LPN to RN transition Test 1

What intervention should be performed by the nurse before applying Montgomery straps?

Apply a skin barrier to the site where the straps will be placed.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips

Apply a skin protectant to the skin around the incision.

What action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

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

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation

In which client would negative pressure wound therapy be contraindicated?

Client with a moderately bleeding wound

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure?

Date and reuse leftover irrigation solution within 24 hours.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Discontinue the therapy and assess the client.

What should the nurse do with any surgical staples removed from a surgical incision?

Dispose of them in a sharps container.

A client with an abdominal wound requires frequent dressing changes because of large amounts of drainage. Which should the nurse use to secure this dressing?

Montgomery straps

What action will the nurse take to ensure a wound is ready for the sutures to be removed?

Remove every other suture and assess the wound edges.

The nurse is explaining the benefits of cold therapy to a client. What should the nurse include in the teaching plan? Select all that apply.

Slows the transmission of pain stimuli, Reduces bleeding and hematoma formation, Reduces swelling and inflammation

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution?

Sterile basin

What is the primary outcome the nurse expects when choosing Montgomery straps to secure a dressing

The client's skin remains free from additional irritation or injury.

The charge nurse is observing the new graduate nurse perform the dressing change for a client with negative pressure wound therapy. Which action by the graduate nurse will require the charge nurse to intervene?

The graduate nurse tightly stretches the transparent adhesive dressing and applies it to the wound.

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound?

When the solution from the wound flows out clear

Which client will the nurse expect to be prescribed sitz baths? Select all that apply.

client who had surgery to the perineum, client who had rectal surgery, client after childbirth

What should the nurse assess before application of sitz bath therapy? Select all that apply.

client's need to void, client's ability to ambulate to the bathroom, client's perineal/rectal area, client's ability to sit for 15 to 20 minutes

Which client is most likely to require that the sutures be left in place for an extended period of time? A client who:

has a current history of alcoholism.

When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect?

increased comfort of client

When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who:

requires that the heat penetrate deeply into the tissues.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

to splint the area when engaging in activity

Wellness 4 components

-Capacity to perform to best of ability - Ability to adjust, adapt to varying situations -Reported feeling of well-being -Feeling that "everything is together, harmonious"

Barriers to Evidence based practice

- Limited timeframe to participate - Difficulty in accessing research materials - Difficulty understanding research articles - Lack of value for research in practice

Which question by the nurse, to the client, will best help evaluate the outcome of having applied cold therapy?

Do you feel your muscle spasms have decreased?"

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

Every 48 to 72 hours

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?

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

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply

Fill the bowl of the sitz bath about halfway full with tepid to warm water., Slowly unclamp the tubing and allow the sitz bath to fill., Ensure that the call bell is within reach., Insert tubing into the infusion port of the sitz bath

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound?

From the upper end of the wound to the lower end

The nurse is teaching a client the reasons for use of negative pressure wound therapy (NPWT). What should the nurse include in the teaching? Select all that apply

It stimulates cell growth and growth of new blood vessels., It promotes wound healing and wound closure., It results in a reduction of bacteria in the wound., It provides a moist wound healing environment.

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe?

Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound

After 30 minutes, the nurse comes to remove the warm compress from a client's wound site. The client requests to leave the warm compress on a little longer. What is the best response by the nurse?

Leaving it on for more than 30 minutes can cause complications such as tissue injury."

A nurse is working with a client who requires frequent changes of a wound dressing. Which equipment would allow the nurse to change the dressing without having to use tape?

Montgomery straps

When assessing a wound 2 hours after removing the surgical staples, the nurse notes that the wound edges have begun to pull apart. What action should the nurse take next?

Notify the health care provider that the wound edges are coming apart.

Place in order, from first to last, the actions the nurse will perform when planning to remove surgical staples. Use all options.

Open the staple removal kit. Position the staple remover under the staple to be removed. Firmly clo se the staple remover and remove every other staple. Assess wound to see if the edges remain approximated. Remove the remaining staple

To assess for circulatory compromise, what assessments will the nurse perform at the site of application before applying a warm compress? Select all that apply.

Presence of sensation, Evidence of edema, Distal pulses, Skin color

When assessing the area of application of a warm compress, the nurse observes skin maceration of the surrounding area, and the client reports increased discomfort. What should the nurse do first?

Stop the heat application and completely remove the compress.

During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the most likely rationale for this occasional effect from sitz bath therapy

The warm water caused vasodilatation.

Which action by the nurse is most appropriate when the sutures are difficult to remove because of crusted dried blood?

Use a sterile gauze and sterile saline to gently remove the crusted dried blood.

A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long should the nurse have the client apply the bag before the nurse removes it?

20 minutes

Place in order, from first to last, the actions the nurse will perform when applying a warmed moist compress. Use all options.

Assess the application site. Remove the compress from the warmed solution. Squeeze out any excess solution. Gently mold the compress to the intended site. Cover the site with a dry, clean bath towel

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.

Clean the incision using the wound cleanser and gauze . Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Using the scissors, cut one side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin Remove every other suture to be sure the wound edges are healed. Apply adhesive closure strips.