Nurs 226 Quiz 2 Practice Qs
A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? a) Ask a colleague for help because the nurse cannot safely perform the procedure alone. b) Gather the equipment and prepare it before informing the client about the procedure. c) Obtain an order to restrain the client before inserting the urinary catheter. d) Inform the primary provider that the nurse cannot perform the procedure because the client is confused
a) Ask a colleague for help because the nurse cannot safely perform the procedure alone.
The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply. a) Assess the patient's response to the procedure b) Teach the patient about the procedure c) Document the procedure in the nursing progress notes d) Ask the patient to assist in the wound care at the next scheduled dressing change
a) Assess the patient's response to the procedure c) Document the procedure in the nursing progress notes
To maintain proper posture, it is important to a) Avoid arching shoulders forward when sitting b) Keep your knees locked whens standing upright c) Keep your stomach muscles relaxed to prevent back spasms d) Sleep on the softest mattress possible
a) Avoid arching shoulders forward when sitting
A patient is receiving 40 mg of enoxaparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for what signs of bleeding? SATA a) Bruising b) Pale yellow urine c) Bleeding gums d) Coffee ground-like vomitus e) Light brown stool
a) Bruising c) Bleeding gums d) Coffee ground-like vomitus
What is the removal of devitalized tissue from a wound called? a) Debridement b) Pressure distribution c) Negative-pressure wound therapy d) Sanitization
a) Debridement Rationale: Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing
A patient has been on bed rest for over 5 days. Which of these findings during the nurse's assessment may indicate a complication of immobility? a) Decreased peristalsis b) Decreased heart rate c) Increased blood pressure d) Increased urinary output
a) Decreased peristalsis
Which are complications of bed rest? Select all that apply. a) Extremity contractures b) Decreased dependency c) Diarrhea d) Pneumonia e) Pressure ulcers f) Thrombi g) Urinary calculi
a) Extremity contractures d) Pneumonia e) Pressure ulcers f) Thrombi g) Urinary calculi Rationale: 'extremity contractures' is loss of the ROM in an extremity due to tightening or shortening of connective tissues, which can occur due to prolonged immobility. A pt on bed rest will have increased dependency on others. Constipation (not diarrhea) is a potential complication of bed rest due to slowed peristalsis.
Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? SATA a) Frequent position changes b) Keeping the buttocks exposed to air at all times c) Using a large absorbent diaper, changing when saturated d) Using an incontinence cleaner e) Applying a moisture barrier ointment
a) Frequent position changes d) Using an incontinence cleaner e) Applying a moisture barrier ointment Rationale: The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure injuries.
What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a) Judgmental b) Too complex c) Legally questionable d) Without supportive data
a) Judgmental
Which of the following could put a nurse or healthcare worker at risk for sustaining a back injury? a) Lifting a box of IV supplied up and over the head to place on a shelf b) Placing the feet 2 feet apart before sliding a patient up in bed c) Raising the bed to waist level when starting an IV d) Squatting to measure the chest tube drainage
a) Lifting a box of IV supplied up and over the head to place on a shelf
What should the nurse teach a young woman with a history ofurinary tract infections (UTIs) about UTI prevention? SATA a) Maintain regular bowel elimination. b) Limit water intake to 1 to 2 glasses a day. c) Wear cotton underwear. d) Cleanse the perineum from front to back. e) Practice pelvic muscle exercise (Kegel) daily.
a) Maintain regular bowel elimination. c) Wear cotton underwear. d) Cleanse the perineum from front to back. Rationale: Maintaining regular bowel elimination prevents the rectum from filling with stool, which can irritate the bladder. Adequate hydration will ensure that the bladder is regularly flushed and will help prevent a UTI. Cotton undergarments are recommended. Pelvic muscle exercises promote pelvic health but do not necessarily prevent UTIs.
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? SATA a) Notify the health care provider. b) Allow the area to be exposed to air until all drainage has stopped. c) Place several cold packs over the area, protecting the skin around the wound. d) Cover the area with sterile, saline-soaked towels immediately. e) Cover the area with sterile gauze and apply an abdominal binder.
a) Notify the health care provider. d) Cover the area with sterile, saline-soaked towels immediately. Rationale: If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? a) Oxygen saturation of 89% b) Irregular radial pulse c) Diminished breath sounds bilateral bases on auscultation d) BP: 132/84 e) Pain reported at 3 on scale of 0 to 10 following medication f) Respiratory rate of 26
a) Oxygen saturation of 89% c) Diminished breath sounds bilateral bases on auscultation f) Respiratory rate of 26 Rationale: Pooling of secretions secondary to atelectasis can cause decreased lung sounds. Tachypneais a common response to dyspnea. Atelectasis can also negatively impact oxygen saturation as exhibited by the 89% oxygen saturation on this patient
The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates the correct understanding in regard to wound dehiscence? a) The nurse should be alert for an increase in serosanguineous drainage from the wound. b) Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. c) The nurse should administer cough suppressant to prevent wound dehiscence. d) The condition is an emergency that requires surgical repair.
a) The nurse should be alert for an increase in serosanguineous drainage from the wound.
The effects of immobility on the cardiac system include which of the following? Select all that apply. a) Thrombus formation b) Increased cardiac workload c) Weak peripheral pulses d) Irregular heartbeat e) Orthostatic hypotension
a) Thrombus formation b) Increased cardiac workload e) Orthostatic hypotension
When is the application of a warm compress to an ankle muscle sprain indicated? SATA a) To relieve edema b) To reduce shivering c) To improve blood flow to an injured part d) To protect bony prominences from pressure injuries e) To immobilize area
a) To relieve edema c) To improve blood flow to an injured part Rationale: Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat
Which of the following are measures to reduce tissue damage from shear? SATA a) Use a transfer device (e.g., transfer board) b) Have head of bed elevated when transferring patient c) Have head of bed flat when repositioning patient d) Raise head of bed 60 degrees when patient positioned supine e) Raise head of bed 30 degrees when patient positioned supine
a) Use a transfer device (e.g., transfer board) c) Have head of bed flat when repositioning patient e) Raise head of bed 30 degrees when patient positioned supine Rationale: A transfer device can pick up a patient and prevent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position causes patient to slide down, causing shear.
Which of the following describes the difference between dehiscence and evisceration? a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent c) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
The client has reddened skin and an open abrasion on his elbow from prolonged bedrest. In examining the components of the nursing diagnosis "Impaired Skin Integrity," the reddened skin and open abrasion would be a) the defining characteristics. b) the diagnostic label. c) the related factors. d) the risk factors.
a) the defining characteristics. Rationale: Defining characteristics are the signs and symptoms that allow the nurse to identify a client problem.
A patient has a wound on the ankle that is not healing. The nurse should assess the patient for which risk factors for delayed wound healing? Select all that apply. a) Atrial fibrillation b) Advancing age c) Type 2 diabetes mellitus d) Hypertension e) Smoking
b) Advancing age c) Type 2 diabetes mellitus e) Smoking
Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? SATA a) Attach a 3-mL syringe to the inflation port. b) Allow the balloon to drain into the syringe by gravity. c) Initiate a voiding record/bladder diary. d) Pull the catheter quickly. e) Clamp the catheter before removal.
b) Allow the balloon to drain into the syringe by gravity. c) Initiate a voiding record/bladder diary. Rationale: By allowing the balloon to drain by gravity, it is possible to avoid the development of creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters before removal.
When preparing a sterile field, which condition indicates to the nurse the field is at risk for contamination? a) The dressing is laying 3 inches away from the border of the sterile field b) An opened sterile package is placed into the middle of the sterile field c) A sterile item is held above waist level and in eye sight d) Clean gloves are used to pore sterile saline into the sterile cup
b) An opened sterile package is placed into the middle of the sterile field
A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to a) Massage both legs firmly with lotion prior to applying the stockings b) Apply the stockings in the morning upon awakening and before getting out of bed c) Roll the stockings down to the knees if they will not stay up on the thighs. d) Remove the stockings while out of bed for one hour, four times a day to allow the legs to rest.
b) Apply the stockings in the morning upon awakening and before getting out of bed Rationale: lotion should not be applied before application of pressure garments. Skin should be dry to reduce chance of skin breakdown. Stocking should never be rolled down, since wrinkles & creasing of the fabric increase friction & risk of impaired skin integrity Pressure stocking should not be removed for a whole hour
When teaching the patient with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the patient to report which symptoms to the health care provider (HCP)? Select all that apply. a) Cloudy urine for the first few days b) Blood in the urine c) Rash d) Mild nausea e) Fever above 100 degrees F (37.8 degrees C) f) Urinating every 3 to 4 hours
b) Blood in the urine c) Rash e) Fever above 100 degrees F (37.8 degrees C) Rationale: cloudy urine is a UTI symptom. Antibiotics make take more than a few days to begin relieving infection symptoms, so it's normal for cloudy urine to persist for a few days after beginning a course of abx.
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? a) Recommend that she be evaluated for an overactive bladder (OAB) medication. b) Establish a toileting schedule. c) Recommend that she be evaluated for an indwelling catheter. d) Start a bladder-retraining program.
b) Establish a toileting schedule. Rationale: The first nursing intervention for any patient with incontinence who is able to toilet is to help him or her with toilet access. This patient has dementia; therefore a bladder-retraining program is inappropriate for her. There is nothing in the assessment to indicate that she may have an overactive bladder. A catheter increases risk for infection and is never the best intervention for incontinence.
Which of the following is a priority nursing diagnosis? a) Impaired verbal communication related to altered central nervous system b) Fluid volume excess related to compromised regulatory mechanism c) Impaired physical mobility related to discomfort d) Activity intolerance related to generalized weakness
b) Fluid volume excess related to compromised regulatory mechanism Rationale: Maslow's hierarchy of human needs places survival needs as a priority. Fluid volume excess can lead to pulmonary edema, impaired gas exchange, and respiratory failure. Fluid volume excess is therefore life-threatening and would be a high priority when ranking problems according to problem urgency.
The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner? a) Call another nurse to assist with the procedure b) Gather all supplies and equipment before entering the patient room c) Instruct and explain the procedure to the patient d) Check the patient's schedule for the day for the most convenient time
b) Gather all supplies and equipment before entering the patient room
Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? a) Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution b) Hanging the urinary drainage bag below the level of the bladder c) Emptying the urinary drainage bag daily d) Irrigating the urinary catheter with sterile water
b) Hanging the urinary drainage bag below the level of the bladder Rationale: Evidence-based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.
The nurse should perform passive range-of-motion (ROM) exercises on which patients? Select all that apply. a) Has septic joints b) Has temporary loss of sensation c) Is unconscious d) Has plantar flexion of the foot e) Has supination of the hand
b) Has temporary loss of sensation c) Is unconscious Rationale: passive ROM exercises are the nurse moving the patient's limbs/joints when the pt is physically unable to do so independently. ROM exercises should not be done on septic joints due to the inflammation and pain assoc. w/ the condition. D & E do not describe pathological conditions, just positions of the hand/foot; so performing ROM exercises do not apply to these answers.
A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures would be appropriate for this patient to prevent complications of bed rest? Select all that apply. a) Administer intravenous analgesic as ordered b) Have patient perform incentive spirometry c) Support patient in active assistive ROM exercises of upper extremities d) Provide patient a low-calorie diet e) Apply sequential compression devices to legs
b) Have patient perform incentive spirometry c) Support patient in active assistive ROM exercises of upper extremities e) Apply sequential compression devices to legs Rationale: Use of incentive spirometry prevents atelectasis. The patient has no upper extremity limitations, so active assistive ROM is appropriate and preventive. The patient should have compression devices on the legs to reduce risk of DVT. Immobilized patients require a high-calorie intake. IV analgesics is appropriate for pain, but is not focused on prevention of immobility complications.
There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? a) Remove the catheter and start all over with a new kit and catheter. b) Leave the catheter there and start over with a new catheter. c) Pull the catheter back and reinsert at a different angle. d) Ask the patient to bear down and insert the catheter farther.
b) Leave the catheter there and start over with a new catheter. Rationale: The catheter may be in the vagina; leave the catheter in the vagina as a landmark indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for catheter-associated urinary tract infection (CAUTI).
Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery? a) Age over 75 years b) Poorly controlled diabetes c) History of one myocardial infarction d) Chronic peripheral vascular disease
b) Poorly controlled diabetes
A nurse is reviewing the laboratory findings for urinalysis (UA) of a client who reports urgency and nocturia. Which of the following findings should the nurse report to the provider? a) Positive for casts b) Positive leukocyte esterase c) Positive for epithelial cells d) Positive for crystals
b) Positive leukocyte esterase
What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. a) Change the catheter daily b) Provide perineal care at least once a day c) Maintain a closed drainage system d) Encourage the patient to drink 3000 mL fluids daily e) Recommend health care provider prescribe antibiotics
b) Provide perineal care at least once a day c) Maintain a closed drainage system d) Encourage the patient to drink 3000 mL fluids daily
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? SATA a) Collection of wound drainage b) Providing support to abdominal tissues when coughing or walking c) Reduction of abdominal swelling d) Reduction of stress on the abdominal incision e) Stimulation of peristalsis (return of bowel function) from direct pressure
b) Providing support to abdominal tissues when coughing or walking d) Reduction of stress on the abdominal incision Rationale: A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
The nurse is assessing a group of older adults. Which patient is at the greatest risk for skin breakdown? A person who has a) Altered balance b) Reduced sensation of pressure c) Impaired hearing ability d) Impaired visual acuity
b) Reduced sensation of pressure
The nurse is assessing the home environment of an elderly patient who is using crutches during the postoperative phase after hip pinning. Which poses the greatest hazard to the patient as a risk for falling at home? a) A four-year-old cocker spaniel b) Scatter rugs c) Snack tables d) Rocking chairs
b) Scatter rugs
While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) Sanguineous b) Serosanguineous c) Serous d) Purosanguineous
b) Serosanguineous
The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a) Stage I pressure ulcer b) Stage 2 pressure ulcer c) Stage 3 pressure ulcer d) Stage 4 pressure ulcer
b) Stage 2 pressure ulcer
Which goal is most appropriate for a patient who has had a total hip replacement? a) The patient will ambulate briskly on the treadmill by the time of discharge. b) The patient will walk 100 feet using a walker by the time of discharge. c) The nurse will assist the patient to ambulate in the hall 2 times a day. d) The patient will ambulate by the time of discharge.
b) The patient will walk 100 feet using a walker by the time of discharge.
What is a critical step when inserting an indwelling catheter into a male patient? a) Slowly inflate the catheter balloon with sterile saline. b) Secure the catheter drainage tubing to the bed sheets. c) Advance the catheter to the bifurcation of the drainage and balloon ports. d) Advance the catheter until urine flows, then insert ¼ inch more.
c) Advance the catheter to the bifurcation of the drainage and balloon ports. Rationale: Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. Advancing the catheter until urine flows and then inserting it ¼ inch more is not unique to the male patient.
A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Which of the following should be included in the instructions? a) Apply petroleum jelly around the nares b) Assure the patient and their family that the patient can still smoke c) Check the position of the nasal cannula frequently d) Remove the nasal cannula during meal time
c) Check the position of the nasal cannula frequently
Which of the following is considered a long-term goal? a) Client's pulse oxygenation level will be greater than 92% on room air by tomorrow. b) Client will administer his own insulin using correct technique by discharge. c) Client's pressure ulcer will show presence of granulation tissue in 30 days. d) Client's urine output will be 400 mL per 8 hr shift within 72 hr.
c) Client's pressure ulcer will show presence of granulation tissue in 30 days. Rationale: A long-term goal indicates that the resolution to a problem is expected to occur over weeks to months or more.
The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery. It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that the patient is independent in bathing. What should the nurse do next? a) Assist with the bath as ordered b) Delegate the bath to the nursing assistant c) Discontinue the nursing order on the plan of care d) Collaborate with the nurse who originally wrote the order
c) Discontinue the nursing order on the plan of care
A nurse is caring for a patient with a Foley catheter. What should the nurse do to reduce the risk of infection? a) Clean the perineum with peroxide after each void b) Decrease oral fluids. c) Empty the Foley bag every 4 to 8 hours. d) Open the bag and Foley system to check for kinks
c) Empty the Foley bag every 4 to 8 hours. Rationale: The perineum should be cleaned with soap & water or skin-safe cleansing wipes Adequate fluid intake reduces risk of infection The foley system should be kept closed at all times
The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? a) Tell the charge nurse that the nurse is going to lunch b) Verify that the charge nurse has assigned someone to take care of the patient c) Give the charge nurse information about what care should be given while the nurse is at lunch d) Remind the charge nurse about the patient's history and current medications
c) Give the charge nurse information about what care should be given while the nurse is at lunch
The nurse knows that the primary reason for the application of a sequential compression device (SCD) on the legs of an immobile patient is to: a) Aid in peripheral circulation to minimize the risk of skin breakdown b) Assist in passive range of motion exercise of the patient's lower extremities c) Help prevent the formation of deep vein thrombosis (DVT) d) Stimulate circulation in the deep arterial vascular system
c) Help prevent the formation of deep vein thrombosis (DVT) Rationale: SCDs aid in/stimulate circulation in the venous (not arterial) system to prevent clots, not to prevent skin breakdown
The nurse is assessing a patient with dark skin for the presence of a stage I pressure ulcer. Which is the best approach to making this assessment? a) Use a fluorescent light source to assess the skin b) Inspect the skin only when the Braden score is above 12 c) Look for skin color that is darker than the surrounding tissue d) Avoid touching the skin during inspection
c) Look for skin color that is darker than the surrounding tissue
An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient post-operatively on the evening of surgery, which of the following would be most important to assess? Select all that apply. a) Patient's usual dietary intake b) Time and date of the patient's last bowel movement c) Pre-admission activity tolerance d) Baseline heart rate e) Patient's home living situation
c) Pre-admission activity tolerance d) Baseline heart rate Rationale: Establishing a baseline activity tolerance and heart rate will help avoid overexerting the patient and help develop expectations (safe target heart rate) that are safe and reasonable as mobility is increased.
A nurse is caring for a client who displays signs of Stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care? a) Recommend a community support group b) Integrate a daily exercise program c) Provide a walker for ambulation d) Consultation with a dietitian
c) Provide a walker for ambulation
Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? a) Limit oral fluid intake to avoid possible urinary incontinence. b) Expect patient complaints of suprapubic fullness and discomfort. c) Report the time and amount of first voiding. d) Instruct patient to stay in bed and use a urinal or bedpan.
c) Report the time and amount of first voiding. Rationale: To adequately assess bladder function after a catheter is removed, voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a urinary tract infection.
What is the correct method for turning an adult patient brought to the ER with a suspected spinal cord injury? a) Ask the patient to assist with the turn by holding the siderails of the bed b) Place a draw sheet under the patient to assist with turning c) Request help form another nurse to perform logrolling technique d) Use a mechanical lift for safe turning and protecting the nurse's back
c) Request help form another nurse to perform logrolling technique Rationale: pts with a SCI or suspected SCI should ALWAYS be moved via logroll technique, which requires 2 nurses. This technique ensures that the spinal cord stays in line & prevents further damage.
The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. It will be most important for the nurse to a) Report this finding to the provider b) Note this finding in the client's record c) Revise the plan of care d) Remove the nursing diagnosis from the plan
c) Revise the plan of care
A patient is admitted with a Stage I pressure ulcer in their sacral area. To provide pressure relief at night, the nurse teaches the patient to sleep in which position? a) Supine with the head of the bed elevated b) Supine with a foam wedge between the knees c) Thirty-degree lateral inclined position d) Full side-lying position supported with pillows
c) Thirty-degree lateral inclined position
Which of the following describes a hydrocolloid dressing? a) A seaweed derivative that is highly absorptive b) Premoistened gauze placed over a granulating wound c) A debriding enzyme that is used to remove necrotic tissue d) A dressing that forms a gel that interacts with the wound surface
d) A dressing that forms a gel that interacts with the wound surface Rationale: A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? a) Obtain a walker for the client to use to transfer back to bed b) Call for additional personnel to assist with the transfer c) Use a transfer belt and assist the client to bed d) Assess the client's ability to help with the transfer
d) Assess the client's ability to help with the transfer Rationale: before attempting to move the pt, nurse should assess the patient's mobility to figure out what assistance is required. ***Test answers that include assessing the pt before doing anything else are usually the correct answer
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? a) A local skin infection requiring antibiotics b) Sensitive skin that requires special bed linen c) A stage 3 pressure injury needing the appropriate dressing d) Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode
d) Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode Rationale: Pressing overthe area compresses the blood vessels in the area. If the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.
An older-adult patient has been bedridden for 2 weeks. Which of these complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? a) Increase of appetite b) Gum soreness c) Difficulty in swallowing d) Left ankle joint stiffness
d) Left ankle joint stiffness Rationale: Temporary immobilization results in some muscleatrophy, loss of muscle tone, and joint stiffness. Two weeks of jointimmobilization without ROM can quickly result in contractures.Patient's left ankle stiffness can be indicative of an early contracture.
The nurse must transfer a dependent patient from a bed to a gurney. Which action by the nurse will be safest for the patient and nurse? a) Adjust the height of the bed b) Avoid movements that twist the spine c) Keep the patient close to the nurse's body when lifting d) Obtain an appropriate mechanical lift device
d) Obtain an appropriate mechanical lift device
Which intervention should the nurse take first to promote the start of urination in a patient who is having difficulty voiding? a) Insert an intermittent, straight catheter b) Insert an indwelling urinary catheter c) Notify the provider immediately d) Pour warm water over the patient's perineum
d) Pour warm water over the patient's perineum Rationale: the nurse/care team should always start with the least invasive methods for treating urinary retention or urinary incontinence. An indwelling foley catheter should be the last resort due to risk of infection, unless the pt has a stage 3-4 sacral pressure ulcer or is on hospice
A truck driver sees the primary care provider because of persistent back pain. The nurse explains that which patient activity documented during the nursing history may contribute to further back injury? a) Lifting an object close to the body b) Shifting positions often when sitting for prolonged periods c) Providing back support with a pillow when sitting d) Prolonged sitting or standing
d) Prolonged sitting or standing
A patient presents on admission with pressure ulcers extending to the bone. The nurse documents this ulcer at what stage? a) Stage 1 pressure ulcer b) Stage 2 pressure ulcer c) Stage 3 pressure ulcer d) Stage 4 pressure ulcer
d) Stage 4 pressure ulcer
Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with diarrhea? a) Edema b) Hypothyroidism c) Pallor d) Tenting
d) Tenting
The nurse is planning the care of a frail, immobile, elderly patient. Which of the following is the best treatment or prevention to protect the patient's skin? a) Administer fluid boluses as directed by the healthcare provider b) Assisting the patient to sit in a chair three times a day c) Offering the patient six small meals a day d) Turning the patient at least every 2 hours
d) Turning the patient at least every 2 hours