BCON exam 2
The nurse is meeting with a community group about medication safety. The nurse must emphasize that patients at high risk for drug interactions include which groups? (Select all that apply.) a.Older patients b.Patients with chronic health conditions c.Patients taking three or more drugs d.Patients dealing with only one pharmacy e.Patients covered by Medicare or Medicaid (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)
Answer: A, B, C.
A 97-year-old patient asks why a protein supplement has been prescribed. What is the nurse's best response? a."You have increased circulation of free drug." b."You have decreased hepatic size." c."You have decreased calcium absorption." d."You have increased motility." (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)
Answer: A.
A nurse observes another nurse taking oral opioids from the medication room at the hospital. Which is the best action by the nurse? a. Report the finding to the nursing supervisor to enable the nurse's participation in a diversion program. b. Ignore the situation to protect the nurse from dismissal and possible loss of licensure. c. Confront the nurse and demand that the drugs be returned before someone notices their absence. d. Ask the nurse to request pain medications from a physician rather than stealing them from the hospital. (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)
Answer: A.
Match the description to the correct term: Thick, yellow, green, tan, or brown. A. Purulent B. Serous C. Serosanguineous D. Sanguineous (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A.
When reviewing the patient's medication regimen, the nurse understands that the interval of drug dosage is related to what? a.Half-life b.Stimulation of receptors c.Therapeutic index d.Trough level (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)
Answer: A.
A patient has a 4-day-old postoperative incision. Which would be a normal finding when changing the dressing? A. Small amount of serous drainage B. Moderate amount of sanguineous drainage C. Small amount of serosanguineous drainage D. Small amount of purulent drainage (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. A small amount of serous drainage is normal postoperatively. A moderate amount of sanguineous drainage would indicate bleeding. Purulent drainage would indicate infection.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? A. Stage I B. Stage II C. Stage III D. Stage IV (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.
The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? A. The nurse should be alert for an increase in serosanguineous drainage from the wound. B. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. C. The nurse should administer cough suppressant to prevent wound dehiscence. D. The condition is an emergency that requires surgical repair. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence most commonly occurs before collagen formation (3 to 11 days after injury). To prevent dehiscence, place a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. Evisceration is an emergency that requires surgical repair. Dehiscence does not necessarily indicate surgery is necessary.
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? A. Ask the prescriber to change the order B. Crush the pill with a mortar and pestle C. Hide the capsule in a piece of solid food (lol!) D. Open the capsule and sprinkle it over pudding (Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)
Answer: A. Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.
Why does a wound bed need to stay moist? A. To support healing by enabling granulation tissue to grow B. To prevent excessive fluid loss from the body C. To determine if the area has reactive hyperemia D. To decrease patient discomfort (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. Granulation tissue is the healthy, red, fleshy projection of moist tissue that indicates healing. If the wound bed were dry, this process would be impaired. Open wounds frequently have fluid loss as drainage. Replacing this loss is relevant to the patient's overall hydration.
When teaching a patient about wound healing, the nurse should tell the patient: A. Inadequate nutrition delays wound healing and increases risk of infection. B. Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible. C. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. D. Fat tissue heals more readily because there is less vascularization. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—delays tissue repair and increases risk for infection. Both full-thickness wounds and partial-thickness wounds heal more efficiently in a moist, protected environment. Long-term steroid therapy may diminish the inflammatory response and reduce the healing potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which decreases transport of nutrients and cellular elements required for healing.
The nurse is teaching the client with loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy will the nurse include in the client's teaching plan? A. Lift hips off the chair at least every 30 minutes. B. Eat a low-fat diet. C. Massage reddened areas. D. Complete a pressure map. (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer: A. Lifting hips off the chair at least every 30 minutes relieves pressure and can prevent pressure ulcers.
The nursing instructor reviews instructions with the nursing student on caring for the older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? A. Massages bony prominences B. Avoids reddened areas C. Repositions the client every 1 to 2 hours D. Uses a moisturizing lotion (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer: A. Massaging bony prominences should be avoided in older adult clients.
Which of the following patients is at greatest risk for developing a wound infection? A. A diabetic obese patient who smokes. B. An adolescent who takes steroids for asthma. C. An alcoholic. D. An elderly patient. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. The diabetic patient has the most risk factors for developing a wound infection. Other risk factors include: having a chronic disease, being obese, and smoking. Although taking steroids is one risk factor, this patient has fewer risk factors than the patient who has a chronic disease, is obese, and smokes. The same is true of the other patients.
The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse's next action? A. Ask the patient's reason for refusal B. Explain that she must take the medication C. Take the medication away and chart the patient's refusal D. Tell the patient that her physician knows what is best for her (Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)
Answer: A. When patients refuse a medication, first ask why they are refusing it.
Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. A. True B. False (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: A. This is the correct definition of healing by primary intention.
Match the description to the correct term: Clear, watery plasma. A. Purulent B. Serous C. Serosanguineous D. Sanguineous (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: B.
The nurse is explaining drug action to a nursing student. Which statement made by the nurse is correct? a."Water-soluble and ionized drugs are quickly absorbed." b."A drug not bound to protein is an active drug." c."Most receptors are found under the cell membrane." d."Toxic effects can result if the trough level is low." (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)
Answer: B.
A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. A. True B. False (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: B. A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.
The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection: A. during the first 24 to 48 hours after injury. B. two to three days after injury. C. Up to five days after injury. D. five to seven days after injury. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: B. A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.
A family member calls the nurse to ask for advice regarding their mother who has developed a "bedsore" on her right heel. The family member describes the pressure ulcer as "a blister that has now popped and you can see redness." Based on this description, at what stage would the nurse classify this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: B. A stage II pressure ulcer can be described as an abrasion, a blister, or shallow crater with skin loss involving the epidermis and/or dermis. A stage I pressure ulcer appears as an area of color change (e.g., persistent redness) on intact skin. A stage III pressure ulcer presents clinically as a deep crater. A stage IV pressure ulcer involves bone, muscle, or supporting structures.
The nurse is observing the patient's wife perform treatment of her husband's pressure ulcer. Which action, if made by the patient's wife, indicates that further instruction is needed? A. She premedicates the patient for pain before beginning the dressing change. B. She performs hand hygiene and removes the old dressing and begins to clean the ulcer with soap and water. C. While wearing gloves, she rinses the ulcer with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze. D. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. She covers the gently packed wound with dry 4 x 4 gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: B. To avoid transfer of microorganisms, the caretaker should apply nonsterile gloves to remove the old dressing and discard the gloves and old dressing materials in a plastic bag. She should perform hand hygiene and apply new gloves before beginning to cleanse the wound. She should use the ordered solution, most generally normal saline, because soap can be very drying to tissues and may leave a residue.
The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? A. Call a pharmacist to interpret the order B. Call the physician to have the order clarified C. Consult the unit manager to help interpret the order D. Ask the unit secretary to interpret the physician's handwriting (Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)
Answer: B. You must have the right documentation and clarify all orders with the prescriber before administering medications.
Which components of pharmacokinetics does the nurse need to understand before administering a drug? (Select all that apply.) a.Drugs with a smaller volume of drug distribution have a longer half-life. b.Oral drugs are dissolved through the process of pinocytosis. c.Patients with kidney disease may have fewer protein-binding sites and are at risk for drug toxicity. d.Rapid absorption decreases the bioavailability of the drug. e.When the drug metabolism rate is decreased, excess drug accumulation can occur, which can cause toxicity. (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)
Answer: C, E.
A patient asks the nurse about drug interactions with OTC preparations. What is the nurse's best response? a. "Discuss this with the health care provider." b. "There are not many interactions, so don't worry about it." c. "Read the labels carefully, and check with your health care provider." d. "Avoid over-the-counter preparations." (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)
Answer: C.
Match the description to the correct term: Pale, red, watery. A. Purulent B. Serous C. Serosanguineous D. Sanguineous (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? A. Collection of wound drainage B. Reduction of abdominal swelling C. Reduction of stress on the abdominal incision D. Stimulation of peristalsis (return of bowel function) from direct pressure (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? A. Emptying a closed drainage container B. Measuring the amount of drainage C. Assessment of wound drainage D. Reporting the amount on the patient's intake and output record (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. Assessment of wound drainage and maintenance of drains and the drainage system require the critical thinking and knowledge application unique to a nurse and therefore are inappropriate to delegate to NAP. ***NAPs CANNOT ASSESS***
During morning rounds, the nurse discovers that the older adult client has been incontinent during the night. To protect the skin, what will the nurse do first? A. Apply a barrier cream. B. Assess the area for skin breakdown. C. Clean the client. D. Place the client in a side-lying position. (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer: C. Cleaning and drying the client is the first priority for skin protection.
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? A. Give the medications B. Identify the patient using two patient identifiers C. Withhold the medications and verify the medication orders D. Provide medication education to the mother to help her better understand her child's medications (Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)
Answer: C. Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.
What is the best way for the nurse to prevent the client's stage I pressure ulcer from advancing to stage II? A. Massage the reddened areas. B. Pad the ulcer. C. Promote mobility and/or frequent repositioning. D. Suggest an egg crate mattress. (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer: C. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? A. Allow the area to be exposed to air until all drainage has stopped B. Place several cold packs over the area, protecting the skin around the wound C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
Which of the following is a method of wound debridement? A. Gauze dressing B. Transparent dressing C. Moist-to-dry dressing D. Hemovac drain (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. Necrotic tissue may be loosened and possibly removed by the use of moist-to-dry dressings. Transparent dressings are used for partial-thickness wounds with minimal wound exudate. Dry gauze dressings are used for wounds that will heal by primary intention with little drainage such as a closed surgical incision. A Hemovac drain is used to collect drainage, but not for wound debridement.
Which description best fits that of serous drainage from a wound? A. Fresh bleeding B. Thick and yellow C. Clear, watery plasma D. Beige to brown and foul smelling (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. Serous fluid generally is serum and presents as light red, almost clear fluid.
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? A. Keeping the buttocks exposed to air at all times B. Using a large absorbent diaper, changing when saturated C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment D. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.
Which of the following patients has the least risk for developing a wound infection? A. An 80-year-old man who has a burn B. A 17-year-old patient who has a metal fragment lodged in his thigh C. A 30-year-old female who had an episiotomy after childbirth D. A patient receiving chemotherapy who has a surgical incision E. A patient with peripheral vascular disease and an ulcer on the heel (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. The chances of wound infection are greater when the wound contains dead or necrotic tissue (as with a burn), there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced or the patient is immunocompromised.
A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient's history indicates obesity with a BMI of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for: A. Developing a blood clot. B. Developing a fistula. C. Wound dehiscence. D. Hemorrhage. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. This patient is at risk for poor wound healing due to the chronic illness of diabetes, being obese (BMI >30), and smoking. Fatty tissue has a poor blood supply for healing and smoking increases the patient's likelihood of coughing. The nurse should observe for an increase in serosanguineous drainage, an indication of potential dehiscence. The nurse should teach the patient to splint the abdomen with a pillow when coughing as a sudden strain on the incision could lead to dehiscence.
The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time? A. Apply sterile gloves and push the intestines back into the wound. B. Instruct the patient to avoid looking at the wound. C. Apply sterile saline-soaked towels to the area. D. Assess the wound to determine the extent of evisceration. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: C. When evisceration occurs, the nurse places sterile towels soaked in sterile saline over the extruding tissues. The patient should be allowed nothing by mouth (NPO), observed for signs and symptoms of shock, and prepared for emergency surgery.
The older adult client who is bedridden has a documented history of protein deficiency. What will the nurse plan to monitor for? A. Anemia B. Decreased wound healing C. Pressure ulcer development D. Weight gain (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer: C. This client is at risk for pressure ulcer if he or she remains bedridden. B is incorrect because there is no indicated wound.
Match the description to the correct term: Bright red: indicates active bleeding. A. Purulent B. Serous C. Serosanguineous D. Sanguineous (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: D.
The nurse is reviewing a patient's list of medications with the patient. The nurse understands that the older adult's slower absorption of oral medications is primarily because of which phenomenon? a. Decreased cardiac output b. Increased blood flow c. Decreased enzyme function d. Increased pH of gastric secretions (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)
Answer: D.
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? A. 2 mL B. 5 mL C. 16 mL D. 30 mL (Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)
Answer: D. 1 tablespoon = 15 mL; 2 tablespoons = 30 mL.
The client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Perform a total skin self-examination monthly. D. Perform a total skin self-examination monthly with a partner. (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer: D. Performing a monthly total skin self-examination with another person is the best secondary preventive measure. B is incorrect because avoiding sun exposure is a primary prevention.
The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? A. These are expected findings for this postoperative time period. B. The patient is becoming dependent upon pain medication. C. The nurse should observe the patient more closely for wound dehiscence. D. The patient is demonstrating signs of a postoperative wound infection. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: D. The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, an elevated white blood cell count, and the edges of the wound may appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: D. When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.
Which of the following may indicate an increased risk for wound dehiscence? A. It is within the first 24 to 48 hours after surgery. B. The patient holds a pillow over the abdomen whenever coughing. C. There is a small amount of serous drainage noted on the dressing. D. There is an increase in serosanguineous drainage from the wound. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answer: D. When there is an increase in serosanguineous drainage from a wound, the nurse should be alert for the potential for dehiscence. Dehiscence most commonly occurs before collagen formation (3 to 11 days after injury or surgery). Risk for hemorrhage is greatest during the first 24 to 48 hours following surgery. Placing a pillow or folded thin blanket over the abdomen provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. This is done to prevent wound dehiscence.
Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? A. Use the Braden scale to determine pressure ulcer risk for a newly admitted client. B. Complete daily sterile dressing changes for a client with a venous leg ulcer. C. Reposition every 2 hours a client who has had a stroke and is incontinent. D. Admit a newly transferred client who had pedicle flap surgery 1 week ago. (Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)
Answer:C. The nursing assistant has the education and scope of practice to reposition a client.
It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.) A. Yellow-tinged drainage B. Temperature 100.3°F (37.94°C) C. Increased complaints of pain at wound site D. White blood cell count 13,000 mm3 (elevated) E. Wound edges of pink to normal skin color F. Foul odor noted from previous dressing (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A, B, C, D, F. The patient has a fever, tenderness, and pain at the wound site and an elevated white blood cell count (normal 5,000 to 10,000 per mm3). Wound edges that appear red and inflamed indicate infection. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.
The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply): A. Applying over-the-counter lotions to skin that is not broken. B. Assisting the client with frequent turning to prevent pressure ulcers. C. Covering the client who complains of being cold with more blankets. D. Placing a sterile gauze pad over broken skin to contain drainage. E. Assessing a patient complaining of an itching rash. (Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)
Answers: A, B, C, D. All the above options can be delegated to an unlicensed assistive personnel employee except for assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.
A patient has nine medications prescribed to take daily. Which are common reasons for nonadherence to the drug regimen in the older adult? (Select all that apply.) a.Taking multiple drugs at one time b.Impaired memory c.Decreased dexterity d.Increased mobility e.Increased visual acuity (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)
Answers: A, B, C.
A patient asks the nurse about cautions related to use of OTC medications. What is the nurse's best response? (Select all that apply.) a. "Over-the-counter drugs may delay professional diagnosis." b. "They may mask symptoms." c. "They may make diagnosis easier." d. "Their inactive ingredients may cause adverse reactions." e. "They may be more expensive." (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)
Answers: A, B, D.
The rate of absorption of drugs can change when two drugs are taken at the same time. The nurse is aware that the rate of absorption can be changed by which actions? (Select all that apply.) a.Modifying gastric emptying time b.Changing gastric pH c.Decreasing inflammation d.Forming drug complexes e.Eating too slowly (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)
Answers: A, B, D.
An 80-year-old patient complains of recent onset of insomnia, saying, "If only I could get to sleep!" If a drug is prescribed, which drug characteristics would be best for this situation? (Select all that apply.) a. Short-intermediate acting b. Rapidly eliminated c. Slowly eliminated d. Multiple metabolites e. Few metabolites (Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)
Answers: A, B, E.
The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply): A. Cleansing the wound. B. Managing pain. C. Applying a dry sterile dressing. D. Using cold water in the bath. (Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)
Answers: A, B. Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.
The nurse is teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Turning patients at least every 2 hours B. Rubbing reddened bony prominences C. Use of pillow bridging when needed D. Positioning the patient in the 30-degree lateral position E. Using a turn sheet to reposition patients F. Decreasing patients' fluid intake to decrease the incidence of incontinence (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A, C, D, E. There are several strategies to prevent the development of pressure ulcers. Patients should be repositioned at least every 2 hours to reduce the duration and intensity of pressure. The use of pillow bridging will prevent direct contact between bony prominences. Using a turning sheet to reposition patients prevents dragging along the sheets (friction). Maintaining the head of the bed at 30 degrees decreases the potential for the patient to slide toward the foot of the bed and incur a shear injury. The 30-degree lateral position should prevent positioning directly over the bony prominence. Avoid massaging reddened bony prominences because this may cause skin breakdown. Incontinence should be managed by methods other than withholding fluids. Dehydration can also negatively affect tissue integrity.
Identify contributing factors to pressure ulcer formation. (Select all that apply.) A. Malnutrition B. Middle age C. Decreased sensory perception/mobility D. Anemia E. Excessive sweating F. Ethnic background (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A, C, D, E. Three pressure-related forces contribute to the development of a pressure ulcer: intensity of pressure (how much pressure is applied), duration of pressure (how long the pressure is applied), and tissue tolerance (the ability of the tissue to redistribute the weight). Having decreased mobility or decreased ability to perceive the need to shift one's weight or change position places an individual at risk for pressure ulcer development. Three extrinsic factors, shear, friction, and moisture, make the tissues less tolerant of pressure. Other factors important in pressure ulcer development include poor nutrition, advanced age, medical conditions that support poor tissue perfusion (low blood pressure, smoking, elevated temperature, anemia), and psychosocial status, in particular stress-induced cortisol secretion.
Identify prevention strategies for pressure ulcers. (Select all that apply.) A. Use a moisture barrier ointment, applied after each incontinent episode. B. Reposition patient at least every 4 hours; use a written schedule. C. When the patient is in the side-lying position in bed, use the 30-degree lateral position. D. Place patient on a pressure-reducing support surface. E. Maintain the head of the bed at 45 degrees. F. Massage reddened bony prominences. G. Oral supplements should be instituted if the patient is found to be undernourished. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A, C, D, G. Patients should be repositioned every 2 hours to reduce the duration and intensity of pressure. The 30-degree lateral position avoids direct contact of the trochanter with the support surface. Placing the patient on a pressure-reducing support surface reduces the amount of pressure exerted against the tissues. The head of the bed should be maintained at 30 degrees. If the head is elevated more than this, it can increase the potential of the patient to slide toward the foot of the bed and incur a shear injury. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue, and therefore it should be avoided. A moisture barrier ointment protects reddened intact skin from incontinence. There is a strong relationship between poor nutrition and pressure ulcer development. Supplements may provide lacking nutrients.
Which of the following are functions of dressings? (Select all that apply.) A. To promote hemostasis B. To keep the wound bed dry C. Wound debridement D. To prevent contamination E. To increase circulation (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A, C, D. Dressings provide several functions, which include debridement, maintaining a moist wound environment, protecting from outside contamination and further injury, preventing the spread of microorganisms, increased patient comfort, and promoting hemostasis by control of bleeding. Dressings are unable to increase circulation.
Which of the following patients would be expected to benefit from a moist-to-dry dressing? (Select all that apply.) A. A 24-year-old patient with an open and infected wound from a spider bite B. A 7-year-old with abrasions on the knees C. A 50-year-old with a postoperative knee-replacement incision D. A 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater-type wound (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A, D. Moist-to-dry dressings are best used with necrotic, infected wounds requiring debridement. Moist dressings are often used for helping to heal full-thickness wounds that look like craters. Dry woven gauze dressings are most often used for abrasions and postoperative incisions when minimal drainage is anticipated.
What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: A. Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.
Which of the following are common sites for the development of pressure ulcers? (Select all that apply.) A. Sternum B. Heels C. Sacrum D. Lateral malleoli E. Trochanters F. Ischial tuberosities (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: B, C, D, E, F. Common sites for the development of pressure ulcers include the sacrum, heels, elbows, lateral malleoli, trochanters, and ischial tuberosities. (Helpful, I know.)
The nurse is observing the patient's wife perform the moist-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) A. Premedicates for pain B. Packs wound tightly C. Leaves contact or primary dressing dripping moist D. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Answers: B, C. Inner gauze should be moist to absorb drainage and adhere to debris. The wound should be loosely packed to facilitate wicking of drainage into the absorbent outer layer of the dressing. The wound should never be over packed because this can cause wound trauma when the dressing is removed. Premedicating for pain will help provide comfort during the dressing change. If dressing sticks on a moist-to-dry dressing, the wife should gently free the dressing and alert the patient of discomfort. The wife was correct in not wetting the dressing as a moist-to-dry dressing should debride the wound.
During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings places him at risk for an adverse drug event? (Select all that apply.) A.Taking two medications for hypertension B.Taking a total of eight different medications during the day. C.Having one physician who reviews all medications D.Patient's health history E.Involvement of the caregiver in assisting with medication administration
Answers: B, D. The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.
A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to (Select all that apply): A. Bathe and dry the skin vigorously to stimulate circulation. B. Keep the head of the bed elevated 30 degrees. C. Offer nutritional supplements and frequent snacks. D. Turn the patient at least every 2 hours. (Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)
Answers: C, D. The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline.
