Fundamentals exam 4
Which factors affect wound healing in the older adult?
Peripheral vascular disease, atherosclerosis, and reduced liver function
A nurse is observing a patient in a skilled nursing facility using a walker. The nurse concludes that the walker is at proper height if the patient's elbows are bent to which angle while the patient is upright and grasping the handgrips.
15 to 30 degrees
A patient who just underwent a left arm cast change to a synthetic fiberglass cast ask when the cast should be dry. The best response is that it should be hardened enough to be durable within:
30mins
A physicians orders the nurse to place a patient in Fowler's position. The nurse should elevate head of the patient's bed
60 to 90
A patient in the skilled nursing facility has left sided paralysis from a stroke several years before as well as generalized weakness. The should should ensure that which of the following devices is in place to prevent flexion contracture.
A rolled washcloth in the palm of her left hand or a hand splint.
The nurse explains that an air fluidized mattress would not be advocated for the patient with:
A spinal cord injury
Goals of anesthesia administration include:
Achieve muscle relaxation, prevent pain, and calm fear
What nurse diagnosis is applicable for the goal expected outcome pain will resolve when infection is cleared ?
Acute pain related to an infected wound
Which factor will promote wound healing ?
Added protein
The nurse is concerned about HIV immunocompromised patient'a ability to heal because of lack of
Adequate fibroblast function, synthesis of collagen, adequate phagocytosis
The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?
An urinary output of 20Ml/hour
The nurse recognizes that of the drugs a patient is currently taking several contribute to delayed healing such as
Antineoplastic drugs, heparin, steroids
The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure is 100/60 mm hg, the pulse is 90 beats per min, and the respiration rate is 20 breaths per min. On the basis of these findings which actions should the nurse take?
Ask how the client feels and inquire about any feelings of dizziness, review the client record to determine time and type of analgesia last received, and review the client record to note the vital signs taken in the post anesthesia care unit.
The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns?
Ask the client to discuss information known about the planned surgery
An anxious patient in skeletal traction is distressed by the clear fluid draining that is oozing from the pin sites. The nurse's best intervention would be to.
Assure the patient that such drainage is expected.
The nurse reminds the 85 yr old patient that his healing will be slower because of age related changes such as:
Atherosclerosis, diminished lung function, slow metabolism
Which type of debridement is used the body's enzymes to break down non viable tissue in the uninfected wound?
Autolytic
A nurse giving instructions to a patient who will be using stairs while ambulating with crutches will instruct the patient
Bring the good leg up first when going up stairs.
Diagnostic test data usually required before surgery include ?
Chest radiograph
A critically ill patient with an unstable spine should have what type of specialty bed?
Continuous lateral-rotation bed
The nurse places Dakin's solution in a wound to accomplish chemical
Debridement
full thickness wound
Dermal layer is no longer present except at the wound margins. To heal all dead tissue must be removed
The nurse clarified that a vacuum assisted closure supports healing of a wound by:
Drawing the wound edges together by negative pressure
A patient who had abdominal surgery is complaining of gas pains and has distention of the abdomen and flatus. To promote patient comfort, the nurse should advise
Early ambulation
A patient has just had a leg cast applied with plaster of Paris. The nurse can best reduce the incidence of edema by
Elevating the leg on one to two pillows
A nurse is caring for a patient with a cast on the left lower extremity the nurse should?
Fold the stockinette over the outside edge of cast to protect from chafing
A patient is due for a wound dressing change for a horizontal lower abdominal incision. I. Which direction should the nurse pull to remove the tape from the old dressing
From each of the four sides toward the wound
The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery?
Have client void before surgery, and determine that the client has signed the informed consent for the surgical procedure
The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the
Heel
In order for the anesthesiologist to accurately calculate the amount of anesthesia needed for an 82-year-old patient, the nurse should have data available on the chart, such as:
Height and weight
A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has an
Hematoma
The nurse is aware that in both the very young and the elderly surgical patient, the risk is much higher for
Hydration issues
Which type of commercial splint is used on an injured knee to prevent movement while an injury heals ?
Immobilizer
Intravenous lactated ringers solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct ?
LR is isotonic to plasma and contains electrolytes
A nurse is instructing one of the facility's unlicensed assistive personnel regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states , I will
Lift using my back muscles
Which phase of healing begins about 3 weeks after injury
Maturation
An emaciated semiconscious bed bound patient does not remain in a side lying position and repeatedly turns onto her back, where she is developing a pressure are over her sacrum. The nurse should add to the nursing care plan to
Place the patient on her stomach (prone position) using a small pillow below her diaphragm.
The circulating nurse is responsible for
Pointing out the observation of contamination immediately to the personnel involved
In the post anesthesia care unit the nurse should ?
Position the patient to prevent aspiration and promote lung expansion .
The nurse designs cafe for the immobilized patient to help combat the major dangers of immobilization which include
Pressure injuries, loss of bone mass, pneumonia, permanent loss of function
A nurse caring for a comatose patient should?
Read card and letters to the patient
A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by _ blood pressure
Restlessness, rising pulse, and falling
There are two main factors in the development of pressure ulcers. One is pressure and the other is
Shearing force
The nurse plans for an immobilized patient who suffered a cerebrovascular accident to be protected from skin disruption by the use of:
Sheepskin pads, water mattresses, pulsating air pads
The nurse caring for a client with a postoperative abdominal observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication
Skin irritation surrounding the wound
A nurse is ambulating an unsteady patient from the bed to a chair in the patient's home. To do so safely the nurse applies a gait belt and:
Slides his hand from the bottom under the gait belt at the middle of the patient's back.
The microorganism most frequently present in wound infection is?
Staphylococcus aureus
The nurse is caring for a postoperative client who has been NPO and the primary health care provider has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's beside?
Suction equipment
A 79 yr old immobile patient who has right sided weakness cause by a recent stroke weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse takes
Summon at least one other person to assist, obtain a lift sheet, place the patient flat on her back
A client has just returned to a nursing unit after an above knee amputation of the right leg. The nurse should plan to place the client in which position
Supine with the residual limb supported with pillows.
The nurse explains to the unlicensed assistive personnel that a shearing force is applied to the patient when
The patient is pulled up in bed without being lifted
The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection?
The presence of purulent drainage, and tender firmness palpable around the incision.
The nurse is explaining the joint commission's universal protocol for preventing wrong site, wrong procedure , and wrong person surgery to a group of nursing students. The nurse explains that site marking involves which action?
The surgeon marking the area of the operative procedure
An abdominal wound left open for drainage and then later closed is an example of healing by ?
Third intention
The nurse is explaining the concept of a time out in the perioperative area. Which statement best describes the purpose of a time out?
To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure , and the site
To provide correct body alignment for a physically immobile patient in bed in the supine position, the nurse :
Uses footboard or places high top sneakers on the patient's feet to maintain dorsiflexion
A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed. The nurse
Uses logrolling to accomplish position changes from side to side
When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:
Vessels have dilated and allowed plasma to leak into the wound site.
What is usually the first mechanical aid used when training an individual to walk after a stroke
Walker
To help prevent errors in the surgical procedure, the national patient safety goal instituted a directive that prior to pre-surgical medication, each patient must
When still conscious participate in marking the surgical site
A client had an aortic balance replacement 2 days ago. This morning, the client tells the nurse, I don't feel any better than I did before surgery. Which response by the nurse is most appropriate?
You are concerned that you don't feel any better after surgery?
A nurse caring for a postoperative patient reports separation of the layers of the surgical abdominal wound this finding is called ?
dehiscence
A nurse finds an increased amount of serosanguineous drainage into the patient's abdominal wound dressing and the patient reports "something has given way." What has likely occurred?
dehiscence
A nursing diagnosis related to the psychosocial needs of the immobile patient is:
disturbed body image related to cast.
Platelet aggregation formation of fibrin and phagocytosis occur during which phase
inflammatory
Phases of wound healing
inflammatory, proliferative, maturation
Which pain medication is most likely to cause confusion in the elderly if used continuously
Meperidine (Demerol)
A patient is ready for discharge following same day surgery. The teaching plan for this patient includes.
Not driving or making important decisions for 24 hours.
To promote respiratory function in a post operative patient a nurse should ?
Notify the physician if the patient reports shortness of breath and pain on inspiration
A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit following a surgical procedure. The urine total is 54ml for the last 2 hours. The most appropriate nursing action is to.
Notify the surgeon of the findings
A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by
Numbness of distal limb
A patient has hip spica cast and will be discharged home to family. The nurse would include in the home teaching plan information relative to
Protecting the cast from soiling , grasping the cast over the leg to help in turning, turning frequently to the prone position.
A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:
Pull outward
To place a patient in the sims' or lateral lying position, the nurse would initially:
Raise the bed to a waist high working level
Measures to improve oxygenation and help prevent pneumonia are
Range of motion exercises, frequent turning, deep breathing exercises
What type of bandage turn should a nurse use for a stomp that is a result of an amputation
Recurrent turn
The daughter of an elderly woman with a diagnosis of a fractured tibia asks why her mother is in buck's traction. The nurse's most informative response would be that buck's traction:
Reduces muscle spasm that accompanies fractures.
An epidural block used in obstetric patient is a type of ?
Regional anesthesia
The nurse discovers that the signed operative permit has misspelled the patient's name. The nurse must:
Request a corrected consent form to be signed
What is a serious concern when a patient's movement is restricted?
Respiratory complication
The nurse is caring for a postoperative client who has Jackson Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain?
Check the drain for patency , check that the drain is decompressed, observe for bright red, bloody drainage , maintain aseptic technique when emptying, empty the drain when it is half full and every 8-12 hrs
A nurse applying a pressure bandage for a patient should terminate the wrap by a
Circular
When cleaning the pins on a patient in skeletal traction, the nurse should
Clean closet to the skin puncture site in a circular motion, secure ends of wire with cork or adhesive tape
The nurse explains that range of motion exercises are necessary so that movement improves venous circulation by:
Compression of muscles on venous walls
A nurse enters the room of a patient who is in buck's traction (skin traction). An error in the traction setup observed would be:
Feet resting against the foot of the bed
A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?
Assess patency of the airway
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:
In a circular motion around the wound circling to the outside.
The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
Increased serosanguineous drainage from the wound
The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?
Increasing restlessness and Unrelieved pain despite recovering analgesics.
The nurse clarified that the first stage of wound healing is
Inflammation
The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before surgery?
Is allergic to penicillin , quit smoking 3 months earlier, wonders if the surgery could cause incontinence, history of deep venous thrombosis in right leg 10 years earlier
After abdominal surgery, a client experiences an evisceration. Which client statement supports this diagnosis ?
It felt like something just slit me wide open
The nurse irrigating an infected wound of the hand would: prioritize the steps
Open strike irrigation basin and solution, pour irrigation solution in basin, place pad under the infected hand, don sterile gloves to apply dressing, irrigate keeping the syringe tip 1 inch from the wound surface, pat wound dry and redress, document procedure
The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should
Outline the area of drainage with a pen and mark it with the date and time.
A patient is having surgery to remove a metastatic tumor causing severe pain in the abdomen. The purpose of the surgery is to relieve pain. What is this type of surgery called ?
Palliative
Complications from incorrect alignment and positioning include which of the following
Pressure ulcers , contractures, fluid in the lungs
When the post stroke patient complains to the nurse, I don't see why you are wasting your time doing passive range of motion exercises on my legs, the nurse's most informative response would be based on the knowledge that the exercises
Prevent contracture of the hips
The most appropriate outcome for the nursing diagnosis risk for infection to surgical wound is which of the following
Promote wound healing
