NUR 326 Exam 2

Normal creatinine level.

0.5-1.3 mg/dL

List some clinical manifestations associated with venous insufficiency.

1. Edema 2. Hemosiderin staining (Brown stains on their legs due to blood pooling in the legs and the capillaries break as a result, when the RBCs break the iron is released, which causes brown/reddish discoloring of the skin.) 3. Thick, hardened skin, leathery 4. Easily breakable skin 5. Capillary refill <3

List some clinical manifestations of PAD.

1. Paresthesia (Numbness or tingling in the toes or feet) 2. Thin, shiny taut skin. 3. Loss of hair on legs. 3. Diminished or absent pedal, popliteal or femoral pulses. 4. *Intermittent claudication* 5. Reactive hyperemia of foot with dependent position 6. Chronic: Rest pain 7. Cold, pale extremities 8. Longer capillary refill

What are the main two causes for diabetic foot ulcers?

1. Peripheral neuropathy (60%) 2. Ischemia from peripheral vascular disease

What four characteristics should be included in the documentation of a newly discovered pressure ulcer?

1. Size 2. Depth 3. Appearance 4. Location

List collaborative care methods for venous insufficiency. How do you treat it? (6)

1. TED hose 2. Moist environment dressings 3. High protein diet 4. Elevation 5. Anticoagulants 6. Hyperbaric support

What are two treatments that can be implemented on patients with diabetic foot ulcers?

1. Wound debridement 2. Offloading

Normal hemoglobin level for men. For women?

13.5-18 g/dL. 12-16 g/dL.

An older adult patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply.)? a. Fluid balance history b. Attitude about surgery c. Foods the patient dislikes d. Current mobility problems e. Current cognitive function f. Patient's opinion about the surgeon

A D E (Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity that puts them at greater risk for over- and underhydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation because they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon are important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.)

Normal RBC count.

4.2-6.2 million/mm3

Normal BUN level.

6-20 mg/dL

Normal chloride levels?

95-105 mEq/L

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient's care? a. Implement a 1-hr turning schedule with skin assessment. b. Place DuoDerm on the patient's sacrum to prevent breakdown. c. Elevate the head of bed to 90 degrees when the patient is supine. d. Continue with weekly skin assessments with no special precautions.

A

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: A. Alteration in tissue perfusion related to compromised circulation B. Dysfunctional use of extremities related to muscle spasms C. Impaired mobility related to stress associated with pain D. Impairment in muscle use associated with pain on exertion

A

Your patient has a reddened area on the right lateral foot from pressure. The skin surface is intact. The area of redness does not pale when compressed. How do you document this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

A

Your patient has a reddened area over the left sacral area that does not blanch with lightly applied pressure. Epidermal skin is intact. How do you document this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

A

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: A. Normal because of the increased blood flow through the leg B. Slightly deteriorating and should be monitored for another hour C. Moderately impaired, and the surgeon should be called. D. Adequate from the arterial approach, but venous complications are arising.

A (An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.)

A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? a. Left lateral position with head supported on a pillow b. Prone position with a pillow supporting the abdomen c. Supine position with head of bed elevated 30 degrees d. Semi-Fowler's position with the head turned to the right

A (An unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. When conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.)

Which of the following is experienced by the patient who is under general anesthesia? a. The patient is unconscious b. The patient is awake c. The patient experiences slight pain d. The patient experiences loss of sensation in the lower half of the body

A (During general anesthesia, the patient is unconscious, with complete analgesia (relief of pain). Loss of sensation in the lower half of the body is experienced by the patient who received spinal anesthesia.)

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed

A (Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.)

The circulating nurse is caring for a patient during a colon resection. What observation made by the nurse is immediately recognized as a violation of aseptic technique? a. A glove contacts the leg of the table that supports the sterile field. b. The cuff of the scrub nurse's sterile gown contacts the sterile field. c. The sterile field was established at 0650, and the current time is 0900. d. Bacteria are present in the nares and upper respiratory passages of the nurse.

A (Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.)

A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, "I am not sure if this surgery is safe." Which response by the nurse is the most appropriate? a. "Tell me what you know about your surgery and the risks involved." b. "Any surgery has risks, but we will be here to take good care of you." c. "You seem anxious. After you sign the consent, I can give you a sedative." d. "You do not need to be concerned. Your surgeon has not had any complaints."

A (The health care provider performing the surgery is responsible for obtaining the patient's consent. The nurse may witness the patient's signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient's need for more information. The other options provide false reassurance or do not respond to the patient's concern.)

A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism

A (The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.)

The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? a. "I will have someone stay with me for 24 hours in case I feel dizzy." b. "I should wait for the pain to be severe before taking the medication." c. "Because I did not have general anesthesia, I will be able to drive home." d. "It is expected after this surgery to have a temperature up to 102.4º F."

A (The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. A responsible adult caregiver must accompany the patient. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.)

The nurse is preparing the preoperative client for surgery. The following statements that indicate the client is knowledgeable about his impending surgery, except: a. "After surgery, I will need to wear the pneumatic compression device while sitting in the chair" b. "The skin prep area is going to be longer and wider than the anticipated incision" c. "I cannot have anything to drink or eat after midnight on the night before the surgery" d. "To ensure my safety, a 'time out' will be conducted in the operating room"

A (The pneumatic compression device is worn during bed rest, not during ambulation. The informed consent document should be signed before preoperative medication administration and before the client enters the operating room.)

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety. b. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. c. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. d. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

A (The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.)

Your patient has a pressure injury that is approximately 11 cm in length and 3 cm in width. Subcutaneous fat is visible in the wound bed. No tendon, bone or muscle is visualized. Slough is present at the left proximal wound edge. The slough does not obscure the depth of tissue loss. How would you document this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

C

Your patient has an area of tissue loss that extends into subcutaneous tissue. The wound is 5 cm in length, 3 cm in width and 0.6 cm in depth. The wound bed contains granulation tissue. How do you document this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

C

Hardening and plaque buildup of arteries and veins, *the leading cause of PAD.*

Atherosclerosis

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. Imbalanced nutrition: obesity related to high-fat foods b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

B

Mr. H. is a 73 year old male who is chairbound. A pressure injury is observed on the right ischial tuberosity. The wound is shallow with a red wound bed. No slough is observed. Tissue loss extends into the dermis. How do you document this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

B

To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection? a. Turn, cough, and deep breathe every 30 minutes around the clock b. Get the client out of bed and ambulate to a bedside chair c. Provide passive range of motion three times a day d. It is not necessary to worry about complications of immobility on the first postoperative day

B

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb above heart level B. Lowering the limb so it is dependent C. Massaging the limb after application of cold compresses D. Placing the limb in a plane horizontal to the body

B

Your patient has a left sacral pressure injury that extends into the dermis. The wound bed is pink red and periwound skin is reddened. How do you document this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

B

A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the client's current diet order to be: a. Bland diet b. Soft diet c. Full liquid diet d. Regular diet

C (A full liquid diet includes and foods that are liquid at room temperature)

A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse? a. Give the hearing aid to the wife as he wishes. b. Tape the hearing aid to his ear to prevent loss. c. Encourage the patient to wear it for the surgery. d. Tell the surgery nurse that he has his hearing aid out.

C (Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.)

The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse? a. Assessing the patient's level of consciousness b. Checking the patient's vital signs c. Checking the patient's identification and correct operative permit d. . Positioning and performing skin preparation to the patient

C (Checking the patient's identification and correct operative permit should be given highest priority when admitting a patient to the operating room. This ensures that the right patient undergoes the right surgical procedures.)

The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list? a. Some medications may alter the patient's perceptions about surgery. b. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. c. Some medications may interact with anesthetics, altering the potency and effect of the drugs. d. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

C (Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that it has been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.)

Which of the following is most the dangerous complication during induction of spinal anesthesia? a. Cardiac arrest b. Hypotension c. Hyperthermia d. Respiratory paralysis

B (Hypotension is the most dangerous complicating of induction of spinal anesthesia. This is due to paralysis of vasomotor nerves.)

The nurse is circulating for a surgical procedure. What clinical manifestation would indicate to the nurse that the patient may be experiencing malignant hyperthermia? a. Hypocapnia b. Muscle rigidity c. Decreased body temperature d. Confusion upon arousal from anesthesia

B (Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.)

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take? a. Have the patient sign the consent form. b. Have the family sign the form for the patient. c. Call the surgeon to obtain consent for surgery. d. Teach the patient about the surgery and get verbal permission.

C (The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.)

The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the preoperative teachings? a. Before administration of preoperative medications b. The afternoon or evening prior to surgery c. Several days prior to surgery d. Upon admission of the client in the recovery room

B (The best time to provide preoperative teaching is the afternoon or evening prior to surgery. This time, the patient had finished undergoing different laboratory and diagnostic procedures. Therefore, he/she can now concentrate on the teachings. Teachings given days before surgery may tend to be forgotten. Teachings given before administration of preoperative medications may not be understood anymore because the anxiety level more likely is high during this time.)

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b. Assess the patient's vital signs. c. Check the rate of the IV infusion. d. Check the physician's postoperative orders.

B (The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.)

A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient's blood pressure is 70/48 mm Hg. What treatment does the nurse anticipate administering? a. Blood administration b. IV fluid administration c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

B (The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.)

Lorazepam (Ativan) 1 mg IV is ordered for a patient before surgery. What is the most appropriate action for the nurse to take before the administration of this medication? a. Ask the patient about an allergy to iodine or shellfish. b. Encourage or assist the patient to the bathroom to void. c. Explain that the medication is used to prevent postoperative nausea. d. Check the laboratory results for the most recent serum potassium level.

B (The nurse should instruct the patient to void before administering preoperative medications that may interfere with balance and increase the fall risk when ambulating to the bathroom. Lorazepam is a benzodiazepine that may be used for sedation and amnesia before surgery. Lorazepam does not affect serum potassium, is not contraindicated in patients with allergies to iodine or shellfish, and is not indicated to prevent or treat nausea.)

The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? a. Supine b. Lateral c. Semi-Fowler's d. High-Fowler's

B (Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.)

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply.)? a. Documenting intraoperative care b. Keeping track of irrigation solutions for monitoring of blood loss c. Passing instruments and supplies to the surgeon by anticipating his or her needs d. Coordinating the flow and activities of members of the surgical team in the surgical suite e. Performing the count of sponges, needles, and instruments used during the surgical procedure

B C E (Both the scrub nurse and circulating nurse participate in the counting of surgical sponges, needles, and instruments. Passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.)

The nurse in an ambulatory surgery center has administered the following preoperative medications to a patient scheduled for general surgery: diazepam, cefazolin, and famotidine. What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient? a. Seated in a wheelchair accompanied by a responsible family member b. Ambulatory and accompanied by a hospital escort and a family member c. Stretcher with side rails up and accompanied by OR transportation personnel d. Ambulatory accompanied by an OR staff member or transportation personnel

C (The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.)

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? C a. Stage I b. Stage II c. Stage III d. Stage IV

C

An example of this type of wound healing process would include a pressure ulcer. A longer period of time is needed to heal because the wound heals from the bottom up. The edges are not well approximated and granulation tissue is needed to fill in the gap.

Secondary intention

Where are PAD ulcers commonly found? What do they look like? Is there drainage?

Tips of toes, foot, or *lateral* malleolus. They are rounded, smooth, the hole usually looks "punched out". The edges are more demarcated. There is minimal drainage. There is black eschar or pale pink granulation. The ulcer may or may not be painful.

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Unstageable pressure ulcer

Soft, moist avascular tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green.

Slough

Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. It doesn't turn white when pressed.

Stage I pressure ulcer

Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. No fat, granulation, slough, or eschar will be present.

Stage II pressure ulcer

Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling.

Stage III pressure ulcer

Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Stage IV pressure ulcer

This type of wound healing process takes the longest. The wound healing is delayed and occurs when the wound that was previously opened is now closed. We open it for a bit, then we close it. It's usually associated with large infected and contaminated wounds. Very wide scar.

Tertiary intention

A client is scheduled for surgery in the morning. Preoperative orders have been written. What is the most important to do before surgery? a. Remove all jewelries or tape wedding ring b. Verify that all laboratory work is complete c. Inform family or next of kin d. Have all consent forms signed

D

All of the following factors ensure validity of informed written consent, except: a. The patient is of legal age with proper mental disposition b. If the patient is a child, secure consent from the parents or legal guardian c. The consent is secured before administration of preoperative medications d. If the patient is unable to write, the nurse signs the consent for the patient

D

The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out? a. Assess the patient's vital signs and oxygen saturation level. b. Check the chart for a signed consent form for the procedure. c. Determine if the patient has any questions about the procedure. d. Verify the procedure and the location of the surgery.

D (During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient's own ID band and chart.)

The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesiologist? a. The patient's grandmother developed hypothermia during a craniotomy. b. The patient's mother developed contact dermatitis related to a latex allergy. c. The patient's brother developed nausea after surgery with general anesthesia. d. The patient's father developed an elevated temperature during a recent surgery.

D (Malignant hyperthermia (MH) is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It may occur if an affected individual is exposed to certain general anesthetic agents. To prevent MH, it is important for the nurse to obtain a careful family history. The patient known or suspected to be at risk for MH can be anesthetized with minimal risks if appropriate precautions are taken.)

Which patient would be at highest risk for hypothermia after surgery? a. A 42-yr-old patient who had a laparoscopic appendectomy b. A 38-yr-old patient who had a lumpectomy for breast cancer c. A 20-yr-old patient with an open reduction of a fractured radius d. A 75-yr-old patient with repair of a femoral neck fracture after a fall

D (Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for hypothermia.)

In which surgical area will the patient's surgical skin scrub prep be performed for surgery, and what clothing is appropriate for the nurse performing the scrub to wear? a. Surgical suite wearing a lab coat b. Preoperative holding area wearing street clothes c. Postanesthesia care unit (PACU) wearing scrubs d. Operating room wearing surgical attire and masks

D (Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. The staff usually wears a lab coat over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.)

All of the following are members of the sterile team in the operating room, expect: a. Surgeon b. Scrub nurse c. Radiology technician d. Circulating nurse

D (The anesthesiologist and circulating nurse are not members of the sterile surgical team. The surgeon, radiology technician, and scrub nurse directly come in contact with the sterile field.)

The patient donated a kidney, and early ambulation is included in the plan of care, but the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

D (The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.)

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: A. Has a pale colored base B. Is deep, with even edges C. Has little granulation tissue D. Has brown pigmentation around it

D (Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 are due to tissue malnutrition; and thus us an arterial problem))

An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient's preoperative teaching (select all that apply.)? a. Information about various options for reconstructive surgery b. Information about the risks and benefits of her particular surgery c. Information about risk factors for breast cancer and the role of screening d. Information about where in the hospital she will be taken postoperatively e. Information about performing postoperative deep-breathing and coughing exercises

D E (During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her surgeon. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.)

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue

Deep tissue injury

Your patient has a pressure injury over the coccyx. The wound bed is covered in eschar and slough and cannot be visualized. How do you document this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

E

Agents that soften skin or treat dry skin

Emollient

Your patient has a localized area of discolored skin on the lateral right heel. A crescent shape portion of this skin is deep maroon in color. The skin surface is intact. How do you document this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

F

True or false: Arterial, venous, and diabetic ulcers are forms of pressure ulcers.

False!

Brown stains on their legs due to blood pooling in the legs and the capillaries break as a result, when the RBCs break the iron is released, which causes brown/reddish discoloring of the skin

Hemosiderin staining

Pain with exercise that is relieved by rest. If there is not a lot of blood flow to extremities, especially while exercising, there is pain from hypoxia and a buildup of lactic acid. Classic with arterial.

Intermittent claudication

Where are ulcers found with venous insufficiency? What does it look like? Is there drainage?

Medial malleolus. It will look irregularly shaped and there will be a moderate to large amount of drainage. There is a yellow slough or dark red, "ruddy" granulation.

What type of wound dressing should be used with a pressure ulcer?

Moist dressing to enhance re-epithelializaiton

What is a normal platelet count?

150,000-450,000/mm3

Normal hematocrit level for men. For women?

40-54%. 38-47%.

What is a normal WBC count?

5000-10,000/mm3

A diabetic patient who had undergone abdominal surgery experiences wound evisceration. Which of the following is the most appropriate immediate nursing action? a. Cover the wound with sterile gauze moistened with sterile normal saline b. Cover the wound with sterile dry gauze c. Cover the wound with water-soaked gauze d. Leave the wound uncovered and pull the skin edges together

A (Wound evisceration should be covered with sterile dressings moistened with normal alien to prevent drying and necrosis of protruding abdominal organs.)

The nurse is caring for a first day postoperative surgical client. Prioritize the patient's desired dietary progression. Arrange in sequence the dietary progression from 1 to 4: 1. Full liquid; 2. NPO; 3. Clear liquid; 4. Soft a. 1, 2, 3, 4 b. 2, 3, 1, 4 c. 2, 1, 4, 3 d. 4, 3, 2, 1

B (The client's status is NPO immediately after surgery. Desired diet progression advances to clear liquid, full liquid, soft and finally a regular diet as tolerated by the client)

Postoperatively, if a patient is unconscious, which position should the patient be placed in? a. Prone b. Lateral c. Supine d. High-fowlers

B (The lateral "recovery" position should be used when a patient is still unconscious from surgery.)

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus; weighs 146 kg; and is 5 feet 8, inches tall. Which patient assessment is a priority related to anesthesia? a. Has hemoglobin A1C of 8.5% b. Has several seasonal allergies c. Has a body mass index of 48.8 kg/m2 d. Has a history of postoperative vomiting

C (The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.)

A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? a. Increased respiratory rate b. Decreased oxygen saturation c. Increased carbon dioxide pressure d. Frequent premature ventricular contractions (PVCs)

C (Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.)

If a patient is experiencing delirium after waking up from surgery, what is the first condition we should suspect is causing the delirium? a. "Waking up Wild" b. Alcohol withdrawal c. Hypoxia d. Pain

C (Hypoxia can cause an altered level of consciousness, and should be the first thing the nurse assesses for if the patient is experiencing delirium.)

While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse? a. "Stay NPO after midnight." b. "Maintain NPO status until after breakfast." c. "You may drink clear liquids up to 2 hours before surgery." d. "You may drink clear liquids up until she is moved to the OR."

C (Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.)

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision.

C (The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.)

Your patient has a pressure injury on the left ear from a medical device. Cartilage can be seen in the wound base. How do you document this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

D

Your patient has a pressure injury over the left buttock that has exposed muscle tissue. Tunneling is present. How do you document this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable f. Deep Tissue Pressure Injury g. Mucosal Membrane Pressure Injury

D

A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)? a. Prevention of infection b. Improved staff communication c. Identify patients at risk for suicide. d. Patient, surgical procedure, and site are checked.

D (During the surgical time-out, the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide is not usually vital before surgery and does not occur during the time-out.)

Are you more likely to need an amputation with PAD or chronic venous insufficiency?

PAD due to them not healing very well and gangrene occurring.

An example of this type of wound healing process would include a laceration or surgical incision. This process has the most rapid healing. The wound margins are well approximated and are touching.

Primary intention

List preventative measures for diabetic foot ulcers. (7)

1. Control blood sugar. 2. Take care of your feet and inspect the bottom of them daily. 3. Wear protective foot wear, don't walk around barefoot, use closed toed closed heeled shoes. 4. Don't use external heat! 5. Have corns and calluses professionally removed. 6. Avoid the cold, caffeine, nicotine, and constrictive garments. 7. Routine professional foot care.

List three surgical/radiographic interventions for treating PAD.

1. Debridement (The removal of damaged tissue or foreign objects from a wound.) 2. Angioplasty (A procedure done to widen the artery occluded. It involves the doctor threading a small tube into the artery that has a balloon attached to it, and the balloon is inflated open to widen the artery and increase blood flow.) 3. Bypass (Surgery done to reroute the blood supply around a blocked artery in your leg.)

Black, brown or tan devitalized tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin.

Necrosis/Eschar

What is offloading?

Offloading is used on people with foot ulcers to redistribute pressure on the ulcer to a different area. This can be done with total contact casting, half shoes, removable cast walkers, wheelchairs, and crutches.