exam 5 Nurs 299

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable pressure injury. ___ 1.Stage 1 ___ 2.Stage 2 ___ 3.Stage 3 ___ 4.Stage 4 ___ 5.Unstageable pressure injury

___ 4.Stage 4

Evisceration

wound separation with protrusion of organs

If the unit is doing a research study on the effects of gum chewing on a patient who has hadabdominal surgery and wants Mrs. Jones to participate in the study, which of the following would be true? A. Mrs. Jones would have to give informed consent. B. Mrs. Jones would have to discuss it with her family first. C. No one could tell Mrs. Jones that she is in the study because it might skew the data. D. Mrs. Jones would have to participate if she wanted to be on that unit

A. Mrs. Jones would have to give informed consent.

Cody is going to document in Mr. Brown's medical record. Which of the following is appropriate to document? A. Patient rates headache pain as a 6. Pain is in L temporal area and does not get better with any positioning. B. IV site looks good. C. Voiding without difficulty. D. Is pleasant to care for

A. Patient rates headache pain as a 6. Pain is in L temporal area and does not get better with any positioning.

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) A. Stage 3 pressure injury B. sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A. Stage 3 pressure injury E. Open burn area

a. Advocacy b. Responsibility c. Accountability d. Confidentiality Match the following w/ the terms __1. You see an open medical record on the computer and close it so that no one else can read the record without proper access. ___2. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the provider and your nurse manager and follow agency procedure. ___3. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request. ___4. You tell your patient that you will return in 30 minutes to give him his next pain medication.

1- D 2- C 3- A 4- B

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." 5. "I will go back to school as soon as I finish orientation."

1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." -Nurses need to be actively involved in their communities and be aware of current issues in health care. Staying abreast of current news and public opinion through the media is essential. Nurses need to join nursing committees to be involved in decision making. Nurses have a powerful voice in the legislature.

Deontology, Utilitarianism, & Feminist ethics

-Deontology is a system of ethics that defines actions as right or wrong based on their "right-making characteristics such as fidelity to promises, truthfulness, and justice." It does not look at the consequences of actions. - Utilitarianism is when the value of something is determined by its usefulness; the main emphasis is on the outcome or consequence of actions. - Feminist ethics focus on inequalities between people; they look to the nature of relationships for guidance.

risk factors for pressure ulcer development

-Impaired sensory perception -Alterations in LOC -Impaired mobility -shear -friction -moisture

Factors influencing pressure injury formation and wound healing

-Nutrition -Tissue perfusion -Infection -Age -Psychosocial impact of wounds

Translation research phases

-Preclinical and animal studies—basic science research -Phase 1 clinical trials—testing safety and efficacy in a small group of human subjects -Phase 2 and 3 clinical trials—testing safety and efficacy in a larger group of human subjects and testing for comparison to standard treatment -Phase 4 clinical trials and outcomes research—translation to practice -Phase 5 population-level outcomes research—translation to community

Classification of pressure injuries

-Stage 1: Non-blanchable erythema of intact skin -Stage 2: Partial-thickness skin loss with exposed dermis -Stage 3: Full-thickness skin loss - no bone or tendon showing -Stage 4: Full-thickness skin and tissue loss - will see bone, tendon, eschar (black tissue) -Unstageable pressure injury: Full-thickness skin and tissue loss obscured by slough or eschar -Deep-tissue pressure injury: Localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister

heat and cold therapy

-heat causes vasodilation when you want inflammation to begin healing. -Cold causes vasoconstriction to limit bleeding. Use cold within first 48 hours. -Must apply heat and cold every 20 minutes

Steps of evidence-based practice

0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICOT format. 2. Search for the best evidence. 3. Critically appraise the evidence. 4. Integrate the evidence. 5. Evaluate the outcomes of practice decision or changes. 6. Communicate the outcomes of the evidence-based practice decision.

A nurse who works in an outpatient chemotherapy infusion center is assigned to the care of a 56-year-old male patient who is receiving chemotherapy for colon cancer. This is the patient's first clinic visit. The nurse reviews the patient's medical record and sees a note about the patient receiving instruction on how chemotherapy treats cancer, but the note does not summarize the patient's response. The doctor makes a quick visit and tells the patient, "We will get your treatment started today and we will be checking your blood each week for any problems." The doctor leaves and the patient asks the nurse, "What are the blood tests for?" To determine this patient's learning needs, what should the nurse assess? (Select all that apply.) 1. Medical record summary of the stage of the cancer 2. The patient's behavior as the nurse interacts with him 3. The patient's level of knowledge about chemotherapy effects 4. The number of treatments the patient will be receiving 5. The patient's health literacy 6. The patient's self-description of severity of his cancer 7. The date of the medical record note describing patient instruction

2. The patient's behavior as the nurse interacts with him 3. The patient's level of knowledge about chemotherapy effects 5. The patient's health literacy 6. The patient's self-description of severity of his cancer

Patient Protection and Affordable Care Act (PPACA)

2010 federal legislation designed for comprehensive health reform, with an intent to expand coverage, control health care costs, and improve the health care delivery system

An incident report is: 1. A legal claim against a nurse for negligent nursing care 2. A summary report of all falls occurring on a nursing unit 3. A report of an event inconsistent with the routine care of a patient 4. A report of a nurse's behavior submitted to the hospital administration

3. A report of an event inconsistent with the routine care of a patient

A research report includes all of the following except: 1. The researcher's interpretation of the study results 2. A description of methods used to conduct the study 3. A summary of other research studies with the same results 4. A summary of literature used to identify the research problem

3. A summary of other research studies with the same results -The summary details the results of the study and explains whether a hypothesis is supported. The results of other studies are not presented.

A student nurse who is employed as a nursing assistant may perform any functions that: 1. Have been learned in school 2. Are expected of a nurse at that level 3. Are identified in the position's job description 4. Require technical rather than professional skill

3. Are identified in the position's job description -Need to perform only those tasks that appear in the job description for a nurse's aide or assistant

When documenting an assessment of a patient's cardiac system in an EHR, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80 and 100 beats/min, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating data, action, and response (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting by exception (CBE) 4. Narrative documentation

3. Charting by exception (CBE)

The nurse is administering a dose of metoprolol to a patient and is completing the steps of bar-code medication administration within the EHR. As the bar-code information on the medication is scanned, an alert that states, "Do not administer dose if apical heart rate (HR) is <60 beats/min or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized provider order entry (CPOE)

3. Clinical decision support system (CDSS) -Clinical decision support systems (CDSSs) are computer programs that prompt health care providers with clinical knowledge and relevant patient information that assists with clinical decision making. A nursing CDSS uses a complex system of rules to analyze data and provide alerts to support clinical decisions made by nurse

A 26-year-old patient visits a medical clinic and asks a nurse to provide instruction on how to perform a breast self-examination. "My mom had cancer so I want to learn how." Which domains are required to learn this skill? (Select all that apply.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain

3. Cognitive domain 5. Psychomotor domain

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? 1. Document her findings and treat the patient. 2. Instruct the mother on safe handling of a 2-year-old child. 3. Contact a child abuse hotline. 4. Discuss this story with a colleague

3. Contact a child abuse hotline. -Nurses are mandated reporters of suspected child abuse. These assessment findings possibly indicate child abuse.

The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology? 1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action. 2. The single focus on power imbalances does not apply to all situations in which ethical problems occur. 3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. 4. The focus on consequences rather than on the "goodness" of an action makes decision makers uncomfortable.

3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. -Deontology is an approach to ethics that identifies the correct action as that which is supported by fundamental principles and duties. The disadvantage of this approach is that its application relies on consensus around what the primary duties and principles are. Option 1 describes a limitation of the ethics of care. Option 2 describes a limitation of feminist ethics, while option 4 describes a limitation of utilitarianism

The ANA Code of Ethics for Nurses articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and right of the patient." This promise to protect includes a promise to protect patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? 1. Yes. Patient privacy would not be violated because patient identifiers were removed. 2. Yes. Respect for autonomy implies that you have the autonomy to decide what constitutes privacy. 3. No. A viewer might identify the patient based on other comments that you make online about the patient's condition and your place of work. 4. No. The principle of justice requires you to allocate resources fairly.

3. No. A viewer might identify the patient based on other comments that you make online about the patient's condition and your place of work. -Privacy is a patient's right to avoid disclosure of their personal health information. Posting information or pictures about patients, even without specific identifiers, is a violation of confidentiality.

Which of these patients has a nutritional risk for pressure injury development? 1. Patient A has an albumin level of 3.5. 2. Patient B has a hemoglobin level within normal limits. 3. Patient C has a protein intake of 0.5 g/kg/day. 4. Patient D has a body weight that is 5% greater than his ideal weight.

3. Patient C has a protein intake of 0.5 g/kg/day. -The recommended protein intake for adults is 0.8 g/kg; a higher intake of up to 1.8 g/kg/day is necessary for healing.

A nurse who works in an outpatient chemotherapy infusion center is assigned to the care of a 56-year-old male patient who is receiving chemotherapy for colon cancer. This is the patient's first clinic visit. The nurse reviews the patient's medical record and sees a note about the patient receiving instruction on how chemotherapy treats cancer; the note does not summarize the patient's response. The nurse's assessment reveals that the patient is motivated to learn more about his chemotherapy and is alert and currently feeling well. The nurse has prepared the first infusion, regulated it, and now takes time to begin instruction. Which teaching approaches are best suited for this situation? 1. Use an entrusting approach in explaining how to monitor for side effects of chemotherapy. 2. Bring the patient together with two other patients in the clinic and conduct a group discussion. 3. Provide verbal one-on-one instruction, with the patient participating in selection of content. 4. Present the patient with a problem situation involving a serious side effect and have the patient decide what to do.

3. Provide verbal one-on-one instruction, with the patient participating in selection of content. -Because this is the first instructional session with this patient, the nurse should choose one-on-one instruction and participation. This will set the groundwork for future teaching sessions. It is too early to use an entrusting approach or to present a problem situation. A group approach is also too early but could be valuable in future visits

A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. REALM test

3. Return demonstration -Return demonstration permits a patient to perform a skill as the nurse observes. It provides excellent feedback and reinforcement.

A nurse is preparing to teach a patient who has sleep apnea how to use a continuous positive airway pressure (CPAP) machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works.

3. Set mutual goals for the education session. -planning should occur before any form of implementation or evaluation. The nurse should build from simple to more complex information. Learning about the purpose of the machine and how it works is basic information needed for the patient to understand and be motivated to use it. Allowing the patient to manipulate the machine will precede instruction on its actual use. Teach-back will inform the nurse as to the patient's level of learning

Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr. Post is at risk for developing a pressure injury on his coccyx because of: 1. Friction 2. Maceration 3. Shearing force 4. Impaired peripheral circulation

3. Shearing force -The force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the patient and the surface

Chapter 23 ati book & quick quiz questions

4

A nurse research investigator is explaining a research study to a patient. The patient is interested in participating in the research study. The nurse investigator reviews the informed consent with the patient. The patient asks the nurse why he must sign the consent to participate in the study. What is the nurse's best response(s) to the patient's question? (Select all that apply.) 1. "The informed consent (IC) provides you with complete information on the research study." 2. "By reviewing the consent with you, I can make sure that you understand the study and what it means for you to participate." 3. "The informed consent provides details on the limitations of the study." 4. "The informed consent provides your voluntary agreement to participate in the research study." 5. "The informed consent explains how the data collected from you will be kept confidential during and after the study."

1. "The informed consent (IC) provides you with complete information on the research study." 2. "By reviewing the consent with you, I can make sure that you understand the study and what it means for you to participate." 4. "The informed consent provides your voluntary agreement to participate in the research study." 5. "The informed consent explains how the data collected from you will be kept confidential during and after the study." -The informed consent (IC) is a document that the research investigator reviews with each study subject. After ensuring that the study participant fully understands the purpose, procedures, data collection, potential harm and benefits, and alternative methods of treatment, the study participant signs the informed consent and it is witnessed by the investigator. The IC outlines how participant data will be kept confidential or anonymous. The participant's signature shows that the participant fully understands the study and is freely choosing to voluntarily consent to or decline participation in the study.

The nurse puts restraints on a patient without the patient's permission and without a physician's order. The nurse may be guilty of: 1. Battery 2. Assault 3. Neglect 4. Invasion of privacy

1. Battery -Unintentional touching without consent

Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (Select all that apply.) 1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 3. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified. 5. Whether a person has a job is an objective measure, but it does not play a role in understanding quality of life.

1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified. -These statements describe why a single definition for the term quality of life is challenging. Options 3 and 5 are true statements, but they do not explain why the definition of quality of life is difficult to agree on, which is what the question asks for

You are working on a patient care unit and observe several other nurses who are not following the agency's policy when preparing and administering medications. When you ask them to explain why they are doing this, they state the new medication administration technology installed on the unit takes too much time to use, so they are using workarounds to get their patient medications administered on time. Which is the best action to take first? 1. Discuss the situation with the nursing manager. 2. Call a colleague who works at another institution to talk about the problem. 3. Look for a position on a different nursing unit. 4. Say nothing and begin your work.

1. Discuss the situation with the nursing manager. -Alerting the nursing manager is the first step in helping identify a problem that may exist related to medication administration. Speaking up about issues that may create an unsafe patient situation for the hospital and nursing staff can help reduce your legal r

A patient is in skeletal traction and has a plaster cast due to a fractured femur. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document and report this to the health care provider because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to provide patient education about cast care 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

1. Failure to document a change in assessment data 5. Failure to notify a health care provider about a change in the patient's condition -The failure to document a change in assessment data and the failure to notify a health care provider about a change in patient status reflect a breach of duty to the patient

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI? (select all that apply) 1. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. 2. Change dressing only when saturated. 3. Apply adhesive remover. 4. Use Montgomery ties to secure the dressing. 5. Immobilize area of wound.

1. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. 3. Apply adhesive remover. 4. Use Montgomery ties to secure the dressing. -To reduce the incidence of or lower the risk for MARSI, use techniques to reduce injuries such as skin tears and abrasions. Pulling the tape parallel with the skin surface reduces shear from tape removal, adhesive removal loosens the tape prior to dressing change, and Montgomery ties reduce the frequency of tape removal

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 small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1. Notify the health care provider. 4. Cover the area with sterile, saline-soaked towels immediately. -Notify the health care provider immediately, because the patient will need emergency surgery. If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. 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; 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 actions, if performed by an RN, could result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) 1. Reviewing the EHR of a family member who is a patient in the same hospital on a different unit 2. Refusing to provide health care information to an older adult's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written order 5. Completing an occurrence report on the unit

1. Reviewing the EHR of a family member who is a patient in the same hospital on a different unit 4. Applying physical restraints without a written order -. Viewing a family member's electronic health record (EHR) violates the patient's rights provided by HIPAA. A physical restraint can be applied only on the written order of a health care provider based on The Joint Commission and Medicare guidelines

Which social media uses can be implemented with patients and families without violating confidentiality? (Select all that apply.) 1. Social media can be used to provide supportive information. 2. Results such as x-ray results can easily be sent via social media. 3. Family and friends who cannot be present can connect with the patient. 4. All health information can be shared on social media. 5. Social media should never be used with patients and families.

1. Social media can be used to provide supportive information. 3. Family and friends who cannot be present can connect with the patient.

A nurse is teaching an older-adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Use basic one- or two-syllable medical terms. 5. Provide specific information in frequent, small amounts. 6. Speak quickly so that you do not take up much of the patient's time.

1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 5. Provide specific information in frequent, small amounts. -Lower tones are easier for patients with hearing deficits to hear. Reinforce important information at the beginning and end of each teaching session to enhance understanding. Providing information in small amounts helps the older adult understand information better. A pamphlet should be written in a color that contrasts with the background (e.g., black 14-point print on matte white paper). Blues and greens are hard to distinguish. Take your time with an older adult. Speaking quickly can easily lead to misunderstanding. An older adult does not require short-syllable terms unless there is evidence of lower health literacy

The scope of nursing practice is legally defined by: 1. State nurse practice acts 2. Professional nursing organizations 3. Hospital policy and procedure manuals 4. Health care providers in the employing institutions

1. State nurse practice acts -Determines the legal boundaries within each state

Resolution of an ethical problem involves discussion with the patient, the patient's family, and participants from appropriate health care disciplines. Which statement best describes the role of the nurse in the resolution of ethical problems? 1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations 2. To study the literature on current research about the possible clinical interventions available for the patient in question 3. To hold a point of view but realize that respect for the authority of administrators and health care providers takes precedence over personal views 4. To allow the patient and the health care provider private time to resolve the dilemma on the basis of ethical principles

1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations -The ideal process for resolving ethical problems engages the perspectives of all involved, and nurses, as members of the health care team, have a valuable and unique point of view to share. Option 2 is a strategy that assists in answering a clinical question but does not address ethics. Options 3 and 4 are incorrect because both suggest that the nurse disengage from her own values and critical thinking and follow an action driven by the points of views of others.

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board). 2. Have head of bed elevated when transferring patient. 3. Have head of bed flat when repositioning patient. 4. Raise head of bed 60 degrees when patient is positioned supine. 5. Raise head of bed 30 degrees when patient is positioned supine.

1. Use a transfer device (e.g., transfer board). 3. Have head of bed flat when repositioning patient. 5. Raise head of bed 30 degrees when patient is positioned supine. - A transfer device can pick up a patient and prevent the skin from sticking to the bedsheet during repositioning. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents the patient from sliding. The head of bed in higher position causes patient to slide down, causing shear

ou are a nurse who is working in an agency that has recently implemented an EHR. Which of the following are acceptable practices for maintaining the security and confidentiality of EHR information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer username and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged into a computer to save time if you only need to step away to administer a medication

1. Using a strong password and changing your password frequently according to agency policy 3. Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care -Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record (EHR) include not sharing passwords, not leaving computers with open EHRs unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (Select all that apply.) Ethics of care: 1. pays attention to the context in which caring occurs. 2. is used only by nurses because it is part of the Nursing Code of Ethics. 3. requires understanding the relationships between involved parties. 4. considers the decision maker's relationships with other involved parties. 5. is an approach that suggests a greater commitment to patient care. 6. considers the decision maker to be in a detached position outside the ethical problem.

1. pays attention to the context in which caring occurs. 3. requires understanding the relationships between involved parties. 4. considers the decision maker's relationships with other involved parties. -The ethics of care emphasizes attention to the context in which an ethical problem occurs and the relationships between involved parties, including relationships with the decision maker. No approach to ethical problems is exclusive to a single discipline, and no approach is superior to the others, nor does any approach demonstrate a higher level of commitment to the patient, so options 2 and 5 are incorrect. Option 6 is true of principle-based approaches such as deontology but not true of the ethics of care

chapter 25 ati book

16&17

A nurse contacts the health care provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the EHR, what should the nurse do? 1. Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR. 3. Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours.

2. "Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR. -Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.

Which of the following scenarios demonstrate that patient learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors.

2. A patient describes how to set up a pill organizer for newly ordered medicines. 4. A patient demonstrates how to take his blood pressure at home. -. Steps 2 and 4 are examples of patients exhibiting behaviors that demonstrate learning. The other three steps are examples of patient involvement in instruction

Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer? 1. Apply a heat lamp to the area for 20 minutes twice daily. 2. Apply a hydrocolloid dressing and change it as necessary. 3. Apply a calcium alginate dressing and change when strikethrough is noted. 4. Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.

2. Apply a hydrocolloid dressing and change it as necessary. -table 48.8 for rationale

When designing a plan for pain management for a patient following surgery, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. If the nurse's actions are driven by respect for autonomy, what aspect of this scenario best demonstrates this action? 1. Assessing the patient's pain on a numeric scale every 2 hours 2. Asking the patient to establish the goal for pain control 3. Using alternative measures such as distraction or repositioning to relieve the pain 4. Monitoring the patient for oversedation as a side effect of his pain medication

2. Asking the patient to establish the goal for pain control -asking the patient to establish the goal for pain control is a demonstration of respect for autonomy. Assessing, monitoring, and using alternative measures are interventions that address pain but that are not necessarily grounded in the principle of autonomy

Which of the following nursing activities apply to an MDRPI? (Select all that apply.) 1. Assess skin under devices every 2 hours. 2. Cushion at risk areas (e.g., ears, nose with foam or protective dressing). 3. Choose correct size of device. 4. Observe for erythema or irritation that conforms to pattern or shape of device. 5. Observe under casts and splints.

2. Cushion at risk areas (e.g., ears, nose with foam or protective dressing). 3. Choose correct size of device. 4. Observe for erythema or irritation that conforms to pattern or shape of device. 5. Observe under casts and splints. Rationale - assessment for MDRPI is based on patient assessment. Some patients (e.g., those who are elderly, febrile, or ventilated) must have more frequent skin assessment to identify early signs of MDRPI and prevent further injury

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Provision of support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Provision of support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision -A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

The nurse is using the QSEN competency of EBP when working with the unit council to initiate a change related to pain management. Which behaviors demonstrate that the nurse is practicing behaviors associated with EBP? (Select all that apply.) 1. Initiating plan for self-development as a team member 2. Reading original research related to pain management 3. Demonstrating effective use of strategies to reduce risk of harm to self or others 4. Valuing EBP as critical to the development of pain management guidelines for the unit 5. Describing to the unit council reliable sources for locating clinical guidelines 6. Applying technology and information management tools to support safe processes of care

2. Reading original research related to pain management 4. Valuing EBP as critical to the development of pain management guidelines for the unit 5. Describing to the unit council reliable sources for locating clinical guidelines -Reading original research related to pain management is an EBP behavior as the nurse searches for and locates the best evidence related to pain management. Valuing EBP as critical to the development of pain management guidelines for the unit is a behavior that shows the nurse recognizes that the best evidence should be used as the foundation for clinical practice. Describing to the unit council reliable sources for locating clinical guidelines is demonstration of a behavior in which the nurse shares knowledge on the clinical unit about locating evidence-based clinical guidelines

A patient in the ICU experiences a sentinel event related to central line catheter care that resulted in serious injury. What PI model should the unit use to identify errors that led to the sentinel event? 1. Six Sigma 2. Root cause analysis 3. PDSA 4. Balanced scorecard

2. Root cause analysis -. The unit should conduct a root cause analysis (RCA). The purpose of the RCA is to gather data and information to identify active and latent errors that occurred leading to the sentinel event. The other options are quality improvement models that focus on process and performance measures leading to practice change. They may be used to improve processes or practice after the RCA has identified the underlying errors that led to the sentinel event.

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? 1. Family member 2. Surgeon 3. Nurse 4. Nurse manager

2. Surgeon -The person performing the procedure is responsible for informing the patient about the procedure and its risks, benefits, and possible complications

A nurse sends a text message to the oncoming nurse that states, "Mr. Kodro in room 3348-1 refused to take his sertraline hydrochloride as ordered this morning because he said he was feeling better." What should the oncoming nurse do? (Select all that apply.) 1. Add this information to the board hanging at the patient's bedside. 2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. 4. Forward the text to the charge nurse. 5. Thank the nurse for sending the information.

2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. -. The Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology Act provide rules Copyright © 2023 Elsevier Inc. All rights reserved. about how and with whom nurses can share patient health information. Sending a text message to another nurse about a patient is a violation of these acts. Report violations of the privacy of patient health information to your supervisor or manager.

A patient suddenly experienced a severe headache with numbness and decreased movement in the left arm. An emergency brain scan confirmed a cerebral vessel clot. With a stroke confirmed, the emergency room physician consults with a neurosurgeon to schedule an emergent angiogram to remove the clot. Which teaching approach is most appropriate for explaining to the patient what to expect from the procedure? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach

2. Telling approach -Telling is the best approach when there is limited time for teaching information

A health care issue often becomes an ethical dilemma because: 1. Decisions must be made based on value systems. 2. The choices involved do not appear to be clearly right or wrong. 3. Decisions must be made quickly, often under stressful conditions. 4. A patient's legal rights coexist with a health professional's obligations.

2. The choices involved do not appear to be clearly right or wrong.

James inspects Mrs. Stone's left foot, her healthy foot, to ensure there are nosigns of impaired skin integrity. He knows to check for blanching, but he doesnot see any when checking Mrs. Stone's skin. Why may he not see blanching ofMrs. Stone's skin? A. Blanching does not occur in darkly pigmented skin. B. There is no sign of a pressure ulcer. C. Blanching only occurs in late-stage ulcers. D. Blanching is not part of the pressure-ulcer assessment

A. Blanching does not occur in darkly pigmented skin.

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A Stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode -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; 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.

The nurse is discussing the advantages of using CPOE with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an EHR? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an EHR. 4. CPOE improves patient safety by reducing transcription errors.

4. CPOE improves patient safety by reducing transcription errors. -Although the other answers loosely describe some positive aspects of CPOE, option 4 provides the best description of the major advantage CPOE offers—the reduction of transcription errors, which reduces medical errors and creates a safer patient care environment

A nurse implements an EBP change that teaches patients the importance of taking their diabetes medications correctly and regularly on time using videos streamed on the Internet. The nurse measures the patients' behavioral outcome from the practice change by using which type of measurement? 1. Measuring the patients' weight 2. Chart auditing teaching sessions 3. Observing patients viewing the videos 4. Checking patients' blood sugars

4. Checking patients' blood sugars -The desired behavioral outcome is the patients' blood sugar levels, which will show the patients' adherence to taking medications as prescribed. Measuring the patients' weight is a desirable physical outcome but not a measure of the effects of the teaching program. Charting auditing teaching sessions is a process measure to track teaching sessions. Observing the patients viewing the videos is also a process measure

Which of the following is correctly charted according to the six guidelines for quality recording? 1. Was depressed today. 2. Respirations rapid; lung sounds clear. 3. Had a good day. Up and about in room. 4. Crying. States she doesn't want visitors to see her like this.

4. Crying. States she doesn't want visitors to see her like this.

A man who is homeless enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the city hospital for care before assessing the patient. This action is most likely a violation of which of the following laws? 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Americans With Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA)

4. Emergency Medical Treatment and Active Labor Act (EMTALA) -EMTALA requires that an emergency situation needs to be established and that the patient needs to be stabilized before a transfer is appropriate

A woman has severe life-threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? 1. Obtain a court order to give the blood. 2. Convince the husband to allow the nurse to give the blood. 3. Call security and have the husband removed from the hospital. 4. Gather more information about the wife's preferences and determine whether the husband has her power of attorney for health care.

4. Gather more information about the wife's preferences and determine whether the husband has her power of attorney for health care. -Adult patients such as those with specific religious objections are able to refuse treatment for personal religious reasons. Because this patient is unresponsive, it is important for the nurse to better understand the patient's preferences and know if the woman has a power of attorney for health care before following the husband's wishes. However, there needs to be clear direction on who can make the decision.

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contains an inappropriate abbreviation included on TJC's "do not use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

4. Insulin aspart 8u SQ every morning before breakfast -In option 4, the word "unit(s)" should be written out because the letter "u" can be mistaken for "0," the number "4," or "cc." The other orders are written appropriately

The nurses on a medical unit have seen an increase in the number of pressure injuries developing in their patients. The nurses decide to initiate a PI project using the PDSA model. Which of the following is an example of "Plan" from that model? 1. Orienting patients to the unit's practice of hourly rounding on patients 2. Reviewing the incidence of pressure injuries on patients cared for using the protocol 3. Based on findings from patients who developed injuries, implementing an evidence-based skin care protocol on all units 4. Meeting with all disciplines to develop a multidisciplinary approach for reducing pressure injuries

4. Meeting with all disciplines to develop a multidisciplinary approach for reducing pressure injuries -Meeting with all disciplines to develop a multidisciplinary approach for reducing pressure injuries is developing a plan to test the change ("Plan").The implementation of the new protocol is the "Do," or carrying out the test. Reviewing the incidence of pressure injuries on patients cared for using the protocol is observing and learning the outcomes ("Study"). Orienting the patients on the unit to the practi

Which of the following patients is most ready to begin a patient-teaching session? 1. Ms. Hernandez, who is unwilling to accept that her back injury may result in permanent paralysis. 2. Mr. Frank, who is newly diagnosed with diabetes, who is complaining that he was awake all night because of his noisy roommate. 3. Mrs. Brown, a patient with irritable bowel syndrome, who has just returned from a morning of testing in the gastrointestinal laboratory. 4. Mr. Jones, a patient who had a heart attack 4 days ago and now seems somewhat anxious about how this will affect his future.

4. Mr. Jones, a patient who had a heart attack 4 days ago and now seems somewhat anxious about how this will affect his future. -Mr. Jones. A mild level of anxiety motivates learning, but a high level of anxiety prevents learning from occurring.

Demonstration of the principles of body mechanics used when transferring patients from bed to chair would be classified under which domain of learning? 1. Social 2. Affective 3. Cognitive 4. Psychomotor

4. Psychomotor -Psychomotor learning involves acquiring skills that integrate mental and muscular activity.

A 55-year-old man has been in the hospital for over a week following surgical complications. The patient has had limited activity but is now ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn

4. Readiness to learn -A patient's readiness to learn is affected by the patient's attentional set. Physical discomfort, fatigue, anxiety, confusion, and environmental distractions influence the ability to concentrate and learn.

Place the steps of the EBP process in the appropriate order. 1. Critically appraise the evidence you gather. 2. Ask the clinical question in PICOT format. 3. Evaluate the outcomes of the practice decision or change. 4. Search for the most relevant and best evidence. 5. Cultivate a spirit of inquiry. 6. Integrate the evidence. 7. Communicate the outcomes of the EBP change.

5. Cultivate a spirit of inquiry. 2. Ask the clinical question in PICOT format. 4. Search for the most relevant and best evidence. 1. Critically appraise the evidence you gather. 6. Integrate the evidence. 3. Evaluate the outcomes of the practice decision or change 7. Communicate the outcomes of the EBP change.

The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution? 1. List all the possible actions that could be taken to resolve the problem. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 3. Develop and implement a plan to address the problem. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 6. Recognize that the problem requires ethics.

6. Recognize that the problem requires ethics. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 1. List all the possible actions that could be taken to resolve the problem. 3. Develop and implement a plan to address the problem.

A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (select all that apply) A. Cover the area with saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply gentle pressure to the exposed tissues D. Position the client supine with the hips and knees bent E. Offer the client a warm beverage (herbal tea)

A. Cover the area with saline-soaked sterile dressings D. Position the client supine with the hips and knees bent

Mr. Smith tells Margaret that he doesn't think he can hold the spoon on his ownand feed himself. Mr. Smith lacks self-efficacy. Self-efficacy comes from which ofthe following sources? (Select all that apply.) A. Enactive mastery experiences B. Vicarious experiences C. Auditory persuasion D. Physiological state

A. Enactive mastery experiences B. Vicarious experiences D. Physiological state -Self-efficacy, which is the person's perceived ability to successfully completea task, comes from four sources: enactive mastery experiences, vicarious experiences,verbal persuasion, and physiological and affective states.

Lee tells his instructor about this issue. His instructor advises him that the ethics committee would be a good place to share this issue. What is the purpose of the ethics committee within a health care organization? (Select all that apply.) A. Ethical case consultation B. Recommendation of policies and procedures related to ethics C. Provision of multidisciplinary input D. Reprimanding of caregivers in ethical issues

A. Ethical case consultation B. Recommendation of policies and procedures related to ethics C. Provision of multidisciplinary input -an ethics committee is an advisory committee that reviews, on request, ethical or moralquestions that may come up during a patient's care. Committee members include doctors, nurses, socialworkers, an attorney, a chaplain, a medical ethics professional, and a member of the community

Michael goes into Mr. Miller's room and finds him on the floor. His granddaughter tells Michael that she had just left the room for a minute, and he fell. What record will Michael need to fill out about what happened? A. Incident or occurrence report B. Living will C. Deposition D. Consent form

A. Incident or occurrence report -An incident report is a record of any unusual occurrence that documents the details of what happened while the incident is fresh in the mind of the person. It is not part of the medical record.

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (select all that apply) A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences frequently C. Apply cornstarch limberly to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. reposition the client at least every 3 hr while in bed

A. Keep the head of the bed elevated 30 degrees D. Have the client sit on a gel cushion when in a chair

Jill wants to find out more about this question, so she goes to the library and uses which of the following as a database to find articles on the subject related to health care? A. MEDLINE B. Dewey Decimal System C. Google D. National Publishers Clearinghouse

A. MEDLINE -MEDLINE is an online database of 11 million citations and abstracts from health andmedical journals and other news sources.

t the end of the shift, the registered nurse assigned to Mr. Brown asks Cody if he would givethe hand-off report to the nurse coming on who is assigned to Mr. Brown. Which of the following statements are true regarding hand-off reports? (Select all that apply.) A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient C. Must be given face to face between the nurses D. Must include an opportunity for the receiver to ask questions of the person giving the repo

A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient D. Must include an opportunity for the receiver to ask questions of the person giving the repo

. During a teaching session, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using the process of: A. analogy B. discovery. C. role playing. D. demonstration

A. analogy

The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. are approximated. B. migrate across the incision. C. appear slightly pink. D. slightly overlap each other.

A. are approximated.

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect ?(select all that apply) A. increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

A. increase in incisional pain B. Fever and chills C. Reddened wound edges

. Information regarding a patient's health status may not be released to non-health care team members because: A. legal and ethical obligations require health care providers to keep information strictly confidential. B. regulations require health care institutions to document evidence of physical and emotional well-being. C. reimbursement issues related to patient care and procedures may be of concern. D. fragmentation of nursing and medical care procedures may be identified.

A. legal and ethical obligations require health care providers to keep information strictly confidential.

Boris charts Mr. Scalini's pain assessment in Mr. Scalini's chart. Which of thefollowing is a correct example of charting as it appears in the chart? A. "Patient appears to be free from pain." B. "Patient states a 0 on a pain-rating scale of 1 to 10." C. "Patient seems to be resting comfortably." D. "Patient seems to have pain at the incision site

B. "Patient states a 0 on a pain-rating scale of 1 to 10."

Tracy uses the six steps of evidence-based practice to help formulate her mock research study. Rank in order the six steps of evidence-based practice. A. Evaluate the practice decision or change. B. Ask a clinical question. C. Critically appraise the evidence you gather. D. Collect the most relevant and best evidence. E. Share the outcomes of evidence-based changes with others. F. Integrate all evidence with one's clinical expertise and patient preferences and values in making a practice decision or change

B. Ask a clinical question. D. Collect the most relevant and best evidence. C. Critically appraise the evidence you gather. F. Integrate all evidence with one's clinical expertise and patient preferences and values in making a practice decision or change A. Evaluate the practice decision or change. E. Share the outcomes of evidence-based changes with others.

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 DM. Their Hgb is 12g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage in the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) A. Extremes in age B. Chronic illness C. Low Hgb D. Malnutrition E. Poor wound care

B. Chronic illness C. Low Hgb D. Malnutrition

Bringing the different points of view of the ethics committee members to agreement and harmony is referred to as collective ethics. A. True B. False

B. False -Building consensus brings different points of view to agreement and is an actof discovery in which "collective wisdom" guides a group to the best possible decision

Which of the following is the first step of the research process? A. Analyze data B. Identify problem C. Conduct study D. Use the findings

B. Identify problem

Joan is assessing Mr. Gordon's skin and notices that he has a 3-cm blister and a shallow crateron his buttock. Mr. Gordon winces when Joan palpates the area. How should Joan stage thisarea? A. Stage I pressure ulcer B. Stage II pressure ulcer C. Stage III pressure ulcer D. Stage IV pressure ulcer

B. Stage II pressure ulcer

Lee refers to the Code of Ethics for Nursing for more guidance. Which of the following statements are true about the American Nurses Association (ANA) Code of Ethics? (Select all that apply.) A. All health care disciplines have the same code of ethics. B. The ANA Code of Ethics promotes principles of responsibility, accountability, and advocacy. C. The ANA Code of Ethics requires all nurses to have the same values. D. The ANA Code of Ethics states that the nurse is the center of the health care team

B. The ANA Code of Ethics promotes principles of responsibility, accountability, and advocacy. -A Code of Ethics is written guidelines issued by an organization, such as the ANA, to itsmembers to help them conduct their actions in accordance with its primary values and ethical considerations.

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record: A. an interpretation of patient behavior. B. objective data that are observed. C. lengthy entry using lay terminology. D. abbreviations familiar to the nurse.

B. objective data that are observed.

Tracy relies on PICOT to help her develop a clinical question for the researchproject. She knows that the "C" in PICOT refers to which of the following? A. Caring B. Clinical component C. Comparison of interest D. Compiled data E. Complicated patient

C. Comparison of interest -The "C" in PICOT refers to the "comparison of interest" that identifies the usual standard of care or current intervention used now in practice

A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurse should understand that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. Autonomy C. Justice D. nonmaleficence

C. Justice

Cody wants to plan his morning. To which documentation form would Cody refer to find outactivity orders, or what treatments Mr. Brown will be receiving today? A. Standardized care plan B. Flow sheet C. Kardex D. Admission history form

C. Kardex -The Kardex is a summary of the current list of orders, treatments, and diagnostic testing. This form allows the nurse to have all of these together instead of having to go to various places in themedical record

Because of Mr. Smith's progressing dementia, he has difficulty feeding himself. When Margaret prompts him to eat his oatmeal at breakfast, he just stares at his spoon. Margaret picks up his spoon and wraps his hand around the handle. For which psychomotor learning skill is Margaret trying to retrain Mr. Smith? A. Set B. Mechanism C. Perception D. Guided response

C. Perception -Perception is the simplest behavior, which requires being aware of objects or qualities through the use of sense organs. Margaret tries to retrain Mr. Smith's perceptions by having him hold his spoon

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an _ethical dilemma? A. a nurse on a medical surgical unit demonstrates signs of chemical impairment B. a nurse overhears another nurse telling an older adult client that if he doesn't stay in bed she will have to apply restraints C. a family has conflicting feelings about the initiation of enteral tube feedings for their father who was terminally ill D. a client who was terminally ill hesitates to name their partner on their durable power of attorney form

C. a family has conflicting feelings about the initiation of enteral tube feedings for their father who was terminally ill

A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: A. PIE documentation. B. SOAP documentation. C. narrative charting. D. charting by exception

C. narrative charting.

Arise when a person is harmed and the person inflicting the harm knew, or should have known, that these actions were less than the accepted scope and standard of practice

Unintentional torts

Standard of proof

What a reasonably prudent nurse would do under similar circumstances in the geographical area in which the alleged breach occurred

a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Adipose tissue (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). ___1.Stage 1 ___ 2.Stage 2 ___ 3.Stage 3 ___ 4.Stage 4 ___ 5.Unstageable pressure injury

___ 2.Stage 2

Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer, and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury. ___ 1.Stage 1 ___ 2.Stage 2 ___ 3.Stage 3 ___ 4.Stage 4 ___ 5.Unstageable pressure injury

___ 3.Stage 3

Full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact, without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. ___ 1.Stage 1 ___ 2.Stage 2 ___ 3.Stage 3 ___ 4.Stage 4 ___ 5.Unstageable pressure injury

___ 5.Unstageable pressure injury

Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep-tissue pressure injury. ____1. .Stage 1 ___ 2.Stage 2 ___ 3.Stage 3 ___ 4.Stage 4 ___ 5.Unstageable pressure injury

____1. .Stage 1

Nurse practice acts

State laws intended to protect citizens, make nurses accountable and assure that care is consistent with best practice within the scope and standards of nursing

Processing an ethical problem

Step 1. Ask: Is this an ethical problem? Step 2. Gather information that is relevant to the case. Step 3. Identify the ethical elements in the problem and examine your values. Step 4. Name the problem Step 5. Identify possible course of action Step 6. Create and implement an action plan and carry it out. Step 7. Evaluate the action plan.

pathogenesis of pressure injuries

1)pressure intensity 2)pressure duration 3)tissue tolerance

Emergency Medical Treatment and Active Labor Act

Prohibits the transfer of patients from private to public hospitals without appropriate screening and stabilization

Acts in which a person may not intend to cause harm to another but does

Quasi-intentional torts

Gold standard for research

Randomized controlled trials (RCT)

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. Autonomy C. Justice D. Beneficence

D. Beneficence

A patient you are assisting has fallen in theshower. You must complete an incidentreport. The purpose of an incident report is to: A. exchange information among health care members. B. provide information about patients from one unit to another unit. C. ensure proper care for the patient. D. aid in the hospital's quality improvement program.

D. aid in the hospital's quality improvement program.

Every health care organization gathers data on health outcomes. Examples of key quality-of-care or performance indicators include: A. discharges. B. medications administered. C. healthy births. D. infection rates.

D. infection rates.

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A. it has no odor. B. a culture is negative. C. the edges reveal the presence of fluid. D. it shows purulent drainage coming from the incision site.

D. it shows purulent drainage coming from the incision site.

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: A. an absorbent surface to collect wound drainage. B. decreased incidence of skin maceration. C. potection from the external environment. D. moisture needed for wound healing

D. moisture needed for wound healing

A nurse questions a medication prescription as too extreme in light of the client's advanced age in unstable status. the nurse understands that this action is an example of which of the following _ethical principles? A. fidelity B. Autonomy C. Justice D. nonmaleficence

D. nonmaleficence

A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes: A. affective learning. B. cognitive learning. C. motivational learning. D. psychomotor learning.

D. psychomotor learning.

Secondary intention healing

Extensive tissue loss Edges cannot be approximated Repair time is longer Scarring is greater Susceptibility to infection is greater

Which of the following is not a subscale on the Braden Scale for predicting pressure injury risk? 1. Age 2. Activity 3. Moisture 4. Sensory perception

1. Age -. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales.

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment.

1. Frequent position changes 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment. -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. The use of an incontinence cleaner provides gentle removal of stool and urine, and the use of the moisture barrier ointment provides a protective layer for the skin during the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure injuries

Good Samaritan laws

Limit liability and offer legal immunity if a nurse helps at the scene of an accident

represents a branch of ethics within the field of health care. The study of bioethics has grown over the last 50 years, beginning with the emergence of technologies related to organ transplant.

bioethics

1. __________ Autonomy 2. __________ Beneficence 3. __________ Nonmaleficence 4. __________ Justice 5. __________ Fidelity a. The agreement to keep promises and the unwillingness to abandon patients b. The best interests of the patient remain more important than self-interest c. Fairness d. Commitment to include patients in decisions about care e. Avoidance of harm or hurt

1. d 2. b 3. e 4. c 5. a

A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. _1.Assessment __2.Communication __3.Cultural __4.Establishment __5.Sensitivity __6.Safety A. Help patients feel culturally secure and able to maintain their cultural identity. B. Remain aware of verbal and nonverbal responses. C. Be aware of how patients from diverse backgrounds perceive their care needs. D. Become aware of your patient's culture and your own cultural biases. E. Learn about the patient's health beliefs and practices. F. Show respect by creating a caring rapport.

1E, 2B, 3D, 4F, 5C, 6A

The nurse works at an agency where military time is used for documentation and needs to document that a patient was medicated for pain after midnight. Identify the correct military time to document medication administered at 12:05 a.m. 1. 2405 2. 0005 3. 2205 4. 1205

2. 0005

A nurse received a bedside report at the change of shift with the night-shift nurse and the patient. The nursing student assigned to the patient asks to review the patient's medical record. The nurse lists patients' medical diagnoses on the message boards in the patients' rooms. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of HIPAA? 1. Discussing patient conditions at the bedside at the change of shift 2. Allowing the nursing student to review the assigned patient's chart before providing care during the clinical experience 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

3. Posting medical information about the patient on a message board in the patient's room -Posting the medical condition of a patient on a message board in the patient's room is not necessary for the patient's treatment. Doing so can result in this information being accessed by persons who are not involved in the patient's treatment

Bandages and Binders Functions

create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings

wound repair: partial thickness

inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers

refer to judgment about behavior, based on specific beliefs, and ethics refers to the study of the ideals of right and wrong behavior.

morals

Affective learning

deals with expression of feelings and acceptance of attitudes, opinions, or values

Uniform Anatomical Gift Act

provides the foundation for the national organ donation system

Tracy knows that the __________ __________ is the foundation of research; thus she includes this in her mock research paper objectively test her hypothesis

scientific method

Cognitive learning

the acquisition of mental information, whether by observing events, by watching others, or through language

Civil wrongful acts or omissions of care made against a person or property

torts

a personal belief about the worth of a given idea, attitude, custom, or object.

value

Primary intention wound healing

wounds that heal under conditions of minimal tissue loss -surgery

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-21: Notified the surgeon by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted the surgeon and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-21 (1015): Surgeon contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

4. 09-3-21 (1015): Surgeon contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN -. This statement includes the date and time the health care provider was contacted, the specific name of the health care provider, descriptive details of the changes of concern noted in the patient assessment, whether any orders were received, and the name and credentials of the nurse who contacted the health care provider

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2021 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage. 7. Rates pain 7/10 at location of surgical incision.

O: 1,2,3,5,6,7 S:4

The nurse works with pediatric patients who have diabetes. Which is the youngest age group to which the nurse can effectively teach psychomotor skills such as insulin administration? 1. Toddler 2. Preschool 3. School age 4. Adolescent

3. School age -Complicated skills, such as learning to use a syringe, require considerable practice but are developmentally appropriate for school-age children.

A nurse is reading a research article discussing a new practice to decrease the incidence of catheter-associated urinary tract infections. One section of the article describes who was studied and how the data were collected to answer the research questions and hypotheses. What section of the research article is currently being read? 1. The literature review 2. The data analysis 3. The methods 4. The implications for practice

3. The methods -The methods section of a study describes the study design, subjects being studied, and how the researcher collects and organizes the data to answer the research question and hypotheses. The methods section also tells you where the study was conducted, how many subjects participated in the study, and what instruments were used to collect the data.

Nurses in a community clinic are conducting an EBP project focused on improving the outcomes of children with asthma. The PICO question asked by the nurses is "In school-age children, does the use of an electronic gaming education module versus educational book affect the usage of inhalers?" In the question, what is the "O"? 1. School-age children 2. Educational book 3. Use of inhalers 4. Electronic gaming education

3. Use of inhalers -The "I" would be an electronic gaming education, the "C" would be an educational book, and the "O" would be use of inhalers

The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is: 1. Exploring reasonable courses of action 2. Identifying people who can solve the difficulty 3. Clarifying values related to the cause of the dilemma 4. Collecting all available information about the situation

4. Collecting all available information about the situation -Incorporate as much information as possible from a variety of sources such as laboratory and test results; the clinical state of the patient; current literature about the condition; and the patient's religious, cultural, and family situation.

The primary purpose of a patient's medical record is to: 1. Provide validation for hospital charges 2. Satisfy requirements of accreditation agencies 3. Provide the nurse with a defense against malpractice 4. Communicate accurate, timely information about the patient

4. Communicate accurate, timely information about the patient

Place the steps when performing wound irrigation of a large open wound in the correct sequence. 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4. Cover the area with sterile, saline-soaked towels immediately. 3. Place several cold packs over the area, protecting the skin around the wound. 2. Allow the area to be exposed to air until all drainage has stopped. 5. Cover the area with sterile gauze and apply an abdominal binder. 1. Notify the health care provider.

A confused patient who fell out of bed because side rails were not used is an example of which type of liability? 1. Felony 2. Battery 3. Assault 4. Negligence

4. Negligence

Psychomotor learning

Acquisition of ability to perform motor skills.

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. fidelity B. Autonomy C. Justice D. nonmaleficence

B. Autonomy

The nurse on the unit where Jill is getting her clinical experience tells Jill that the unit is questioning whether a patient who has abdominal surgery will have less nausea if she chews gum. In this PICOT question, what represents the "I"? A. The surgical patient B. Chewing gum C. Having less nausea D. Postoperative abdominal surgery patients

B. Chewing gum -the I of a PICOT question is the intervention or area of interest

During the meeting the committee discusses ethical theories such as deontology. Which of the following terms are associated and mean that the value of something is determined by its usefulness? (Select all that apply.) A. Accountability B. Consequentialism C. Advocacy D. Teleology E. Utilitarianism

B. Consequentialism D. Teleology E. Utilitarianism

Mr. Smith becomes agitated as Margaret tries to retrain him in his use of eating utensils. Margaret knows that, as his anxiety increases, his ability to pay attention also increases. A. True B. False

B. False

ichael is filing out the admission paperwork. He asks Jennifer if Mr. Miller has anadvance directive. Jennifer asks Michael what that is. Which of the following is correctfor Michael to answer? A. It is a document that allows the hospital to apply restraints if needed. B. It documents the wishes of a person in the event that he or she is incapacitated or appoints someone to make those decisions on his or her behalf. C. It is a document that a family member signs for the patient if he or she is unable to sign. D. It is a form that a family member signs that states that the patient is not to be resuscitated

B. It documents the wishes of a person in the event that he or she is incapacitated or appoints someone to make those decisions on his or her behalf. -Advance directives guide the health care provider in predetermined instructions regarding health care and end-of-life decisions and appoint a person to make decisions on the patient's behalf.

Mrs. Stone's right foot decubitus is a stage III ulcer. List in order the stages ofpressure ulcers. A. Full-thickness skin loss B. Nonblanchable redness or intact skin C. Full-thickness tissue loss D. Partial-thickness skin loss or blister

B. Nonblanchable redness or intact skin D. Partial-thickness skin loss or blister A. Full-thickness skin loss C. Full-thickness tissue loss

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

Boris completes Mr. Scalini's admission paperwork. Which of the followingestablishes reimbursement to the hospital for Mr. Scalini's care? A. Patient care plan B. Joint Commission standards C. Nanda diagnoses D. Diagnosis-related groups

D. Diagnosis-related groups -diagnosis-related groups enable hospitals to be reimbursed a predetermined dollar amount by Medicare

Wound Repair: Full Thickness

Extend into dermis. Involves granulation

Patient Self-Determination Act

Requires health care institutions to provide written information to patients concerning their rights to make decisions about their care, including the right to refuse treatment and to formulate an advance directive

Mental Health Parity and Addiction Equity Act

Requires health insurance companies to provide coverage for mental health and substance use disorder (SUD) treatment

Match the components of PICO using the question "Does the use of guided imagery compared with standard care affect the postoperative pain in hospitalized adolescents? (P)___ Patient/population (i)____ intervention, (C)___ Comparison, (O)__ Outcome A. Adolescents receiving standard care B. Postoperative pain C. Hospitalized adolescents D. Guided imagery

P = Hospitalized adolescents I = Guided imagery C = Adolescents receiving standard care O = Postoperative pain

Ask a clinical question in PICOT format

P- patient population of interest I- intervention of interest C- comparison of interest O- outcome T- time

Health Insurance Portability and Accountability Act (HIPAA)

Provides rights to patients and protects employees

Code of ethics

Set of guiding principles that all members of a profession accept

The nurse identifies which of the following as outcomes measurements? (Select all that apply.) 1. A nurse teaches a patient how to administer an injection and then watches the patient do a return demonstration. 2. A nurse implements a new pain-management protocol and checks patients' charts to confirm whether interventions are being provided. 3. A nursing unit adopts a set of strategies for reducing pressure injuries, and the UPC members use direct observation of the skin to measure incidence of pressure injuries. 4. A nursing unit implements a new fall prevention protocol and checks the monthly performance data for incidence of falls on the unit. 5. A nursing unit implements a patient rounding program, and the charge nurse watches the assistive personnel to see whether hourly rounding is being done on patients.

1. A nurse teaches a patient how to administer an injection and then watches the patient do a return demonstration. 3. A nursing unit adopts a set of strategies for reducing pressure injuries, and the UPC members use direct observation of the skin to measure incidence of pressure injuries. 4. A nursing unit implements a new fall prevention protocol and checks the monthly performance data for incidence of falls on the unit. -Outcomes measurements are the observable or measurable effects of health care interventions. A nurse observing a patient's return demonstration, directly observing patients' skin to measure incidence of pressure injuries, and checking the monthly performance data for incidence of falls are all outcome measures. The other options are examples of process measurements

Which statements properly apply an ethical principle to justify access to health care? (Select all that apply.) 1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 3. Access to health care is a privilege in the United States, not a right. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. -Access to health care services can be justified through the application of the principles of justice, beneficence, respect for autonomy, and nonmaleficence. While option 3 is an opinion that can be justified with ethical analysis, no justification is offered in this statement, so this option is not correct. Option 5 is incorrect because justice refers to fairness in the distribution of resources, and basing access to medication only on income may not be fair.

The nurse who works at the local health care agency is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's EHR must be printed and faxed to the acute rehabilitation center. Which of the following actions are appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding. -Nurses have the legal and ethical obligation to safeguard any patient information that is printed or extracted from the electronic (or paper) health record. Best practice is to use all measures to fax information securely, and to shred any printed health record material after it has been used for the purpose intended.

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1. Debridement -Debridement is the removal of nonliving tissue; it is a mechanical cleansing of the wound to move toward healing