Test 3 NSG 100
Stage 3 Dermal Ulcer
Tissue damage to all three layers of skin, down to the subcutaneous fat. Crater like appearance.
The nurse is teaching a client who had been discharged home with a prescription for an enteric-coated tablet. Which statement by the client indicates understanding of the teaching?
"I should report a delay in onset of the drug effects after taking the tablet"
The nurse is providing discharge instructions for the patient with sleep pattern disturbances. Which statement by the patient indicates a need for further education?
"My bedtime routine can include watching TV in bed until I fall asleep."
The nurse is caring for several clients in the ER. Which client will the nurse anticipate is most likely to experience an alteration in drug metabolism?
A 2 week old premature infant
The nurse understands which wound will heal by secondary intention?
A boys road rash that he got by falling off his bicycle
The nurse is caring for 4 postoperative clients. Which client would be at highest risk for impaired wound healing?
A geriatric client type 2 diabetes
The nurse is caring for a client who is 36 hours postoperative following a thoracotomy. The nurse assesses the client and finds the client to have a RR of 36 bpm and a SAO2 90% and is short of breath. Prioritize the following nursing interventions: A. auscultate the lung sounds B. have the client take deep breaths and cough C. call the HCP D. have the client ambulate to the bathroom and back to the bed
A, B, C, D
The nurse understands that a client with impaired circulation will have an impairment in which phase of the medications pharmacokinetics?
Absorption of the drug
The nurse is doing a medication reconciliation with a client. Which data should the nurse obtain?
Allergies Use of herbal and over the counter products Ability to swallow
The nurse is caring for a client who has started a new medication for hypertension. Thirty minutes after taking the medication, the client develops dyspnea, a cardiac arrhythmia, and decreased level of consciousness. How should the nurse interpret this reaction?
Anaphylactic reaction
The nurse enters the room of a postoperative client and notes a wound evisceration. What is the most important action by the nurse?
Cover the protruding internal organs with sterile gauze moistened with sterile saline
A nurse is admitting a client who has a diagnosis of right lower lobe pneumonia. Upon assessment, the nurse notices the client is wearing an herbal pack on the chest. What will the nurse do first?
Ask the patient about the herbal pack
The nurse is educating a client who has emphysema and has been given a new prescription for theophylline. Which of the following instructions should the nurse provide?
Avoid caffeine while taking this medication
The nurse is caring for client diagnosed with pneumonia. The nurse finds the following assessments: Temp 102F HR 120 RR 30/min BP 130/76 SAO2 90% RA Prioritize the following nursing interventions: A. administer antibiotics B. administer O2 C. collect a sputum sample for culture and sensitivity D. educate the client on obtaining a yearly influenza vaccine and a pneumonia vaccine as recommended by HCP
B, C, A, D
The nurse is caring for a client and finds the following assessments: SAO2 of 91% audible wheezing in lung fields use of accessory muscles when breathing Which of the following classes of medications should the nurse expect to administer?
Beta, agonist
The nurse is preparing to administer two IV medications with one working IV line. The nurse checks the drug handbook and notices that the two medications should not be given using the same IV line. What would be the nurse's next action?
Call the HCP and notify them of the drug incompatibility
The nurse caring for a patient with severe pain and applied the first 50 mcg transdermal-fentanyl patch 2 hours ago. The patient states that the pain is presently rated at 9 out of 10 on the pain scale. What is the nurse's best action?
Check the provider's orders for a short acting narcotic medication to administer for breakthrough pain
The nurse is caring for a hospitalized client who is morbidly obese and has limited mobility. The nurse should address the client's risk for skin breakdown by:
Cleaning and drying regularly within the clients skin folds
The nurse understands which clients are at high risk for drug interactions?
Clients who take supplements and OTC medications with prescription medication Clients who are taking multiple medications Clients who are several specialists
The nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, the client states, "I'm really having a good deal of pain in my hip right now." What would be most appropriate for the nurse to do?
Delay the full exam until the client's pain has been addressed
The nurse is caring for a client who has a reddened sacral area that is unrelieved by changing positions. Which interventions should the nurse initiate?
Develop an updated turning schedule for the client
The nurse is performing an admission assessment on a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?
Do you have difficulty staying awake while you are driving?
The nurse interprets the routine scheduled ABG results of a COPD client as compensated respiratory acidosis. The client is calm, SAO2 reading in 90%, and the respirations are unlabored at this time. What is the nurses next course of action?
Document findings and notify HCP during rounds
The nurse is turning an immobile client and notices that both heels have a deep purple area on them. What independent intervention would the nurse initiate?
Elevate heels off of the bed and apply protective boots
A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan?
Elevate the affected leg on 2 pillows
A 66yo client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. The client is tachypneic, with prolonged expiratory phase and has no cough. The client leans forward with the arms braced on the knees to support the chest and shoulders for breathing. Based on these assessments, the nurse suspects that the client is experiencing:
Emphysema
The nurse is caring for a client with a temp of 103F, pleuritic chest pain, a productive cough with thick yellow sputum, weakness and fatigue. What would the nurse include in the clients plan of care?
Encourage use of incentive spirometer Administer breathing treatments as ordered by the HCP Consult a dietitian to increase intake of high calorie Protein rich meals, and high fowler's position
The nurse is assessing a client for a sleep disorder. Which of the following information provided by the clients bed partner is most associated with sleep apnea?
Excessive snoring
The nurse caring for a client who has a history of chronic pain. The nurse is aware that which pain management therapy is best practice for pain management?
Scheduling pain interventions around the clock to keep pain at a more tolerable level
The nurse is caring for a postoperative client and is concerned that the client's incision may be at risk dehiscence. Which of the following is the best intervention to prevent this complication?
Have the client splint the incision when coughing
The nurse is educating the parents of a child diagnosed with asthma. Which of the following should the nurse include in the teaching?
Identify what triggers the asthma attack and avoid triggers as much as possible
The nurse is reviewing the HCP prescription for vancomycin trough level to be drawn on a client. The nurse understands that the trough level should be drawn:
Immediately prior to the next scheduled dose to be given
The nurse has given a newly admitted client a score of 10 on the Braden scale. Which is the best nursing intervention for a client with a Braden score of 10?
Implement interventions for an At Risk for Impaired Skin Integrity client
The nurse is preparing to administer a medication to a client with a history of liver disease. The nurse understands that this client will need to be monitored closely for:
Increased therapeutic ranges
The nurse is providing care for a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
It facilitates the clients deep breathing
The nurse is planning care to prevent pressure ulcers in a client who is at high risk. Which interventions should the nurse include in the plan of care?
Keep skin clean and dry Assess nutritional status
The nurse is preparing to administer medications. Which of the following inpatient medication prescriptions would a nurse question?
Lisinopril 20 daily
The nurse will include which intervention to help improve sleep quality during hospitalization in all clients care plans?
Maintaining sleep routines, cluster care, using relaxation measures, and providing light snacks.
The client is caring for a client who has a prescription for a patient controlled analgesia (PCA) pump following surgery. Which of the following statements made by the client indicates the client known how to use the pump?
My doctor says how much medicine I can get and how often.
Stage 1 Dermal Ulcer
No visible opening, epidermal tissue damage, non blanchable, area is red and may be warm to the touch
The nurse is preparing to administer a drug that is eliminated through the kidneys. The nurse reviews the patient's chart and notes that the patient has elevated serum creatinine and blood urea nitrogen (BUN) levels. What should the nurse do next?
Notify the provider
The nurse is working on the pulmonary unit at the local hospital when a client with COPD appears restless and short of breath. What would be the nurses priority action?
Perform a focused respiratory exam and check the clients SAO2
The nurse is caring for a client with moderate emphysema. Which breathing would the nurse teach the client to help promote easier breathing/exhalation?
Pursed lip breathing
The nurse conducting a sleep workshop in the community would identify which clients to be at risk for obstructive sleep apnea (OSA)?
Recent tonsillectomy, Deviated septum, large neck, alcohol use
A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI (metered dose inhaler) twice daily. Which of the following instructions should the nurse include?
Rinse your mouth after each dose and inspect your mouth daily for lesions
The nurse is interviewing a client in the clinic when the client complains of excessive daytime drowsiness, severe headaches, and difficulty concentrating. The nurse does a physical exam and notices the client is unsteady on his feet and stumbles often. What would the nurse suspect the client has?
Sleep deprivation
The nurse is admitting a patient to the general medical-surgical unit. What should the nurse assess as part of a routine sleep assessment?
Sleeping environment preferences, Bedtime routines, and Usual sleeping and waking times
The nurse working in an outpatient clinic is educating a client on primary prevention of COPD. What strategy would the nurse encourage the client to do?
Stop smoking
The nurse is performing a pain assessment on a post surgical client and notices the following assessments: BP 180/99 HR 110 RR 36 What would we suspect?
The client is having an acute pain episode.
The nurse is caring for a client with recurrent headaches who has been told by the physician that the cause is likely psychosomatic. The client repeats this conversation to the nurse and says, "That just can't be true! My head hurts so bad sometimes that it makes me sick to my stomach." Which statement is the nurse's best response?
The pain in your head is very real
The nurse is caring for a client who has a stage two pressure injury. The nurse applies a transparent film dressing. The nurse understands the reason for a transparent dressing is:
The transparent dressing keeps the wound moist
The nurse is educating a group of new employees on oxygen use with COPD clients. What is the best answer for the nurse educator to give when asked why a client with emphysema should receive only 1-4 liters of supplemental oxygen?
These clients only breath when their O2 levels dip below a certain level.
The nurse is preparing to administer meperidine (demerol) which is an opioid analgesic, and promethazine (phenergan), which is an antimetic and antihistamine. The nurse understands that these drugs are given in combination for which reasons?
They have synergistic effects to help the medications work better.
The nurse is caring for a client for whom the health care provider has prescribed wet-to-dry dressings for an infected dermal ulcer with necrotic tissue. What should the nurse teach the client about this intervention?
This will help debride the wound
Stage 4 Dermal Ulcer
Ulcers that are deep wounds that impacts the muscle, tendons, ligaments, and bone. Area is severely damaged and a large wound is present.
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following should the nurse use to help maintain the integrity of the clients skin?
Use a transfer device to lift client up in bed
A nurse is caring for a nonverbal client. The nurse is charting the client's pain level. Which pain assessment methods are appropriate in this situation?
Wong-Baker Scale
The nurse is administering albuterol via nebulizer for a client admitted for an acute asthma attack. The nurse understands this medication produces the desired effect by what mechanism of action?
agonist
A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indicator that the client has pain?
clenching the teeth, moaning, restlessness
The nurse assesses a patient who is receiving morphine sulfate intravenously using a patient controlled analgesia pump. The nurse notes somnolence and respiratory depression, which are signs of morphine toxicity. The nurse will prepare to administer naloxone (Narcan) because:
is a narcotic antagonist
Stage 2 Dermal Ulcer
ulcer has a break in the top two layers of the skin may be an open sore, scrape, or blister
