NUR113 Test 2: A13 (Blood Products), A1 (Peri Op), A6 (Tissue Integrity)

Herpes, cold sores, Herpes Simplex type 1 (these are waist up), Herpes Simplex 2 (these are waist down)?

Vesicles

Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin ? which is essential for preventing the development of rickets.

Vitamin D (pg. 1802, Brunner)

How long do we clean the top of a vial and with what do we use to clean it?

• "Scrub the hub" clean the top of the vial for 15 seconds • using a 70%-alcohol wipe

Post-operative Healing phases of a simple wound

•Inflammatory phase •Fibroblastic phase •Maturation phase

What are the three types of Intravenous Solutions?

•Isotonic •Hypertonic •Hypotonic

Intraoperative Events without warning?

•Malignant hyperthermia (MH)- rare metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can result in death. •Anaphylactic reactions-life threatening pulmonary and circulatory complications.

Intraoperative What infection control is used?

•Surgical attire •Surgical scrub •Site preparation •Aseptic technique •Positioning the patient •Safety precautions

Post-op Pain management?

*NSAIDS for mild to moderated pain (PO, IM, IV) -Ibuprofen, ketorolac *Opioids for moderated to severe pain (IM, IVP, PCA) -Demerol, Morphine, Dilaudid *Antiemetic for N/V -Ondansetron, Promethazine

The nurse is having difficulty seeing a client's rash. Which action(s) should the nurse perform to facilitate the assessment? Select all that apply. 1. Point a penlight laterally across the affected part. 2. Stretch the skin gently. 3. Pull the skin downward. 4. Apply an emollient.

1, 2

The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply. 1.Red, raised papules 2.Large plaques covered by silvery scales 3.Tiny red vesicles that weep serous material 4.Erythema noted mostly under the breast area 5.Pink to dark red, patchy eruptions on the skin

1, 2

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

1, 2, 3, 4

When caring for a child during an extensive hospital stay, the nurse reduces the child's and family's stress by: Select all that apply. 1. Show a video about another child experiencing the same type of hospitalization. 2. Giving the child a doll that the child can practice giving injections on. 3. Using guided imagery. 4. Encourage rooming-in. 5. Limiting visitors to reduce infection risks.

1, 2, 3, 4 (pg. 471-474, Maternal-child)

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. 1.Stop the infusion. 2.Prepare to apply ice or heat to the site. 3.Restart the IV at a distal part of the same vein. 4.Notify the primary health care provider (PHCP). 5.Prepare to administer a prescribed antidote into the site. 6.Increase the flow rate of the solution to flush the skin and subcutaneous tissue.

1, 2, 4, 5

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 positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1, 3, 5

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which 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, 4

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, 4, 5

A client who has undergone pre-admission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum Creatinine, 0.8 g/dL (70.6 mcmol/L) 4. Platelets, 210,000 cells/mm3 (210x 10^9/L)

1

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? 1. Iron deficiency anemia 2. Long-standing cardiopulmonary disease 3. Poor circulation 4. Fungal infection

1

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription? 1.Gastric lavage 2.Intravenous (IV) fluid therapy 3.Nothing by mouth (NPO) status 4.Preparation for laboratory studies

1

The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? 1.Applying warm compresses to the affected area 2.Placing iced compresses to the affected area every 4 hours 3.Alternating the application of hot and iced compresses every 2 hours 4.Placing antibiotic ointment on the affected site followed by continuous heat lamp application

1

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20mL/hr 2. Temperature of 37.6*C (99.6*F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

1

The nurse is caring for a client with a skin lesion that is oozing. The surrounding skin is acutely inflamed. What type of dressing should the nurse apply? 1. Interactive 2. Passive 3. Protective 4. Occlusive

1

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test? 1. Biopsy 2. Patch test 3. Tzanck smear 4. Skin scraping

1

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification? 1. Corticosteroids 2. Antivirals 3. Saline irrigations 4. Antifungals

1

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increase restlessness 2. A pulse of 86 beats per minute 3. Blood pressure of 110/70mm Hg 4. Hypoactive bowel sounds in a ll 4 quadrants

1

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? 1.Clustered skin vesicles 2.A generalized body rash 3.Small blue-white spots with a red base 4.A fiery-red edematous rash on the cheeks

1

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

1

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of IV fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

1

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of 1. anemia. 2. albinism. 3. local arterial insufficiency. 4. vitiligo.

1

The nurse receives a telephone call from the post-anesthesia care unit stating that the client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess the bleeding. 4. Assess the vital signs to compare with preoperative measurements.

1

The nurse teaches the client who demonstrates herpes zoster (shingles) that 1. the infection results from reactivation of the chickenpox virus. 2. once the client has had shingles, they will not have it a second time. 3. no known medications affect the course of shingles. 4. a person who has had chickenpox can contract it again upon exposure to a person with shingles.

1

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

1

When conducting a skin assessment, the nurse notes a purple macular lesion on the client's right upper extremity. The nurse differentiates the lesion as a petechia or ecchymosis based on 1. size. 2. erythema. 3. exudate. 4. location.

1

Which condition is an autoimmune disease involving immunoglobulin G? 1. Pemphigus 2. Toxic epidural necrolysis (TEN) 3. Bullous pemphigoid 4. Stevens-Johnson syndrome (SJS)

1

Which infecting agent causes scabies? 1. Itch mite 2. Bacteria 3. Reactivated virus 4. Parasitic fungi

1

Which term describes the transfer of heat from the body to a cooler object in contact with it? 1. Conduction 2. Evaporation 3. Lichenification 4. Radiation

1

Which type of cell is believed to play a significant role in cutaneous immune system reactions? 1. Langerhans cells 2. Melanocytes 3. Merkel cells 4. Phagocytes

1

Describe Hypotonic solutions

•0.45% Normal Saline (1/2 NS)

Describe Isotonic solution

•0.9% Normal Saline •Lactated Ringers •Dextrose 5% (D5W)

What are some tips for Peripheral IV insertion?

•ALWAYS prime lines!!! •Do not shave site •Remove tourniquet as soon as possible •Apply tourniquet 4 to 6 inches above selected site •May stroke or apply warm washcloth to site to dilate vein •Try to use 20 G or above for adult...needed for blood and surgical procedures •NEVER let IV tubing touch the floor

Preoperative Care Review of systems?

•Cardiovascular •Respiratory •Nervous •Urinary •GI •Hepatic •Integumentary •Musculoskeletal •Endocrine •Immune •Fluid & Electrolytes •Nutrition

How often is dressing changed on an IV site?

•Damp, loosened or soiled •Gauze: q48hrs

A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? 1.Serum sodium of 120 mEq/L (120 mmol/L) 2.Serum potassium of 3.0 mEq/L (3.0 mmol/L) 3.White blood cell count of 3000 mm3 (3 × 109/L) 4.pH of 7.30, PaCO2 of 32 mm Hg (32 mmHg), HCO3- of 19 mEq/L (19 mmol/L)

3

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1."Come to the emergency department." 2."Apply calamine lotion immediately to the exposed skin areas." 3."Take a shower immediately, lathering and rinsing several times." 4."It is not necessary to do anything if you cannot see anything on your skin."

3

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

3

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."

3

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

3

The nurse is instructing the parents of a child with head lice. Which statement should the nurse include? 1. Use shampoo with Kwell. 2. Wash clothes in cold water. 3. Use shampoo with piperonyl butoxide. 4. Disinfect brushes and combs with bleach.

3

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? 1. Liver spots 2. Bright red moles 3. Yellowish waxy deposits on the eyelids 4. Dark discoloration of the skin

3

The nurse is teaching health promotion to a class on osteoporosis prevention. The nurse determines that the participants understand the teaching when they identify that clients need how much sun exposure to synthesize sufficient vitamin D? 1. 30 to 60 minutes weekly 2. 90 to 120 minutes twice a week 3. 5 to 30 minutes twice a week 4. 60 to 90 minutes weekly

3

The nurse notes red, papular, round lesions on the client's back that blanch with light pressure. Which is the appropriate action by the nurse? 1. Apply barrier cream. 2. Notify the physician. 3. Document the finding. 4. Turn and reposition the client.

3

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as 1. ecchymosis. 2. spider angioma. 3. petechiae. 4. telangiectasia.

3

The nurse teaches the client who demonstrates herpes zoster (shingles) that 1. a person who has had chickenpox can contract it again upon exposure to a person with shingles. 2. once a client has had shingles, they will not have it a second time. 3. the infection results from reactivation of the chickenpox virus. 4. no known medications affect the course of shingles.

3

Which secondary skin lesions are associated with eczema? 1. Scales 2. Ulcers 3. Crusts 4. Erosion

3

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria? 1. Poison ivy 2. Pediculosis capitis 3. Impetigo 4. Scabies

3

The nurse recognizes which condition is associated with emboli to the skin? 1. Ecchymosis 2. Spider angioma 3. Petechiae 4. Telangiectasia

3 Petechiae are small, round red or purple macules and are associated with bleeding tendencies or emboli to the skin.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1.The nurse who never had roseola 2.The nurse who never had mumps 3.The nurse who never had chickenpox 4.The nurse who never had German measles 5.The nurse who never received the varicella-zoster vaccine

3, 5

When properly examining the head of a 26-month-old patient, the nurse should: Select all that apply. 1. Palpate the anterior fontanelle 2. Pull the pinna up and back to view the internal structures of the ears with the otoscope. 3. Note palpable 1-cm lymph nodes in the neck to be normal. 4. Perform a visual screening. 5. Use the Hirschberg corneal reflex test to screen for strabismus.

3, 5 (pg. 464-465, Maternal-child)

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1.A pink, edematous hand 2.Fiery red skin with edema in the nailbeds 3.Black fingertips surrounded by an erythematous rash 4.A white color to the skin, which is insensitive to touch

4

A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? 1.Dry sterile dressing 2.Wet to dry dressing 3.Gelfoam sponge dressing 4.Semipermeable film dressing

4

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? 1."It is an acute superficial infection." 2."It is an inflammation of the epidermis." 3."Staphylococcus is the cause of this epidermal infection." 4."This skin infection involves the deep dermis and subcutaneous fat."

4

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of the client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member following agency policy.

4

An outbreak of head lice infestation has occurred at a local school. The school nurse is providing instructions to the mothers of the children attending the school regarding the application of malathion. The nurse should tell the mothers to take which action? 1.Apply the lotion immediately after washing the hair. 2.Pour the lotion onto the hair and then rinse immediately. 3.Allow the lotion to remain on the hair for 10 minutes and then rinse with water. 4.Leave the lotion on for 8 to 12 hours, and then wash the hair with nonmedicated shampoo

4

Development of malignant melanoma is associated with which risk factor? 1. Skin that tans easily 2. African American heritage 3. Residence in the Northeast 4. History of severe sunburn

4

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? 1.Brown-red macules with scales 2.Pustules on the trunk of the body 3.White patches noted on the elbows and knees 4.Multiple straight or wavy thread-like lines underneath the skin

4

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? 1. Sclera 2. Fingernails 3. Nose 4. Oral mucosa

4

Which drug is a topical corticosteroid used to treat psoriasis? 1. Coal tar 2. Methotrexate 3. Neutrogena 4. Triamcinolone

4

Which factor aggravates the condition caused by acne vulgaris? 1. High-fat diet 2. Chocolate 3. Sunlight 4. Friction

4

Which is the primary preventable cause of skin cancer? 1. Fair skin 2. Skin disease 3. Excess melanin 4. Exposure to UV radiation

4

Which is the principal hardening ingredient of the hair and nails? 1. Merkel cells 2. Melanin 3. Sebaceous gland 4. Keratin

4

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4

Which primary lesions are associated with acne caused by sebum blockage in hair follicles? 1. Carbuncles 2. Striae 3. Furuncles 4. Comedones

4

Which sedative medication is effective for treating pruritus? 1. Fexofenadine 2. Benzoyl peroxide 3. Tetracycline 4. Hydroxyzine

4

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? 1. Homograft 2. Allograft 3. Heterograft 4. Autograft

4

A hospitalized 2-year-old is refusing to take a medication. What can the nurse do to get the child to take the necessary medication? 1. Hide the medication in a juice or food the child likes so the child will take the medication. 2. Leave the medication in the room with the parent and allow the child to self-administer the medication. 3. Allow the child to choose how they take the medication. 4. Have the parent administer the medication to the child.

4 (pg. 475, Maternal-child)

The nurse is instructing unlicensed personnel on gerontologic considerations of the skin. The nurse finds that the participants understand the instructions when they know that the elderly are at a higher risk for shear injuries due to 1. loss of subcutaneous tissue. 2. sun damage over time. 3. decreased capillary loops. 4. loss of rete ridges.

4 Elderly clients are at a higher risk for shear injuries due to loss of rete ridges from thinning at the junction of the dermis and epidermis.

When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. The nurse documents the presence of 1. a comedone. 2. cheilitis. 3. a carbuncle. 4. a furuncle.

4 Furuncles are localized skin infections of a single hair follicle

The nurse is providing teaching to a client with acne who is using isotretinoin therapy. Which statement should the nurse make? 1. The side effects are irreversible. 2. Take vitamin A supplements. 3. Contraceptives are not needed during treatment. 4. It is teratogenic in humans.

4 Isotretinoin is teratogenic in humans, meaning that it can have an adverse effect on a fetus, causing central nervous system and cardiovascular defects, and structural abnormalities of the face.

What is the correct sequence of steps when performing wound irrigation to a large open wound? 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, 3, 2, 5, 1

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. 1.Presence of striae 2.Palpable radial pulses 3.Absence of any ecchymosis on the extremities 4.Thinner and decrease in number of reddish papules 5.Scarce amount of silvery-white scaly patches on the arms

4, 5

Match the pressure injury stages with the correct definition. 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, 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). b. 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. c. 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. d. Full-thickness loss of skin, in which adipose (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/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

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

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1.An inflammation of the epidermis only 2.A skin infection of the dermis and underlying hypodermis 3.An acute superficial infection of the dermis and lymphatics 4.An epidermal and lymphatic infection caused by Staphylococcus

2

A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? 1.Change the hydrocolloid dressing daily. 2.Change the hydrocolloid dressing every 3 to 5 days. 3.Apply the hydrocolloid dressing over a dry, sterile dressing. 4.Apply the hydrocolloid dressing over a normal saline-soaked dressing.

2

The classic lesions of impetigo manifest as 1. abscessed skin and subcutaneous tissue. 2. honey-yellow crusted lesions on an erythematous base. 3. comedones in the facial area. 4. patches of grouped vesicles on red and swollen skin.

2

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition? 1. Allergic reactions 2. Kaposi sarcoma 3. Platelet disorders 4. Syphilis

2

The nurse assesses the client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

2

The nurse caring for a client with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include? 1. Wear gloves during the day. 2. Avoid cosmetics with fragrance. 3. Use a fabric softener. 4. Wash skin in very hot water.

2

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? 1.Pillow 2.Foam pad 3.Folded blankets 4.Plastic-lined absorbent pad

2

The nurse is assessing a client's skin when the client points out a mole. The nurse brings the mole to the physician's attention when which characteristic is noted? 1. Symmetrical appearance 2. Diameter exceeding 6 mm 3. Uniform light brown color 4. Distinct borders

2

The nurse is assessing an African American client and notes a streak of pigmentation in the client's fingernails. The nurse determines that this finding indicates 1. melanoma. 2. normal variation. 3. smoker's fingernails. 4. chronic anemia.

2

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as 1. cysts. 2. vesicles. 3. wheals. 4. pustules.

2

The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make? 1. It metastasizes through blood or the lymphatic system. 2. It begins as a small, waxy nodule with rolled translucent, pearly borders. 3. It is a malignant proliferation arising from the epidermis. 4. It is more invasive than squamous cell carcinoma (SCC).

2

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted? 1. Circumscribed border 2. Elevated and palpable 3. Greater than 1 cm in diameter 4. Flat with skin color change

2

The nurse working at a physician's office is providing teaching to the parent of a child diagnosed with Tinea capitis (ringworm of the head). How often should the nurse instruct the parent to shampoo the child's hair with ketoconazole or a selenium sulfide shampoo? 1. Daily 2. Twice weekly 3. Once 4. Weekly

2

Which material consists of a powder in water? 1. Liniment 2. Suspension 3. Paste 4. Hygroscopic agent

2 A suspension requires shaking before application, exemplified by calamine lotion.

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding? 1. Hyperpigmentation 2. Hirsutism 3. Alopecia 4. Jaundice

2 hirsutism, or excessive hair growth

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. Providing 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, 4

The clinic nurse notes that the primary health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1.Positive patch test 2.Positive culture results 3.Abnormal biopsy results 4.Wood's light examination indicative of infection

2. Positive Culture results

When caring for a child in pain, the nurse knows all of the following are true except: Select all that apply. A. Children cannot tell you where they hurt. B. Children's behaviors are indicative of their pain intensity. C. Children are not at a higher risk of respiratory depression from narcotics given for pain than adults. D. Severe pain causes constricted pupils and low blood pressure. E. A first-born child in a family may handle pain differently than a middle child in the same family.

A, B, D (pg.467-469, Maternal-child)

A nurse working in a pediatric clinic gets many phone calls from parents with concerns about skin infections. The nurse knows which of the following are the most common causes of bacterial skin infections? Select all that apply. A. Staphylococcus aureus B. Herpes simplex 1 C. Streptococcus D. Candida albicans E. Pseudomonas

A, C, E (pg. 757, Maternal-child)

A student nurse preparing a pamphlet about scabies for community awareness should include which information? Select all that apply. Living in close quarters such as at a summer camp, dorm, or sharing a bed increases risk. A. It is most common in school-age children. B. Scabies causes itching that is worse when hot or sweating. C. Scabies rash appears in a circular or oval raised area. D. All members in a family must be treated for scabies if one person is diagnosed.

A, D (pg. 768-769, Maternal-child)

A teenager is seen in the health-care provider's office seeking treatment for acne. The child is prescribed minocycline. What should the nurse include when providing teaching about this medication? Select all that apply. A. It is important to apply sunscreen every day. B. Pregnancy tests are required monthly while on this medication. C. Blood pressure should be monitored regularly. D. Birth control is recommended if sexually active. E. Moisturizer should be used daily.

A, D, E (pg. 758-759, Maternal-child)

A father calls the triage nurse line because his 4-year-old son was just stung by a wasp. The father asks for advice how to care for the sting. What should the nurse tell the father to do first? 1. Remove the stinger. 2. Administer EpiPen. 3. Administer diphenhydramine. 4. Apply ice to the sting.

A (pg. 477, Maternal-child)

A nurse assessing a child in the office notices the child has primary lesions that are red, slightly raised, patchy areas on the skin that the child is scratching. The child recently started a sulfa antibiotic for an infection a day ago. The nurse identifies the skin lesions as: A. Wheals B. Vesicles C. Macules D. Erosions

A (pg.754, Maternal-child)

A nurse is caring for a 4-month-old infant in the pediatric intensive care unit. The infant has just returned to the unit after undergoing open heart surgery. Which of the following findings would earn the infant the most points when using the FLACC scale to assess the infant's pain scale rating? A. Increased heart rate B. Restlessness C. Arched back D. Infant on minimal ventilator settings E. Whimpering

C (pg. 468, Maternal-child)

When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area

1, 3

The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply. 1.Back 2.Axilla 3.Eyelids 4.Soles of the feet 5.Palms of the hands

1, 4, 5

Performing hand hygiene, setting up sterile field, tables, equipment. Also assist the surgeon

Scrub nurse

What type or wound healing is being described: • WOUNDS THAT OCCUR FROM TRAUMA, ULCERATION, AND INFECTION HAVE LARGE AMOUNTS OF EXUDATE AND WIDE, IRREGULAR WOUND MARGINS WITH EXTENSIVE TISSUE LOSS • EDGES CANNOT BE APPROXIMATED • RESULTS IN MORE DEBRIS, CELLS, AND EXUDATE

Secondary Intention

Preoperative Care Medication prep for surgery? Single drugs or combinations may be ordered:

Sedative/hypnotics/tranquilizers (Benzodiazepines) Narcotics (opioids) Anticholingergics Histamine H-2 antagonists Antihistamines Anti-emetics Neuromuscular blocking

Why is it important for a patient to be NPO before a procedure?

To prevent aspiration.

Cyanosis is the bluish hue in the skin of individuals that results from a lack of oxygenation of the blood. T/F

True (pg. 1804, Brunner)

Vitiligo is a condition characterized by the destruction of the melanocytes in circumscribed areas of the skin. T/F

True (pg. 1804, Brunner)

The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster and herpes simplex. T/F

True (pg. 1813, Brunner)

A furuncle is an acute inflammation that arises deep in one or more hair follicles and spreads into the surrounding dermis. T/F

True (pg. 1835, Brunner)

Warts are common, benign skin tumors caused by viral infections occurring most frequently between the ages of 12 and 16 years. T/F

True (pg. 1852, Brunner)

Kaposi sarcoma is a malignancy of endothelial cells that line the blood vessels of the skin, oral cavity, GI tract, and lungs. T/F

True (pg. 1859, Brunner)

Rhytidectomy is a surgical procedure that removes soft tissue folds and minimizes cutaneous wrinkles on the face. T/F

True (pg. 1860, Brunner)

• ACUTE• HEALINGOCCURSIN2TO3WEEKS,USUALLYLEAVINGNORESIDUALDAMAGE • NEUTROPHILSAREPREDOMINANTCELLTYPEATSITEOFINFLAMMATION • SUBACUTE• HASSAMEFEATURESASACUTEINFLAMMATIONBUTPERSISTSLONGER • CHRONIC• MAYLASTFORYEARS• INJURIOUSAGENTPERSISTSORREPEATSINJURYTOSITE• PREDOMINANTCELLTYPESINVOLVEDARELYMPHOCYTESANDMACROPHAGES • MAYRESULTFROMCHANGESINIMMUNESYSTEM (E.G.,AUTOIMMUNEDISEASE)

Types of Inflammation

What are VADs and what are they used for?

Vascular Access Devices •Designed for repeated access to the vascular system •Short-term use -Peripheral Catheters (Ex.: fluid restoration, IV antibiotics) •Long-term use -Central catheters -Implanted ports -PICC lines

Use of sigmoidoscope to inspect the sigmoid colon

Sigmoidoscopy

Hives and impetigo are example of primary __________ lesions.

Vesicle

Endoscopy of gastrointestinal tract with a pill that contains a mini camera.

Video capsule endoscopy

Extensive conduction nerve block that is produced when a local anesthetic agent is introduced into the subarachnoid space at the lumbar level, between L4 and L5.

Spinal anesthesia

The most common types of nonmelanoma skin cancers are basal cell carcinoma and ______________ cell carcinoma.

Squamous (pg. 1852, Brunner)

What are these classifications used for? • CAUSE • SURGICAL OR NONSURGICAL • ACUTE OR CHRONIC • DEPTH OF TISSUE AFFECTED • SUPERFICIAL, PARTIAL THICKNESS, FULL THICKNESS • SKIN TEAR • WOUND CAUSED BY SHEAR, FRICTION, AND/OR BLUNT FORCE • RESULTS IN SEPARATION OF SKIN LAYERS • COMMON IN OLDER ADULTS AND CRITICALLY OR CHRONICALLY ILL ADULTS

Wound classification

Which diagnostic test is used to examine cells from herpes zoster? 1. Tzanck smear 2. Skin scrapings 3. Skin biopsy 4. Patch testing

1 A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus.

A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement? 1. The wound may have a foul odor. 2. Do not use a dressing 6 hours/day. 3. Keep the dressing very wet at all times. 4. Cleanse the wound with Dakin's solution.

1 During autolytic débridement therapy, a foul odor will be produced by the breakdown of cellular debris.

What type or wound healing is being described: • DELAYED PRIMARY INTENTION DUE TO DELAYED SUTURING OF THE WOUND • OCCURS WHEN A CONTAMINATED WOUND IS LEFT OPEN AND SUTURED CLOSED AFTER THE INFECTION IS CONTROLLED

TERTIARY INTENTION

According to the following clues, what are you dealing with? Assessment Findings Redness, tenderness, pain, warmth along course of vein starting at access site; possible red streak and/or palpable cord along vein Nursing Interventions Stop infusion and discontinue IV line (see Skill 42.3). Start new IV line in other extremity or proximal to previous insertion site if continued IV therapy is necessary. Apply warm, moist compress or contact IV therapy team or health care provider if area needs additional treatment. Elevate affected extremity. Document ? using a standardized scale, including nursing interventions per agency policy and procedure.

Phlebitis

Inflammation of inner layer of a vein warmth along course of the vein

Phlebitis

During the assessment of the skin, _____________ may be used to document nature and extent of skin conditions as well as to document progress resulting from treatment.

Photographs

Primary Intention healing

Post-operative Wound Healing What stage is this?

Secondary Intention healing

Post-operative Wound Healing What stage is this?

Tertiary Intention

Post-operative Wound Healing What stage is this?

Device: Drainage tubing Pressure Areas: Area immediately next to drainage tube Adjacent area during patient position changes

Prevention Strategies: Apply appropriate dressing around drainage tube insertion site. Check tubing placement with each position change. Instruct patient not to lie on the tubing (Pittman et al., 2015).

Device: Immobilization devices Pressure Areas: Wrists Ankles

Prevention Strategies: Apply dressing between immobilizer and patient's skin (Black et al., 2015). Verify that there is some space between immobilizer and patient's skin. With assistive personnel present, remove restraints one at a time to inspect skin (see Chapter 27).

Device: Oxygen cannula and tubing Pressure Areas: Ears Nose

Prevention Strategies: Apply dressing to external ear. Periodically remove cannula to relieve pressure and inspect for pressure injury (Schallom et al., 2015) (Chapter 41).

Device: Noninvasive positive-pressure ventilation (NIPPV)/bi-level positive airway pressure (BiPAP) Pressure Areas: Forehead Nose/nasal bridge

Prevention Strategies: Apply protective dressing or liquid skin barrier to bridge of nose or forehead before application of device. If appropriate, remove mask periodically for a few minutes.

Device: Indwelling urinary catheter Pressure Areas: Thighs Female: urethra, labia Male: tip of penis

Prevention Strategies: Provide meticulous perineal care (see Chapter 40). Anchor and secure catheter to reduce pressure (see Chapter 46).

Device: Neck collar Pressure Areas: Neck and occipital region Scalp

Prevention Strategies: Remove hard collars as soon as possible and replace with softer collar (Black et al., 2015). Inspect scalp daily.

Device: Nasotracheal tube Pressure Areas: Nose/nasal bridge Nares

Prevention Strategies: Remove securing device daily and inspect for pressure injury (Branson et al., 2014) (see Chapter 41). Reposition.

Device: Endotracheal tubes Pressure Areas: Lips Tongue

Prevention Strategies: Remove securing device daily and inspect for pressure injury (Branson et al., 2014) (see Chapter 41). Rotate tube every shift or more often.

Device: Tracheostomy tubes Pressure Areas: Front of neck and stoma site

Prevention Strategies: Remove securing device daily. Increase stoma care (Chapter 41).

Device: Feeding tubes and nasogastric tubes Pressure Areas: Nares Skin on nasal bridge

Prevention Strategies: Secure tube using pressure-relieving techniques, which direct the pressure from the tube away from the nares (see Chapters 45 and 47). Reposition tube.

Device: Compression stockings Pressure Areas: Calf Behind knee Heel Toes

Prevention Strategies: Verify proper fit. To reduce pressure and risk of injury to skin and underlying tissue, remove stockings twice daily for at least 1 hour (Black et al., 2015) (Chapter 39).

Device: Orthopedic devices Pressure Areas: All areas where device (e.g., cast or brace) comes in contact with patient's skin and tissues

Prevention Strategies: When possible and not contraindicated, inspect under the device.

What you connect maintenance fluids to or intermittent medications?

Primary IV line

What drug? therapeutic class: general anesthetics action: induction and maintenance of anesthesia teaching: will decrease mental recall of procedure

Propofol (Diprivan)

___________ is a common, chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate.

Psoriasis (pg. 1842, Brunner)

Who is allowed to administer an IV Push?

RN role ONLY

What does an IV Bolus do?

Can be run on pump or gravity, large amount of fluid very quickly (usually in emergency situations, ex. low BP)

CRBSI is known as what?

Catheter related blood stream infection

What kind of prep will be required for patients receiving a colonoscopy?

Cleansing of colon. Can take laxatives for 2 nights prior to exam, enema, or PEG electrolyte lavage situations.

The best tool to use for assessing the pain of a 9-year-old is: A. Wong-Baker FACES scale B. FLACC scale C. CHEOPS scale D. 0-10 pain scale

D (pg. 467-468, Maternal-child)

What type of scarring is seen here?

Dehiscence

Uses heat that's made from electric currents to dispose of tissue

Electrocautery machine

Radiographic visualization and examination of bile ducts and pancreas

Endoscopic retrograde Cholangiopancreatography (ERCP)

Anesthesia produced by injection of a local anesthetic into the epidural space of the spinal cord

Epidural block

A primary macular skin lesion, such as port wine stains, is a raised discoloration or disruption to the normal skin. T/F

False (usually not elevated above the skin) (pg. 1811, Brunner)

Pediculosis capitis, head lice, may infest anyone and is a sign of poor hygiene. T/F

False (usually the cleanlier the hygiene, the better the chance of getting) (pg. 1838, Brunner)

What drug? therapeutic class: opioid analgesics pharm. class: opioid agonists action: decrease in pain teaching: avoid grapefruit juice

Fentanyl

Functions of the skin, the largest organ of the body, is to provide protection, sensation, _______________, and temperature regulation.

Fluid balance

Where is a common place for an IV in a child?

Foot IV's, avoid foot IV's in adults due to thrombophlebitis (blood clot with inflammation and pain).

What assessment would need to be performed prior yo offering fluids to a patient who has had an esophagogastroduodenoscopy?

Gag reflex

Short line connected to IV catheter itself?

Heplock/Saline lock

What type of scarring is seen here?

Hypertrophic scarring

Because it is the leading cause of death in patients with blistering diseases, meticulous assessment for signs and symptoms of local and systemic _____________ is required.

Infections (pg. 1855, Brunner)

When IV line gets out side of vein and inside subQ tissue skin is swollen, cool to touch (adults-2hr, peds-1 hr) what is this known as happening?

Infiltration

According to the following clues, what are you dealing with? Assessment Findings Skin around catheter site taut, blanched, cool to touch, edematous; may be painful as ? or ? increases; infusion may slow or stop Nursing Interventions Stop infusion. Discontinue IV infusion if no vesicant drug (see Skill 42.3). If vesicant drug, disconnect IV tubing and aspirate drug from catheter. Agency policy and procedures may require delivery of antidote through catheter before removal. Elevate affected extremity. Avoid applying pressure over site; can force solution into contact with more tissue. Contact health care provider if solution contained KCl, a vasoconstrictor, or other potential vesicant. Apply warm, moist or cold compress according to procedure for type of solution infiltrated. Start new IV line in other extremity. Use standard scale for assessing and documenting ? (INS, 2016a).

Infiltration & Extravasation

Edema scale: Match description with correct measurement 1. Very deep pitting with 8mm of indention that lasts 2-3 minutes dependent extremity has gross edema. 2. Slight pitting with 2mm of indentation that disappears rapidly no visible extremity exchanges. 3. Depression of 6mm that lasts more than a minute dependent extremity has visible edema. 4. Deeper pitting with 4mm of indentation that disappears in about 10-15 seconds; no visible extremity changes. A. +3 B. +4 C. +2 D. +1

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

What is the order of Draw?

1. Blood cultures 2. Citrate (BLUE) 3. Serum (RED) 4. Heparin (Green) 5. EDTA (PURPLE) 6. Oxalate (GRAY)

What type of scarring is seen here?

Keloid scarring

___________, an insoluble, fibrous protein, is the principal hardening ingredient of the hair and nails.

Keratin

Who can assess wounds?

LPN's and techs A RN must sign behind them (ultimately they are responsible for all assessments.)

Injection of a solution containing the anesthetic agent into tissues of the planned incision site.

Local anesthesia

Rare inherited muscle disorder that is chemically induced by anesthetic agents

Malignant hyperthermia

An irregularly shaped lesion found on the skin during an assessment would be concern for potential ______________.

Melanoma (pg. 1855, Brunner)

What drug? therapeutic class: opioid analgesics pharm call: opioid agonists action: binds to opiate receptors in CNS decrease pain teaching: change positions slowly

Meperidine (demerol)

What drug? therapeutic class: antianxiety, anticonvulsants, sedative action: short term sedation, post operative, termination of seizure teaching: notify if suicidal thought or attempts to commit suicide

Midazolam (versed)

Form of anesthesia that involves the IV administration of sedatives or analgesics meds to reduce patient anxiety and control pain.

Moderate Sedation

Which factor causes wrinkles among older adults? 1. Decrease in estrogen production 2. Loss of subcutaneous tissue 3. Decrease in sebum 4. Decrease in melanin

2

The nurse is providing instruction to a client with acne. The nurse promotes avoidance of which food(s)? Select all that apply. 1. Bananas 2. Chocolate 3. Ice cream 4. Onions

2, 3

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply. 1. Pattern of eruption 2. Wound bed 3. Periwound skin 4. Wound size

2, 3,4

The nurse is teaching a client about the correct use of topical concentrated corticosteroids. The nurse includes which statement(s)? Select all that apply. 1. Apply to intertriginous areas. 2. Avoid applying to the face. 3. Hypertrichosis is normal. 4. Avoid prolonged use.

2, 4

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 1.White color 2.Pink or red color 3.Weeping blisters 4.Insensitivity to pain and cold

2.

The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? Refer to figure. 1.Document the findings. 2.Apply a sterile non-adherent dressing. 3.Redress the wound with a dry sterile dressing. 4.Ask the client to cough to assess for protrusion of the internal structures.

2.

The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as 1. acantholysis. 2. dermatitis. 3. lichenification. 4. pyodermas.

3 The nurse should note this as being lichenification, also called scaling

A client comes into the hospital with a Tegaderm dressing in place on the buttocks. The nurse documents this as being which type of dressing? 1. Inactive 2. Interactive 3. Passive 4. Active

3 There are three categories of wound dressings: active, passive, and interactive. The nurse labels Tegaderm as being a passive dressing, one that acts as a protective, moist environment for natural healing. Interactive dressings absorb wound exudate and include hydrocolloids. Active dressings decrease healing time to improve the healing process and include biologic skin substitutes.

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? 1. Telangiectases 2. Hirsutism 3. Vitiligo 4. Lichenification

3 Vitiligo results in the development of white patches that may be localized or widespread

The nurse recommends which type of therapeutic bath for its antipruritic action? 1. Bath oil 2. Water 3. Colloidal (oatmeal) 4. Saline

3

How often are IV caps (injection caps) changed?

q72hrs

Box 48.13 Choice of Dry or Moist Applications Advantages of Moist Applications?

• Moist application reduces drying of skin and softens wound exudate. • Moist compresses conform well to most body areas. • Moist heat penetrates deeply into tissue layers. • Warm, moist heat does not promote sweating and insensible fluid loss.

WHAT CAN YOU DO AS THE NURSE for a patient with a wound?

• NURSING IMPLEMENTATION • ACUTE INTERVENTION • DRUG THERAPY • RICE

Moderate sedation given by anesthesiologist and/or CRNA

Monitor Anesthesia Care (MAC)

Qualified and specifically trained healthcare professional who administers anesthetic agents, has graduated from an accredited nurse anesthesia program, and has passed examination by the American Association of Nurse Anesthetists.

Nurse Anesthetist

For total parenteral nutrition, a (banana bag), can hang for how long and why?

Only for 24hrs because bacteria can develop.

Production of melanin is controlled by a hormone secreted by which gland? 1. Parathyroid 2. Adrenal 3. Thyroid 4. Hypothalamus

4

The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted? 1. Red coloration 2. Blue-green hue 3. White patches 4. Purple-gray cast

4

The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as 1. scale. 2. ulcer. 3. erosion. 4. fissure.

4

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

4

The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include? 1. Limit fluids. 2. Apply a continuous current of warm air. 3. Use friction when repositioning the client. 4. Frequently inspect the oral cavity.

4

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of 1. local arterial insufficiency. 2. albinism. 3. vitiligo. 4. anemia.

4

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1.Intact skin 2.Full-thickness skin loss 3.Exposed bone, tendon, or muscle 4.Partial-thickness skin loss of the dermis

4

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

Box 48.13 Choice of Dry or Moist Applications Advantages of Dry Applications

• Dry heat has less risk of burns to skin than moist applications. • Dry application does not cause skin maceration. • Dry heat retains temperature longer because evaporation does not occur.

Box 48.13 Choice of Dry or Moist Applications Disadvantages of Dry Applications?

• Dry heat increases body fluid loss through sweating. • Dry applications do not penetrate deep into tissues. • Dry heat causes increased drying of skin.

Box 48.13 Choice of Dry or Moist Applications Disadvantages of Moist Applications?

• Prolonged exposure causes maceration of skin. • Moist heat cools rapidly because of moisture evaporation. • Moist heat creates greater risk for burns to skin because moisture conducts heat.

Important tips regarding blood collection

•ALL SPECIMENS MUST: •Be placed in specific blood tubes according to the type of •Tube colors vary from institution to institution. •Some tubes contain preservatives and must be rotated 10 times after blood draw to prevent clotting. •Be labeled at the patient's bedside. •Be transported in biohazard bags. Always use a transfer device. •Do not insert needle into collection tubes. •Do not tamper with safety devices. •Dispose of sharps in the sharps container in the room.

Post-operative Wound Healing What factors contribute to delayed healing?

•Age •Malnutrition •Poor circulation •Corticosteroids' •Foreign bodies •Infection dead space •radiation •Obesity •PVD (Peripheral vascular disease)

Preoperative Care Impacts on surgical procedures and decisions?

•Age •General health •Nutrition •Medications •Mental status

What areas do we avoid IV insertion?

•Any area that is red, tender, swollen, and possibly warm to the touch •An extremity with vascular (dialysis) graft/fistula •Same side as mastectomy •Any areas of flexion, if possible (Ex: Antecubital)

Post-op What is the nurse's focus?

•Assessment Review orders •Lab review •Fluid balance •Temperature- Hypothermia vs.hyperthermia •Pain Management •N/V control (nausea, vomiting)

Post-op Nursing Dx

•At Risk for Hemorrhage •At Risk for Ineffective tissue perfusion (DVT) •At Risk for Impaired gas exchange (PE), (pneumonia), (atelectasis) •At risk for infection RT impaired skin integrity (incision)/ invasive processes, CATH, IV, dressing changes •At Risk for alterations in elimination: urinary/bowel

How often is IV tubing changed?

•At least q96hrs (Continuous fluids) •At least q24hrs (Intermediate fluids) •Lipids/TPN: q24hrs •Blood: every unit (changed with every unit)

What outcomes are our goals for patients?

•Attains and maintains adequate lung expansion and respiratory function •Has complete wound healing without complications •Has an acceptable comfort level after surgery

What is the Role of the RN for IV therapy?

•Choose and insert appropriate IV catheters and infusion devices •Assess patients for fluid and electrolyte disturbances. •Administer IV fluids and meds to unstable/critically ill patients. •Evaluate pt. for clinical manifestations of fluid overload or hypovolemia and initiate changes in IV fluids.

Preoperative Care Nursing responsibilities in this stage?

•Consent •Assessment •Pre-operative teaching •Pre-operative preparation

How do we document an IV insertion?

•Date and time of insertion •Number and sites of attempts •Precise description on insertion site •Catheter gauge and length •Type of dressing and catheter stabilization device if used •Type of infusion and flow rate •Integrity and patency of system •Patient tolerance

Describe Hypertonic solutions

•Dextrose 5% in 0.45 Normal Saline (D5 1/2NS) •Dextrose 5% in 0.9% Normal Saline D5NS) •Dextrose 5% in lactated ringers (D5LR) •Dextrose 10% (D10W)

Intraoperative What are the types of anesthesia?

•General •Regional •Conscious sedation •Dissociative Anesthesia

Post operative Complications

•Hypoxia •Airway obstruction •Pneumonia / Atelectasis •Bronchospasm •Hypoventilation •Syncope •Hiccups •Hemorrhage •Shock •DVT (Deep vein Thrombosis) •PE (Pulmonary Embolism) •Elimination -Bowel and bladder •Wound infections •Dehiscence •Evisceration

Preoperative Care Developmental considerations of individuals having surgery (Erickson vs. Maslow)

•Infancy •Toddler •Preschooler •School age •Adults •Adolescents •Elderly

What is the role of the LPN for IV therapy?

•Insert IV catheters (according to state nurse practice act and agency policy) •Administer IV fluids and meds to STABLE patients (according to state nurse practice act and agency policy) •Adjust IV flow rate for STABLE patients (according to practice act/agency policy) •Monitor for clinical manifestations of adverse reactions to IV fluids or meds.

Questions to ask yourself when administering IVPBs

•Is the piggyback compatible with the primary IV solution? •Do we have an IV pump? •What is the ordered infusion rate? •Can it flow by gravity? •Do we have an IV cap to use after the medication has infused? •NEVER double back the IV tubing

What do we need to remember when Collecting Blood Cultures?

•Must use two different sites •Prep sites with special swabs and allow to dry before stick (Do not use alcohol swabs) •Collect up to 10mL of blood per culture tube

Preoperative Care What nurses do before procedure?

•NPO status •Post-op exercises •TCDB (turn, cough, deep breath) •Splinting

Post-Operative How are patients take care of?

•Pacu nurse receives report from anesthesiologist and circulating nurse •Critical period •Vital signs-temp, pulse, bp, airway & respirations are monitored carefully •Fluid status is assessed and maintained •I and O •Mental status and LOC •Pain managed thru use of analgesics •Orientation to time and place and events •Emotional support

Preoperative Care Surgical procedures are grouped according to?

•Purpose •Degree of urgency •Degree of risk

Post-operative Wound Healing Drainage types?

•Serous •Sanguineous •Purulent •Serosanguineous

Regional anesthesia Methods of administration?

•Topical- Emla cream •Infiltration- Lidocaine, Benzocaine, Tetracaine •Sprays- Ethyl Chloride

Intraoperative Why is an Endotracheal tube used?

•Used to maintain airway during general anesthesia , to ventilate, to administer meds, prevent aspiration •Can cause irritation, laryngeal edema hoarseness, damage of vocal cords

Post-op Teaching

•When to return to the doctor -Follow up appointment •Wound care -What to clean with/signs of infection/what to dress with •Diet -High protein and vitamin C, feso4 •Exercises/activities -Avoid straining the wound or surrounding area, can he climb stairs, drive or return to work, weight lifting limits •Signs and symptoms to look for -Fever, drainage malaise, fatigue, chest pain, •Pain management -Meds and how to take

When you have orders to Draw, what goes first?

Always draw Blood Cultures first.

Physician specifically trained in the art and science of anesthesiology.

Anesthesiologist

Air in the vein from unpurged syringe or tubing.

Air embolism

What size syringe do we want to use for PICC lines?

Always want to use 10 mL/cc syringe

When caring for a child with a nursing diagnosis of altered coping related to the hospitalization, nursing considerations should include which of the following? Select all that apply. A. Instruct the parents when they must leave to do so once the child falls asleep to lessen the child getting upset. B. Encourage parents to bring familiar objects from home. C. Give the parents choices in the child's care. D. Arrange for limited visiting times to reduce stress. E. Assign the same nurse to take care of the child each day as much as possible.

B, E (pg. 471;471, Maternal-child)

How often do we change an IV site?

At least every 72 hours (q72hrs) Emergency situations every 24 hours (q24hrs)

Oozing or slow, continuous seepage of blood from venipuncture site

Bleeding at venipuncture site

A 3-year-old is seen in the outpatient clinic for suspected impetigo. Where are impetigo lesions most commonly found in children? A. Trunk B. Hands and feet C. Nose D. Buttocks

C (pg. 759, Maternal-child)

Works in collaboration with surgeons, anesthesia providers and other health care providers to plan the best course of action.

Circulating nurse:

IV solution infused too rapidly or in too great an amount

Circulatory overload of IV solution

A keloid lesion refers to hypertrophied scar tissue that is secondary to excessive ___________ formation during wound healing.

Collagen

Procedure consisting of insertion of a flexible endoscope through anus to inspect colon and ileum

Colonoscopy

What does EID stand for?

Electronic infusion device (IV pumps)

Examination of upper GI tract with a flexible fiber

Esophagogastroduodenoscopy (EGD)

Technical term used when a vesicant (tissue-damaging) drug (e.g., chemotherapy) enters tissues

Extravasation

State of narcosis, analgesia, relaxation, and reflex loss. Patient under general anesthesia is not aware not even to painful stimuli.

General anesthesia

What reasons do we start fluids for fluid & Electrolyte imbalances?

Osmolar Imbalance • Diabetes Insepidus • DKA • Hypertonic IVF • SIADH • Excess Water Intake Isotonic Imbalance • Diarrhea • Vomiting • Burns • Hemorrhage • Fever • Diuretics • CHF • Renal Failure

Infection at catheter-skin entry point during infusion or after removal of IV catheter

Local infection

Assess pressure as you swallow.

Manometric studies

What is Goal 7 in the National Patient Safety Goals?

Reduce the risk of health care-associated infections -Comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines. -Implement evidence-based practices to prevent central line-associated bloodstream infections.

An anesthetic agent is injected around nerves so that the region supplied by these nerves anesthetized.

Regional anesthesia:

IV piggyback is also known as?

Secondary IV line

Preoperative Care What nurses do before surgery?

Pre op check list •Verify informed consent signed •Blood permit signed.. Religious implications, autologous blood in blood bank •Ensure Identification, blood and allergy bands are correct •Assist with bathing and grooming (remove under garments) •Reinforce teaching •Remove nail polish •Remove hair pins and jewelry (may tape ring) **Mark operative site •Is skin or bowel prep completed •Is IV inserted •Remove denture, artificial eye, hearing aid if needed leave in and notify or nurse •Is height and weight on chart •Post labs on chart •If cath not placed have pt to empty bladder

The most common symptom of patients with dermatologic disorders is ________ which may occur without a rash or lesion.

Pruritus (pg. 1829, Brunner)

Match the correct colors with the correct needle gauges: 1. 14 gauge 2. 16 gauge 3. 18 gauge 4. 20 gauge 5. 22 gauge 6. 24 gauge 7. 26 gauge a. orange b. violet c. gray d. yellow e. green f. blue g. pink

Needle length 1. a (1 7/8") 2. c (1 7/8") 3. e (1 7/8") & (1 1/4") 4. g (1 1/4") & (1") 5. f (1") 6. d (3/4") 7. b

On a Braden scale, what does a lower score indicate about that patient?

They are at a higher risk for pressure sores.

Where do we want to avoid putting an IV?

In dominant hand, or the hand in general.