nurs 120 quiz 3

When to take pictures of pressure ulcers

Admission, weekly, transfer or change, discharge

Age is most at risk for fat embolism

Adults age 70 to 80 and meals between 20 and 40 years old

Identify the pressure ulcer after a client had a long extensive recovery following a surgical procedure when completing an incident report about the pressure ulcer the nurse should take which of the following actions

And any relevant statements the client made about the ulcer

A nurse is assessing a client who has a pressure ulcer the nurse should recognize which of the following findings is a manifestation of a stage three pressure ulcer?

necrotic subcutaneous tissue

Client was in skeletal traction fine femur fracture and she notices he slid down towards the front of the bed and the way it is on the floor will action shut the nurse take?

Add the client use a trapeze to pull himself up while ensuring the way he hangs freely

Which activities can the nurse working in the outpatient clinic delegate to a license vocational nurse

Administer patch testing to a patient with allergic dermatitis Apply a sterile dressing after the healthcare provider exercises the mall

On the first postoperative day a patient with a below the knee amputation complains of pain in the amputated limb which action is best for the nurse to take?

Administer prescribe analgesics to relieve the pain

Pelvic fractures

Assess abdomen, if pelvic bone has fracture to the stomach it can cause distended stomach which can cause absent bowel sounds,

Displaced fracture

Bone fragments

Skin traction

Bucks traction, used for hip fractures There's a weight to pull the leg down to mobilize is it Don't let weights touch the floor or move risk for skin breakdown

plaster casts

Cheaper, heavier, slow drying 24 to 48 hours, can't get them wet

A dark skinned patient has been admitted to the hospital with chronic heart failure Howard the nurse assess the patient for cyanosis

Check the lips and oral mucous membranes

A patient is admitted to the emergency department with possible left lower leg fractures which of the following should be the initial action by the nurse?

Check the pump pedal dorsalis pedis and posterior tibial pulses

Jackson-Pratt drain

Close drain, placed during surgery by MD, measured drain and observed type of drain in document, squeeze bulb to create negative suction, if less than 30 mL you can remove the drainage

Carpal tunnel syndrome

Compression of the median nerve in wrist, Paresthesia of fingers, assembly line workers are most at risk, DX with Tinel sign: 90° palm and tap to feel numbness, phalens sign: inverted prayer

compartments syndrome SS and interventions

DO NOT want to ice or elevate, Paresthesia (numb and tingle), Paralysis, pulselessness, pain, pressure, Pallor (cool/loss of color)

Client with a fractured developed compartment syndrome which of the following signs should alert the nurse to impending Penny

Dark reddish brown urine

Halo fixation

Deep cervical spine in place and stable

Fibroblast cast

Drive very fast, can get wet

Moisture related wounds

Due to sweat and found under skin folds, breasts, armpits, groin area I need to further skin breakdown, keep skin dry and clean and protect the skin, monitor for incontinence

A nurse is assessing a client who is 24 hour postoperative following an open reduction and internal fixation to repair a fracture of the femur which of the following assessment findings as an early manifestation of fat embolism syndrome?

Dyspnea

Went first applying cast what do you do in the beginning

Elevate extremity for 24 hours to reduce swelling and edema which would reduce risks of compartment syndrome

A nurse is developing a plan of care for a client who has cellulitis of the leg which of the following intervention should the nurse include in the plan

Elevate the affected leg on two pillows

Jena rides in the emergency department with a swollen ankle after his soccer injury which action by the nurse is appropriate?

Elevate the ankle above the heart level

A nurse is caring for a client who is in the queue ankle sprain which of the following actions should the nurse take?

Encourage rest Place a compression bandage on the ankle elevate ankle

How often to inspect cast

Every 8 to 12 hours

How often to check underneath Boot for irritation during bucks traction

Every eight hours checking for irritation and swelling and skin breakdown

How long to perform neurovascular status on affected body part

Every on ehour for 24 hours and every four hours after that

Complication of fracture

Fat embolism syndrome, compartment syndrome, necrotic tissue, DVT

Venous stasis

Fragile skin cellulitis

Complete fracture

Goes through entire bone dividing into distinct parts

Nurse is caring for a client who is one day postoperative following a total hip arthroplasty it is 830 and the client is scheduled for physical therapy at zero 900 which of the following intervention should the nurse take

Identify the clients pain level and medicate if needed

Highest risk for pressure injury

Immobility

Cellulitis

Inflammation of deep connective tissue due to infection, and venous stasis Elevate extremity, can lead to weeping Edema which is fluid moving out of the cells with increase with white blood cells and is red and swollen and painful

Nurse working in an emergency room is assessing a client who had a leg wound. the nurse notes a full thickness wound with jagged edges and muscle tissue visible the nurse should document as which type of wound

Laceration

Diabetic wounds

Microvascular complications due to neuropathy

Halo fixation interventions

Monitor the clients vital signs every four hours, monitor the clients pin sites for loosening, check the client skin to ensure jacket is not applying pressure

A patient who has had an open reduction and internal fixation ORIF of left lower leg fractures complains of constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable in the foot is cool which action should the nurse take next?

Notify the healthcare provider

open reduction internal fixation

ORIF, surgical alignment of fractured bones using screws, pins, wires, or nails to maintain bone alignment. more for compound fractures rather than distal fractures

A nurse is preparing to care for a client who is in balance skeletal traction to stabilize the femur fracture. Which of the following actions should the nurse include in the clients plan of care?

Offering the client a diet and high fluid and fiber, to promote gastrointestinal function

Simple fracture has what

One fracture line while I communicated fracture has multiple fractures lines splitting the bone

A nurse is caring for a client immediately following a plaster cast what should the nurse monitor for report as a finding of compartment syndrome?

Paresthesias of the extremity,

Compartment syndrome findings

Paresthesias, numbness, tingling, weakness, pain that doesn't respond to medication

Cast care and patient teaching

Perform neurovascular assessment (6 ps), elevated 24 hrs after notify provider of purulent drainage or smell teach patient to use blow dryer with cold air for itching, teach them to keep moving and do ROM exercises to promote blood return

A nurse in the clinic is caring for an older adult client who reports dry flaky skin on her upper back which of the following is an intervention the nurse should complete?

Pinch a fold of skin to check for turgor

What does bucks extension traction do

Reduces pain, decreases muscle spasm, and stabilizes

Nurse is teaching in assistive personnel about the purpose of a foot plate on the bed for a client whose leg is in bucks traction which of the following statements indicates the AP understands the teaching?

Play helps to prevent foot drop

What are the four pulses to check for neurovascular assessment bilaterally on the legs

Poplietal, femoral, dorsal pedis, tibial

Braden scale

Pressure ulcers lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers

Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the healthcare provider?

Prolong capillary refill of the left foot

DVT

Pulling of blood, diagnosed with Doppler ultrasound, edema, redness, weak pulses, sense of doom

suspected deep tissue injury

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.

A patient is seen in the clinic complaining of knee pain following a arthroscopic procedure seven days ago and the healthcare provider performs arthrocentesis. Which finding will be of most concern to the nurse?

Purulent appearing fluid

A nurse is assessing a client who is 24 hour postoperative following in above the elbow amputation which of the following findings should the nurse identify as a priority?

Report of muscle spasms

Young male patient with paraplegia has a stage to sacral pressure injury and is being cared for at home by his family to prevent further tissue damage with instructions are most important for the nurse to teach patient and the family?

Reposition every 1 to 2 hours

Pressure ulcer interventions

Reposition every two hours, assessed frequently, when transferring patient don't slide patient on bed because the sheets can irritate the skin. lift patient of bed don't slide

Planning care for a patient who has had hip replacement surgery which nursing action camera nurse delegate to experience nursing assistant personnel

Reposition patient every 1 to 2 hours

Fracture or sprain or strain nursing interventions

Rest Ice, within the first 24 to 48 hours intermittently for vaso constriction 15 to 20 minutes then takeoff Compress, venous return Elevate

Types of wound drainage

Serous- clear, watery Sanguineous- active bleeding - bright red (active process) Serosanguineous- pale, red, watery: mixture of clear red fluid (pink)-thin Purulent- yellow, green, tan or brown & odor

A nurse is discussing the differences between skeleton skin traction with a newly licensed nurse which of the following statements by the newly licensed nurse indicates understanding?

Skeletal traction is more appropriate than skin traction for reducing a fracture

Hip fracture interventions

Splint leg and rice Post hip fracture surgery keep them abductor pillow to immobilize hip joint give anticoagulants prophylactic for DVT, provide compression stockings, raise higher to prevent flexing of hips (>90 degrees), educate not to bear weight and to rest it

Delegation that cannot be given to uap

T teaching A assesment P planning E evaluating

Skeletal traction

The most effective means of traction, applying to a bone with wire pins which can become loose and cause infection Notify provider if redness inflammation present

The nurse could delegate care of which patient to a license vocational nurse

The patient who requires a hydrocolloid dressing change for a stage three sacral ulcer

athroplasty

The surgical replacement of a joint splint to keep in place, asses skin breakdown, compression stockings, anticoagulants, pain/edema

A nurse is providing teaching for a client who is postoperative following below the knee amputation the nurse should instruct the client to which of the following nutrients is necessary for wound healing?

Vitamin C

The nurse is caring for a patient who is on bed rest after having a complex pelvic fracture which assessment finding is most important to report to the healthcare provider?

abdominal distention is present and bowel tones are absent

uap things can do

ambulate, turn, bathe, I and O (no IV), mouth care, toileting, linen, feeding (no aspiration), stable pts, do not give meds,

Fat embolism syndrome

blocking of small blood vessels by fat globules subsequent to a fracture, especially one of long bones or pelvis Petechiae is usually found on eyes, treat with anticoagulants heparin, DO NOT elevate or ice, O2 sat will be lower because the fat particles so you can give up to 2 L O2 nasal cannula without doctor prescription

open (compound) fracture

broken bone penetrates through the skin Grade 1 minimal skin damage grade 2 damage includes skin and muscle contusions but without extensive soft tissue injury Grade 3 damages excessive to skin muscles nerves and blood vessels

Unstageable

covered with necrosis

Closed simple fracture

does not break the skin

compartment syndrome signs and symptoms

early signs: hypoxia dyspnea, necrotic tissue late sigsn: headaches and agitation

heel wound interventions

heel protectant to prevent skin breakdown, don't let the heel touch the edge a better sheets

Moderate ankle injury grade 2, actions?

ice

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles Requires fasciotomy, common with casts, pain not relieved by pain meds,

Delegation of wound care

necrotic tissue: wound care nurse or physician LVN can perform wound care but cannot teach about it, can do dressing after everything has been established including medication and first wound dressing change CNA cannot perform dressing changes only reposition and ambulation

Closed reduction

nonsurgical realignment of broken bone ends and splinting of bone ss: erythema, discoloration, edema, pain and limited rom

Is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia which of the following is the priority action for the nurse to take

perform neurovascular assessment

Arthrocentesis

remove fluid from joint

5 rights of delegation

right task right circumstance right person right direction/communication right supervision/evaluation

lvp can do

same as uap + stable pt with chronic predictable dx, no new admission, no education, can gather data like vitals, cannot interpret data, give vaccines, cannot do IV/blood products, can give po meds

Braden scale factors

sensory perception, moisture, activity, mobility, nutrition, friction and shear

Russell traction

skin traction, a sling is positioned under the knee which suspends the distal thigh above the bed, risk for skin breakdown

open reduction

surgical realignment of broken under anasthesia More for compound fractures location ss: erythema, discoloration, edema, pain and limited rom

arthroplasty

surgical repair or replacement of a joint Splint to keep in place put surgically Abductor pillow or wedge pillow immobile precautions: Assess skin breakdown give, compression stockings etc.