Med Surg Ch 11

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? a. Local response b. Systemic response c. Infectious response d. Acute inflammatory response

b. Systemic response

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? a. Serous b. Purulent c. Fibrinous d. Catarrhal

b. Purulent

an 82-year-old man is being cared for at home by his family. a pressure ulcer on his right buttock measures 1 x 2 x 0.8cm in depth and pink subcutaneous tissue is completely visible on the wound bed. which stage would the nurse document on the wound assessment form? a. stage I b. stage II c. stage III d. stage IV

c. stage III

Which patient is most at risk for the development of a pressure ulcer? a. An older patient who is septic, bedridden, and incontinent b. An obese woman with leukemia who is receiving chemotherapy c. A middle-aged thin man in a halo cast after a motor vehicle accident d. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis

a. An older patient who is septic, bedridden, and incontinent

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? a. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F b. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F c. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F d. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

a. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F

The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? a. Provide a light blanket. b. Encourage a hot shower. c. Monitor temperature every hour. d. Turn up the thermostat in the patient's room

a. Provide a light blanket.

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? a. Reposition every 2 hours. b. Measure the size of the reddened area. c. Massage the area to increase blood flow. d. Evaluate the area later to see if it is better.

a. Reposition every 2 hours.

an 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this info, how should the nurse plan for this patient's care? a. implement a 1 hr turning schedule to assess the skin b. place DuoDerm on the patient's sacrum to prevent breakdown c. elevate the head of bed to 90degrees when the patient is supine d. continue with weekly skin assessments with no special precautions

a. implement a 1 hr turning schedule to assess the skin

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? a. Apple b. Custard c. Popsicle d. Potato chips

b. Custard

a 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. which nursing diagnoses are MOST appropriate? (Select all) a. acute pain related to tissue damage and inflammation b. Impaired skin integrity related to immobility and decreased sensation c. impaired tissue integrity related to inadequate circulation secondary to pressure d. risk for infection related to loss of tissue integrity and under-nutrition secondary to stroke e. ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area

b. Impaired skin integrity related to immobility and decreased sensation c. impaired tissue integrity related to inadequate circulation secondary to pressure

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? a. Pain level b. Intake and output c. Oxygen saturation d. Level of consciousness

b. Intake and output

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? a. Keep the pressure ulcer clean and dry. b. Maintain protein intake of at least 1.25 g/kg/day. c. Use a 10-mL syringe to irrigate the pressure ulcer. d. Irrigate the pressure ulcer with hydrogen peroxide.

b. Maintain protein intake of at least 1.25 g/kg/day.

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? a. Administer aspirin on a scheduled basis around the clock. b. Provide acetaminophen every 4 hours to maintain consistent blood levels. c. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. d. Provide drug interventions if complementary and alternative therapies have failed.

b. Provide acetaminophen every 4 hours to maintain consistent blood levels.

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? a. Warm, moist heat and massage b. Rest, ice, compression, and elevation c. Antipyretic and antibiotic drug therapy d. Active movement and exercise to prevent stiffness

b. Rest, ice, compression, and elevation

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5 degree temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response. c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician needs to be notified about her condition.

b. The patient is having a normal inflammatory response.

the nurse assessing a patient with chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. what would the nurse anticipate being ordered to assess the patient's systemic response? a. serum protein analysis b. WBC count and differential c. punch biopsy of center of wound d. culture and sensitivity of the wound

b. WBC count and differential

a patient in the unit has a 103.7 f temperature. which intervention would be MOSt effective in restoring normal body temperature? a. use a cooling blanket while the patient is febrile b. administer antipyretics on an around the clock schedule c. provide increased fluids and have the UAP give sponge baths d. give prescribed antibiotics and provide warm blankets for comfort.

b. administer antipyretics on an around the clock schedule

a nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. the patient's WBC count is 15.0 x 10^6/uL and he has coolness of the lower extremities, weighs 75 pounds more than his ideal body weight, and smokes 2 packs of cigarettes per day. Which PRIORITY nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. imbalanced nutrition: obesity related to high-fat foods b. impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

b. impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking

a nurse is caring fora patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. how should the nurse anticipate healing to occur? a. tertiary intention b. secondary intention c. regeneration of cells d. remodeling of tissues

b. secondary intention

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? a. Notify the health care provider. b. Document the fistula formation. c. Assess the patient and vaginal drainage. d. Have the UAP apply a dressing to the vagina.

c. Assess the patient and vaginal drainage.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? a. Frequent examination of the character and quantity of exudate b. Monitoring for signs and symptoms of local or systemic infections c. Assessment of the patient's circulation distal to the location of the dressing d. Assessment of the range of motion of the ankle and the patient's activity tolerance

c. Assessment of the patient's circulation distal to the location of the dressing

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? a. Take the antibiotic until the wound feels better. b. Take the analgesic every day to promote adequate rest for healing. c. Be sure to wash hands after changing the dressing to avoid infection. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. e. Notify the health care provider of redness, swelling, and increased drainage.

c. Be sure to wash hands after changing the dressing to avoid infection. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? a. Dress it with an absorbent dressing for exudate. b. Handle the wound gently and let it dry out to heal. c. Debride the nonviable, eschar tissue to allow healing. d. Use negative-pressure wound (vacuum) therapy to facilitate healing.

c. Debride the nonviable, eschar tissue to allow healing.

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? a. Increased platelet count b. Increased blood urea nitrogen c. Increased number of band neutrophils d. Increased number of segmented myelocytes

c. Increased number of band neutrophils

The nurse assesses impaired skin integrity in this patient. How will the nurse document this? mc004-1.jpg (1 x 1 x 0.8, pink subcutaneous tissue showing) a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? a. The wound will be stapled together until it heals. b. The healing will contract the area to close the wound. c. The wound will be left open and heal from the edges inward. d. The wound will be sutured after the current infection is controlled.

c. The wound will be left open and heal from the edges inward.

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? a. White blood cell (WBC) count of 8000/ìL; temperature of 101?5? F b. White blood cell (WBC) count of 4000/ìL; temperature of 100?5? F c. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F d. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8?5? F

c. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F

which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer: a. pack the ulcer with foam dressing b. turn and position the patient every hour c. clean the ulcer every shift with Dakin's solution d. assess for pain and medicate before dressing change

c. clean the ulcer every shift with Dakin's solution

When the nurse changes the dressing and documents that there is serosanguineous drainage, which type of drainage did she see on the dressing? (Images from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St Louis, 2009, Mosby.) a. clear b. bright red with dark red spots c. red d. yellow

c. red

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue

d. Excess granulation tissue

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? a. Fever and chills b. Increased blood pressure c. Increased respiratory rate d. General malaise and fatigue

d. General malaise and fatigue