Fundamentals Review

A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain? A) Phantom B) Psychogenic C) Referred D) Radiating

A

What is typically the most reliable indicator of pain? A) Patient's self-report B) Behavioral cues C) Description by caregiver(s) D) Past medical history

A

A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use? A) Advise taking acetaminophen with meals to prevent gastric irritation. B) Explain that physical dependence may occur with long-term oral use. C) Explain that acetaminophen increases the risk for bleeding. D) Caution the patient against combining acetaminophen with alcohol.

D) Caution the patient against combining acetaminophen with alcohol. Even in recommended doses, acetaminophen can cause hepatoxicity in those who consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs), not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence. (page 740)

10. Which side effects associated with opioid use may improve after taking a few doses of the drug? A) Difficulty with urination B) Constipation C) Dry mouth D) Drowsiness

D) Drowsiness

Why is an accurate description of the location of a wound important? Choose all that apply. A) Affects patient movement and mobility B) Determines the appropriate treatment choice C) Will affect the frequency of dressing changes D) Influences the rate of healing

D, A

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Choose all that apply. A) Granulation B) Inflammation C) Hemostasis D) Epithelialization

During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site. Correct Answer(s): C, B

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? A) Sheet hydrogel B) Frequent turn schedule C) Transparent film dressing D) Enzymatic débridement

The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic débridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure. Correct Answer(s): B

A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What should the nurse instruct the patient to do? A) Take the medication with 8 ounces of water. B) Take the medication with food. C) Take the medication before bedtime. D) Notify the prescriber immediately.

B

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: A) Tertiary intention healing. B) Secondary intention healing. C) Approximation healing. D) Primary intention healing.

B

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: A) Relies on caregiver to provide pain relief without asking. B) Cannot communicate the character of his pain effectively. C) Recalls pain at a later time than when it occurs. D) Experiences less pain than in earlier stages of cancer.

B

What is the primary difference between acute and chronic wounds? Chronic wounds: A) Are usually infected, whereas acute wounds are contaminated. B) Exceed the typical healing time, but acute wounds heal readily. C) Are full-thickness wounds, but acute wounds are superficial. D) Result from pressure, but acute wounds result from surgery.

B

A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? A) Hemothorax B) Pneumonia C) Pneumothorax D) Metabolic alkalosis

B Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting.

Pressure ulcers are directly caused by which of the following conditions at the site? A) Inadequate venous return B) Compromised blood flow C) Edema D) Shearing forces

B) Compromised blood flow Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: A) Cleanse wounds from most contaminated to least contaminated. B) Irrigate wounds from least contaminated to most contaminated. C) Treat wounds on the patient's side first, then the front and back of the patient. D) Remove all of the soiled dressings before beginning wound treatment.

B) Irrigate wounds from least contaminated to most contaminated. To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: A) A minimal amount of drainage is noted. B) The wound bed contains 100% granulated tissue. C) The ulcer is completely healed with minimal scarring. D) The patient reports no pain at the site.

B) The wound bed contains 100% granulated tissue. A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction(s) by the nurse might help relieve the patient's constipation? Choose all that apply. A) "Avoid using stool softeners because they may become habit forming." B) "Increase the amount of fruit, vegetables, and fiber in your diet." C) "Drink at least eight 8-ounce glasses of water each day." D) "Increase your exercise routine to include 1 hour of exercise a day."

B, C

A patient develops a respiratory rate 6 breaths/minute after receiving IV hydromorphone (Dilaudid) 2.0 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? A) Flumazenil (Romazicon) B) Protamine sulfate C) Naloxone (Narcan) D) Physostigmine (Antilirium)

C

The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? A) Sequential muscle relaxation B) Guided imagery C) Distraction D) Hypnosis

C

When should the nurse assess pain? A) Every 4 hours for the first 2 days after surgery B) During the admission interview C) Whenever a full set of vital signs is taken D) Only when the patient complains of pain

C

What are two risk assessment tools used in the United States to evaluate a patient's risk for skin problems? Choose all that apply. A) Norton scale B) Waterlow scale C) Braden scale D) FLACC scale

C & A

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? A) Neuropathic B) Intractable C) Acute D) Chronic

C) Acute

Which of the following are examples of nonselective mechanical débridement methods? Choose all that apply. A) Pulsed lavage B) Whirlpool C) Wet-to-dry dressings D) Sharp débridement

C, B, A

1 oz is equivalent to: A) 15 ml B) 4 ml C) 30 ml D) 5 ml

Correct Answer(s): C

A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale(s) would be appropriate to use with this patient? Choose all that apply. A) Visual analogue B) Simple descriptor C) Numerical rating D) Wong-Baker face rating

Correct Answer(s): C, D

Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: A) Predispose to hematoma formation. B) Delay wound healing. C) Can cause cellular toxicity. D) Increase the risk of ischemia.

D

The physician orders Zestril 15 mg po daily for hypertension. The medication is supplied in 5-mg tablets. How many tablets will the nurse administer? ______________ A) 4 tablets B) 1 tablet C) 2 tablets D) 3 tablets

D

What intervention would be most appropriate for a wound with a beefy red wound bed? A) Mechanical débridement B) Autolytic débridement C) Removal of devitalized tissue and a sterile dressing D) Dressing to keep the wound moist and clean

D

When applying heat or cold therapy to a wound, what should the nurse do? A) When using cold, ensure the temperature is less than 32°F (0°C) before applying it. B) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. C) Leave the therapy on each area no longer than 30 minutes. D) Leave the therapy on each area no longer than 15 minutes.

D

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? A) The patient will need to take antibiotics until the wound is completely healed. B) The patient should expect to remain hospitalized until complete wound healing occurs. C) Because the patient's wound was left open, the wound will likely become infected. D) The patient will have more scar tissue formation than for a wound closed at surgery.

D

Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? A) Administer a dose of pain medication. B) Prepare to administer naloxone (Narcan). C) Notify the physician immediately. D) Stimulate the patient.

D

While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? A) Serous B) Purosanguineous C) Sanguineous D) Serosanguineous

D

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? A) Temperature 100.6°F B) Oxygen saturation 95% C) Heart rate 80 beats/min D) Blood pressure 160/92 mm Hg

D) Blood pressure 160/92 mm Hg This patient has an elevation in blood pressure, which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits.