site. Which needle should the nurse select for this injection?

1-inch; 22-gauge Explanation: IM injections using the deltoid site require a 20- to 25-gauge needle that is between 1 and 1½ inches (2.5 and 4 cm) in length.

A nurse is providing wound care for a client who has a pressure inury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options.

1. Give pain medication. 2. Use nonsterile gloves. 3. Remove old dressing. 4. Apply sterile gloves. 5. Cleanse the wound with normal saline. 6. Apply wound covering. Explanation: The correct order for this dressing change is giving pain medication, applying nonsterile gloves to remove old dressing, removing old dressing, applying sterile gloves, cleansing the wound with normal saline, and applying a wound covering.

A client is receiving three different intravenous medications. Two of the medications are not compatible with each other. Which type of access is most appropriate for this client?

7-French triple lumen central catheter Explanation: With a multiple lumen central line, incompatible medications can be administered simultaneously, as each lumen is a channel that exits the catheter at a separate location near the heart. While peripheral IV catheters could be used, more than one line would be necessary for this client. While peripheral catheters can have multiple lumens to administer medication through, the actual venous access is one channel, which allows medications to mix. This would not be an appropriate option for this client.

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 Penrose drain promotes passive drainage into a dressing. Explanation: A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

A school nurse interviewing parents of a child who is doing poorly in school determines that the parents practice a laissez-faire method of discipline. What are examples of this form of value transmission? Select all that apply.

A teenage boy explores religions of friends in hopes of developing his own faith. A teenage girl tries alcohol at a party with her friends. Explanation: The laissez-faire approach to discipline would leave children to explore values on their own and to develop a personal value system from this exploration. This approach often involves little or no parental guidance, and may lead to confusion and conflict for the child. Examples of this form of discipline would be a teenage girl trying alcohol at a party with her friends and a teenage boy exploring religions of friends in hopes of developing his own faith. A child reciting a prayer learned by the parents would not be an example of this method. A child being taken for ice cream to celebrate would not be an example of this method. A child taught how to behave by the school teacher is not an example. A teenager being punished by the parents for breaking curfew is not an example.

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Explanation: Analgesia can be provided before drain care, if necessary. A gauze pad is used to cleanse the outlet after emptying and the drain is secured to the client's gown with a safety pin. Goggles are not normally necessary. The drain does not require 5 to 7 minutes in order to become fully empty.

A client presents in the emergency department with signs and symptoms of venous thromboembolism. What type of medication administration would most likely be ordered to infuse a large dose of heparin for this client?

Administer heparin by intravenous bolus or push through an intravenous infusion. Explanation: A bolus push involves a single injection of a concentrated solution directly into an intravenous line and is frequently used to treat emergencies. In continuous infusion, the client receives the medication slowly, over a long period. With intermittent intravenous infusion and a volume-control administration set, the drug is mixed with a small amount of the intravenous solution and administered over a short period at the prescribed interval. Heparin is not administered via a piggyback.

he nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation?

Aloe vera Explanation: Lotions and gels containing aloe vera are widely accepted as adjuvants to standard medical topical treatments for wounds, especially minor burns, insect bites, dermatitis, and dry skin. Chamomile, lavender, and tea tree oils are commonly used for healing wounds.

The nurse is preparing to administer an intramuscular dose of dimenhydrinate to an adult client. Which of the nurse's actions best demonstrates correct technique?

Appropriate landmarking for the ventrogluteal site is into the center of the triangle formed by the index finger, the middle finger, and the iliac crest. Injection should be at 90 degrees, and gloves should be worn. The nurse should not inject adjacent to his or her fingers to prevent a needlestick injury.

The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?

Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification Explanation: Distractions to learning, such as the television being on or the client being at meal time, diminish the effectiveness of any education plan. An authoritarian style of teaching does not honor the client as a partner in the learning process. Age does not necessarily determine developmental stage. Assessing the client's developmental stage and understanding of the health problem, clarifying information that is difficult for the client to understand, and ensuring that the client is physically able to perform the task are all aspects of a well-planned education session for all clients.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a nonskid floor. Explanation: The nurse can ensure the client's safety by checking for nonskid strips on the floors of bathtubs and showers, along with strategically placed handles and grab bars that reduce the risk of falls for older adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach of the dominant arm. As the client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs, as they increase the risk of falls.

A nurse is assessing children for spirituality and identifies which central themes in children's descriptions of God, based on David Heller's study? Select all that apply.

Children have a notion of a God who works through human intimacy. Children believe in the interconnectedness of human lives. Children show considerable anxiety in the face of God's power. Explanation: Studies have shown that the central themes in all the children's descriptions of their beliefs in God included the following:· Notion of a God who works through human intimacy and the interconnectedness of lives· Belief that God is involved in self-change and growth and transformations that make the world fresh, alive, and meaningful· Attributing to God tremendous and expansive power and then showing considerable anxiety in the face of this power.

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis Explanation: Because activity of the sebaceous and sweat glands decreases, the skin will become dryer and the client may have pruritis. The perineal area should be washed daily but the nurse should avoid full bathing of the body on a daily basis. Harsh soaps should be avoided and only used sparingly. The fluid intake should be increased unless otherwise contraindicated by medical condition. Pressure points are not related to the action of sebaceous and sweat gland activity, but the pressure points should be checked for redness after 30 minutes.

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps. Explanation: Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

A client is brought to the emergency department by an adult child, who states, "I am unable to care for my parent anymore. Although I would like to, financially and physically I can't do it anymore." What ethical problem is the adult child experiencing?

Distress Explanation: Ethical distress is when someone wants to do the right thing but is not able. The adult child brings the parent to the emergency department to maintain the client's safety, although the child needs to take care of the parent. Dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially equally undesirable ones. The client is not experiencing a dilemma. Uncertainty means a feeling of not knowing what will happen. The adult child is certain that he or she cannot care for the parent. Dissatisfaction implies a sense of dislike for, or unhappiness in, one's surroundings. While the adult child is unhappy, this is not the primary ethical problem.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

Document the findings. Explanation: The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24 to 48 hours. For this reason, the wound care nurse does not need to be notified.

The Nurse Corps of the United States Army was established by whom?

Dorothea Dix Explanation: Dorothea Dix established the Nurse Corps of the United States Army. Lillian Wald established a neighborhood nursing service for the sick and poor in New York City and is considered the founder of public health nursing. Florence Nightingale initiated major reforms in health care and nursing training that helped establish the modern profession of nursing. Isabel Hampton Robb was a leader in nursing and nursing education who established the nursing school at Johns Hopkins Hospital.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply an emollient as indicated. Explanation: When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.

The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?

Educator Explanation: Under the overall umbrella of nursing process, the nurse in this situation is performing the the implemention of the care plan interventions.The nurse is acting in the role of educator by explaining each step at a level, and to a degree that the client can process, ask questions if necessary, and understand. The act of changing the dressing is an aspect of the caregiver role. Once the nurse moves beyond the care plan interventions, it may become necessary to make a decision or advocate for the client as a result of the assessment of wound and client learning during the teaching of wound care occurring.

Which statement best conveys the concept of ethical agency?

Ethical practice requires a skill set that must be conscientiously learned and nurtured. Explanation: Ethical agency must be cultivated in the same way that nurses cultivate the ability to do the scientifically right thing in response to a physiologic alteration. It is inaccurate to assume that it will passively develop from the presence of other ethical practitioners, or from years of experience. It is not an innate characteristic of personality.

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action?

Give written instructions to the client and caregivers. Explanation: Older adults may not be able to remember instructions in order to repeat them back clearly. It is appropriate to provide written instructions so the client and caregivers have a quick reference to use for medication administration.

A dying client expresses to the nurse a desire to not see family to avoid causing them more sadness. Which action by the nurse is most appropriate?

Help the client clarify personal values. Explanation: Values clarification is a method of self-discovery by which people identify their personal values and value rankings. The client's value of family may be obscured because of the client's overwhelming need to protect the family. Arranging a meeting between the family and client would be inappropriate, as it would go against the client's wishes and thus would violate the principle of autonomy. Neither educating the client on the concepts of death and dying nor allowing the client time for quiet reflection would address the client's need to clarify personal values.

A nurse is preparing to give medications to an elderly client who, due to a recent stroke, needs help putting them in her mouth. The family member appears anxious and tells the nurse not to touch the client's mouth. Which religion does the nurse assume this client practices?

Hinduism Explanation: The nurse administering medications should avoid touching the lips of a Hindu client. The other religions do not hold beliefs precluding such contact.

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select?

Hydrocolloid Explanation: The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication. Explanation: A meter-dose inhaler has a canister that contains medication under pressure. It is much more commonly used than the turbo-inhaler, which is a propeller-driven device that spins and suspends a finely powdered medication. A turbo-inhaler, not a meter-dose inhaler, has propellers that get activated during inhalation.

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice?

It is appropriate to use clean technique during this procedure. Explanation: Chronic wounds and pressure injuries may be treated using clean technique; aseptic technique is not always necessary. Disinfectants are not normally applied to wound beds except in exceptional circumstances.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?

Keep hair off the face and wash hair daily. Explanation: Keeping hair off the face and washing the hair daily will help prevent oil from transferring from the hair to the skin, causing clogged pores. The client should avoid squeezing or picking infected areas because this can spread the infection and cause scarring. The adolescent should be taught to gently wash the face twice a day with a mild cleanser and warm (not hot) water.

A client who is admitted for a debilitating disease is talking to the nurse. The client relates that family is the only thing that matters, stating that family helps fulfill all the spiritual needs by first fulfilling the most basic of all needs. What is this basic need?

Love Explanation: Love develops from the basic human need to love and be loved, and we cannot be spiritually whole, spiritually healthy, unless this need is met. Autonomy is freedom from external control or influence. Self reliance is reliance on one's own powers and resources rather than those of others. Autonomy and self reliance are higher level of needs. A sense of belonging is a human need, just like the need for food and shelter but love is more important.

A client has a prescription for amoxicillin 500 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit?

Malpractice Explanation: The facility and nurse could be charged with malpractice, which is failing to perform (or performing) an act that causes harm to a client. Administering the medication intravenously instead of orally as prescribed has caused harm to a client. Negligence is failing to perform care for a client. When a person threatens to touch a client without consent, it is assault, whereas battery is carrying out the implied threat (assault).

A nurse is caring for Mr. Glanden, who recently underwent a lung resection. As the nurse is completeing the physical assessment, he asks to have the elders from his church perform a "laying on of hands". The nurse interprets this as a healing process associated which of the following religions?

Mormon Explanation: Mormons believe in divine healing through the "laying on of hands. The Baha'i International Community believes in a basic harmony between religion and science. Jehovah's Witnesses oppose the "false teachings" of other sects; opposition often extends to modern science, including medicine. Buddhists believe in the Four Noble Truths and the Noble Eightfold Path.

The nurse is preparing to give the second dose of ordered antibiotics to a client and notes that no one has documented that the first dose was given. What is the appropriate nursing action?

Notify the health care provider. Explanation: The nurse will notify the health care provider and follow internal policies regarding incident reporting. The nurse will receive information from the health care provider about new orders to make sure the client gets both doses of medication. The pharmacy may be notified later, but it is not appropriate to initially notify them without clarifying with the health care provider. The nurse manager may be notified about the discrepancy but will not be able to confirm if the first dose was given.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Explanation: With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel. Explanation: The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel wound.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain Explanation: Penrose drains are commonly used after a surgical procedure or to drain an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is typically placed into a vascular cavity where blood drainage is expected after surgery, and wound pouching is used on wounds that have excessive drainage.

The nurse is preparing to complete a spiritual assessment of a client. What step should the nurse complete first?

Perform a self-assessment of her own spiritual beliefs. Explanation: Prior to assessment, nurses should be aware of their own spiritual condition. Acknowledging and recognizing select spiritual beliefs as personal will allow the nurse to discern and focus on the specific needs of the client.

The physiologic and biochemical effects of a drug on the body defines:

Pharmacodynamics Explanation: Pharmacodynamics refers to the physiologic and biochemical effects of a drug on the body.

The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems?

Plan and coordinate a multidisciplinary team conference including the chaplain. Explanation: The nurse should facilitate a care-planning conference involving the social support network including family and friends. Initiating a multidisciplinary social network of conferences facilitates a sense of acceptance, love, and belonging. The nurse should work with the client to explore and build on past positive coping mechanisms, which helps enhance a sense of self-control and self-esteem. Encouraging the client to watch movies when alone does not allow the client to interact and find positive elements of his or her life. Although spiritual review can be helpful, the nurse should not "scare" the client away from action by mentioning negative spiritual outcomes.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Pour the liquid into a sterile container within the sterile field.

The nurse is assessing a client who was seen 7 days ago with strep throat. The client states, "I felt better after 2 days of the antibiotic the provider prescribed, so I quit taking it." What would the nurse do to address this situation?

Provide education on taking all antibiotics for effective treatment Explanation: Although benefits of antibiotics may be felt in a few days after starting therapy, the nurse will teach the client that the entire course of medication must be taken to rid the body of infection. Discontinuing the antibiotic prematurely may cause the infection to reoccur. The incomplete use of an antibiotic is one factor that contributes to the evolution of resistant microbial organisms so the nurse would not instruct the client to returning to the previous regimen. Consulting the health care provider for alternate treatment options may or may not be applicable and also is not particularly the most important. The mixture of antibiotics would typically not be prescribed in this client.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan?

Record the quantity of drainage once per shift and document on the intake and output record. Explanation: Output from NPWT should be recorded once per shift. Leaks can often be resolved by reinforcing the dressing and the treatment should continue 24 hrs/day. Dressings are normally changed two to three times per week

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?

Red Explanation: Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply.

Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session in a quiet environment. Explanation: Remaining calm and conducting the teaching session in a quiet environment would decrease anxiety or distractions that interfere with learning for the older adult. Keeping the session short will increase concentration, but is not unique to older adults. The nurse is to use colorful materials in a variety of ways and the nurse's tone and pitch should vary.

Question 8 See full question50sReport this Question What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?

Secure the drain to the client's gown with a safety pin below the level of the wound. Explanation: To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.

A nurse in the community has been asked to join an organization based on the leadership abilities demonstrated both in the facility of employment and community-based activities. Which organization is most likely being described?

Sigma Theta Tau International Explanation: Sigma Theta Tau, the nursing honor society, extends membership invitations to students who demonstrate excellence in scholarship and nurses in the community who demonstrate excellence in leadership. The ANA is open to all licensed registered professional nurses. The AACN sets standards and publishes essential components of baccalaureate, master's and doctoral education in nursing. The NCSBN is responsible for NCLEX testing standards.

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?

Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

A client receiving a blood transfusion reports shaking and chills. Which action should the nurse take?

Stop the transfusion and keep the IV open with normal saline. Explanation: Febrile reactions to blood components can occur if the recipient is hypersensitive to antigens on cell components, particularly the leukocytes. The client develops a fever and chills and may report headache and malaise. Sometimes, clients are given antipyretics before the transfusion to prevent shaking and chills. If symptoms occur after the infusion has started, the nurse stops the transfusion immediately and keeps the IV open with normal saline. The nurse then notifies the health care provider and the blood bank, and monitors vital signs. Leukocyte-reduced blood components can be prescribed for clients with a history of febrile reactions.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

Supports the area around the wound Explanation: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?

The client receiving the care Explanation: The client receiving the care is always the central focus of the nursing care provided. The central focus is not the nurse, the nursing actions, or nursing as a profession.

Which nursing action(s) best demonstrate the ethical principle of autonomy? Select all that apply.

The nurse checks to ensure an informed consent document is signed prior to transferring the client for a surgical procedure. The nurse documents that a client refused a new medication. Explanation: Autonomy is respect for the client's right to make health care decisions. Informed consent and right to refuse medications are a part of autonomy. Reviewing standards of practice and checking a medication dosage are related to nonmaleficence. Yearly continuing education is related to keeping the promise to remain competent (fidelity).

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. Explanation: Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which precaution should the nurse take when combining drugs?

Withdraw exact amounts of each drug from each container. Explanation: When combining more than one drug in a single syringe, the nurse should take exact amounts from each drug container because, once the drugs are in the barrel of the syringe, there is no way to expel one without expelling the other. Mixing the two drugs before administering, or shaking the drug containers before withdrawing, is not suitable because it can cause chemical reactions and precipitates. Expelling both the drugs separately in a vial before use could also lead to a chemical reaction, which often causes a precipitate to form.

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 client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider?

alginate Explanation: Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue. Hydrogels are used with dry wounds or wounds with minimal drainage. Hydrocolloids are used with light to moderate drainage in wounds with necrosis or slough. Transparent dressings are used with wounds having minimal drainage, small size, and partial thickness.

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?

an alginate dressing Explanation: Alginate dressings contain alginic acid from brown seaweed. Covered in calcium-sodium salts, they absorb exudate, maintain a moist wound environment, and facilitate autolytic debridement. A secondary dressing is required to secure them. Transparent film allows frequent assessment of the site but provides a barrier. A hydrogel dressing comprises an 80%-99% water base and is used with partial- and full-thickness wounds. An antimicrobial dressing has an antibiotic that reduces bacterial growth.

The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

art of nursing Explanation: In this example, the nurse is utilizing a holistic approach to the provision of nursing care based on the knowledge of providing psychosocial interventions, such as allowing the client to verbalize feelings/fears. This application of knowledge is the art of nursing. The science of nursing is the knowledge base for the provision of care. Evidence-based practice and application of research are using research to make decisions on how to care for clients.

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding?

avulsion Explanation: An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke Explanation: When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

evisceration Explanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn Explanation: A figure-of-eight turn is used for joints like the elbows and knees.

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?

foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

he client who is 48-hours postsurgical procedure Explanation: Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between clients, the nurse should see clients from the "clean" to "dirty." The nurse should see the client who has no signs of infection first. Among these clients, the nurse should begin with the client who is postoperative, then see the other clients who have symptoms of infections.

A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply.

insufficient protein and vitamin C intake weak tissue and muscular support due to obesity distention of the abdomen from accumulated intestinal gas Explanation: The nurse should remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distention of the abdomen from accumulated intestinal gas are likely causes of surgical complications. Premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; and compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complications. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are factors that interfere with wound healing.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia. Explanation: Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation Explanation: The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last 6 months to 2 years. The inflammatory phase is the physiologic defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and reestablish normal function. This forms part of the proliferation phase.

A recently graduated nurse is working with a client who is suffering from excruciating pain with no relief. The client tells the nurse that religion and spirituality are a big part of her life. The nurse wants to help nurture this client's spirituality and can do so in which of the following ways? Select all that apply.

promoting meaning and purpose promoting love and relatedness promoting forgiveness Explanation: The nurse can help the client to nurture her own spirituality by promoting meaning and purpose, promoting love and relatedness, and promoting forgiveness. Although promoting pain relief and independence are both good nursing actions, they do not help in nurturing one's spirituality.

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 has adhered to the wound bed. Which modification is most appropriate?

reducing the interval between dressing changes Explanation: Reducing the interval between dressing changes allows the dressing change to be performed without causing pain and promotes secondary intention. If the dressing becomes dry, the more pain the client experiences and the more likely damage to the newly formed epithelial and granulating tissue becomes. The packing material should be completely saturated when placed in the wound. Using less packing material impairs secondary intention. A hydrocolloid dressing is not indicated.

The nurse is engaged in dialogue with a client in an effort to identify the client's values. Value systems are often formally embedded and integrated into:

religion. Explanation: Values are often codified and embedded into religion. This phenomenon is not noted in relation to nature, treatment, and activity.

Which best describes the proliferative phase, the third phase of the wound healing process?

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization Explanation: In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

serosanguineous Explanation: This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

The client twisted his ankle while hiking in an isolated area. The client reports pain and is unable to bear weight on the ankle. A nurse who is present has conducted an assessment and recommended the client rest and elevate the leg while waiting for rescue. The nurse is applying to the ankle a commercially prepared ice pack that contains a chemical. What precautions would the nurse employ when applying cold therapy to the client's ankle? Select all that apply.

squeeze the nonfrozen chemical pack to activate assess the client's ankle skin frequently ask the client about numbness and pain related to the cold therapy place a cloth between the ice pack and the skin Explanation: Commercially prepared ice packs that contain a chemical are activated by squeezing the ice pack. During an application of cold therapy, the nurse assesses the skin and asks the client about pain and numbness. The nurse places a cloth between the ice pack and the skin to prevent injury caused by the cold pack. The ice pack is applied for 30 minutes and removed for 1 hour prior to reapplication.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

stage III Explanation: Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Stage IV exposes muscle and bone.

What is the primary purpose of standards of nursing practice?

to ensure knowledgeable, safe, comprehensive nursing care Explanation: Each nurse is accountable for his or her own quality of practice and is responsible for using standards to ensure knowledgeable, safe, comprehensive care. Standards of practice do not provide the ability to safely perform skills, establish nursing as a profession and discipline, or enable nurses to have a voice in health care policy.

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage?

under the client Explanation: The amount and color of wound drainage depends on the size and location of the wound. Drainage can be assessed on the wound, on the dressings, in drainage collection devices, or under the client.

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:

understand that his culture may influence his hygiene and ask him his preference. Explanation: Preferences for hygiene vary widely among individuals and across cultures.

Which action by the nurse will allow the nurse to deposit the drug deep within the muscle of a client when using the Z-track technique for administering an injection?

using a 1½- to 2-inch needle Explanation: Using a 1½- to 2-inch (3- to 5-cm) needle is correct, as the length of the needle is long enough to go deep in the client's muscle. Applying pressure to the injection site is incorrect, as this action allows the medication to remain sealed. Adding a 0.2-ml bubble of air in the syringe is incorrect because this action allows the air to flush all the medication from the syringe during an injection. Withdrawing the needle and immediately releasing the taut skin is incorrect, as this creates a diagonal path that prevents leaking in the subcutaneous tissue and does not deposit the drug deep within the muscle.

The nurse is preparing to give a vaccination to an infant. At which site should the nurse plan to administer the injection?

vastus lateralis Explanation: The vastus lateralis site is particularly desirable for infants and children, whose gluteal muscles are poorly developed.