Tissue Integrity & Perioperative Nursing

The nurse knows albumin is an important indicator of nutritional status. The nurse understands that a value below ________ g/dL indicates poor nutrition and may increase the risk of poor healing and infection. 1. 3.5 2. 3.6 3. 3.8 4. 3.9

1. 3.5 Rationale: Albumin is an important indicator of nutritional status. A value below 3.5 g/dL indicates poor nutrition and may increase the risk of poor healing and infection.

On the second postoperative day after an above-the-knee amputation, the client's elastic dressing accidentally comes off. Which should the nurse do first? 1. Wrap the residual limb with an elastic compression bandage 2. Apply a saline dressing to the residual limb 3. Notify the primary health-care provider 4. Place two pillows under the limb

1. Wrap the residual limb with an elastic compression bandage Rationale: Gently compression is desirable because it prevents bleeding and promotes molding and shrinkage of the residual limb.

A nurse is caring for a postoperative client. The client asks the nurse why vitamin C was prescribed by the primary health-care provider. Which information should the nurse include in a response to this question? Select all that apply. 1. Facilitates healing 2. Improves digetsive processes 3. Increases transport of oxygen to cells 4. Encourages growth of red blood cells 5. Minimizes formation of deep vein thrombosis

1 Rationale: Vitamin C (ascorbic acid) promotes collagen production, as essential component of the proliferative phase of wound healing. In addition, vitamin C enhances capillary formation, decreases capillary fragility, increases the tensile strength of the wound, and provides a defense against infection because of its role in the immune response.

A nurse is caring for a postoperative client who had abdominal surgery. The client states, "The incision just felt like it gave way." The nurse identifies that the client had a dehiscence with slight evisceration. Which of the following should the nurse implement? Select al that apply. 1. Instruct the client to avoid coughing or bearing down 2. Notify the primary health-care provider immediately 3. Position the client in the low-Fowler position 4. Cover the incision with a sterile dressing 5. Prepare the client for surgery

1, 2, 3, 4, and 5 Rationale: 1; Coughing or bearing down will increase tension on the suture line, potentially extending the dehiscence and evisceration, and should be avoided. 2; The client needs emergency surgical care, and the primary health-care provider should be notified immediately 3; The client should be placed in the low-Fowler position with the knees slightly flexed to reduce stress on the suture line. 4; Covering the wound with a sterile dressing protects the open wound from contamination. 5; The client should be prepared for surgery because the surgeon will most likely return the client to the operating room for surgical repair of the incision

The nurse plans to remove the client's sutures. Which action demonstrates appropriate standard of care? Select all that apply. 1. Use clean technique 2. Grasp the suture at the knot with a pair of forceps 3. Place the curved tip of the suture scissors under the suture as close to the skin as possible 4. Remove suture material that is visible beneath the skin during removal 5. Remove alternate sutures first

1, 2, 3, and 5 Rationale: Option 4i is not correct. The suture material that is visible in contact with bacteria and must not be pulled beneath the skin during removal.

Which of the following independent and dependent nursing intervention help prevent thrombophlebitis during the postoperative period? Select all that apply. 1. Applying lower-extremity sequential compression devices when in bed 2. Wearing an antiembolism stockings when out of bed 3, Walking in the hall several times a day 4. Using an incentive spirometer 5. Coughing and deep breathing 6. Keeping the legs uncrossed

1, 2, 3, and 6 Rationale: 1; Sequential compression devices apply pressure progressively from the ankles to the thighs, promoting venous return. Volume and velocity of blood flow in the superficial and deep veins in the legs increase, preventing venous stasis. Venous stasis promotes the development of a thrombus 2; Antiembolism stockings are elastic garments worn around the leg; they exert pressure against the legs, reducing the diameter of the veins. When the diameter of veins is reduced, the volume and velocity of blood flow increases, preventing venous stasis. Venous stasis promotes the formation of a thrombus 3; Walking contracts the muscles of the lower extremities and increases cardiac output. Both increase the volume and velocity of blood flow through the veins of the lower extremities, preventing venous stasis and thrombus formation. 6; Keeping the legs uncrossed eliminates pressure against the calves or behind the knee (popliteal space), depending on where the legs are crossed. Pressure to these areas impairs venous return, which promotes venous stasis and thrombus formation.

Which of the following items are used to perform wound irrigation? Select all that apply. 1. Clean gloves 2. Mask 3. Refrigerated irrigating solution 4. 60-mL syringe 5. Forceps

1, 2, and 4 Rationale: To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid. A mask should be worn when splashing can occur such as when irrigating a wound. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be room or body temperature-certainly not refrigerated. Forceps may be used to remove or apply a dressing but are not required for irrigation.

A nurse is caring for a client recovering from abdominal surgery. Which nursing action is effective in facilitating ventilation? Select all that apply. 1. Encouraging fluid intake 2. Preventing abdominal distention 3. Positioning in the side-lying position 4. Implementing passive range-of-motion exercises 5. Ensuring that an incentive spirometer is used every hour when awake

1, 2, and 5 Rationale: 1; Increase in fluid intake will make respiratory secretions less vicious and easier to expectorate, thereby facilitating ventilation. 2; Abdominal distention raises the pressure within the abdominal cavity, which exerts pressure against the diaphragm, impeding its contraction and limiting thoracic excursion 5; An incentive spirometer will help increase depth of inspirations, preventing stasis of secretions in the respiratory tract, which will facilitate ventilation.

Which of the following are primary risk factors for pressure injuries? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1, 3, and 4 Rationale: Risk factors for pressure injuries include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of a fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different body parts of the body and would reduce the chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chances of skin breakdown.

A client has a right abdominal incision. Which should the nurse teach the client to do when getting out of bed? Select all that apply. 1. Exit from the left side of the bed 2. Ask the nurse to apply an abdominal binder 3. Hold a pillow against the abdomen with both hands 4. Use the left arm to push up to a sitting position on the side of the bed 5. Sit on the side of the bed for a few minutes before moving to a standing position

1, 4, and 5 Rationale: 1; When exiting from the left side of the bed, the left-lateral side of the abdomen will be compressed against the bed by body weight. The left, not right, side of the abdomen will absorb the majority of the muscular strain exerted by the transfer. 4; Using the left arm to assist in lifting the body to a sitting position on the side of themed places less strain on the abdominal muscles in the area of the incision. 5; Sitting on the side of the bed for a few minutes before moving to a standing position allows the blood pressure to adjust to the change in position, thus avoiding orthostatic hypotension.

The client's postoperative orders state "diet as tolerated." The client has been NPO. The nurse will advance the client's diet to clear liquids based on which assessment? Select all that apply. 1. Does not complain of nausea or vomiting. 2. Pain level is maintained at a rating of 2-3 out of 10. 3. States passing flatus. 4. Ambulates with minimal assistance. 5. Expresses feeling "hungry."

1, and 3 Rationale: The absence of nausea and vomiting indicated that the client may be ready for clear liquids. Anesthetics, narcotics, fasting, and inactivity all inhibit peristalsis. Oral fluids and foods are started after the return of peristalsis. The client may feel hungry but peristalsis may not be present (option 5). Options 2 and 4 are important but not related specifically to advancing the client's diet.

A nurse is evaluating a client's understanding of performing deep-breathing exercises. Which of the following statements indicates a need for further teaching? 1. "I will hold my breath for 6 to 8 seconds." 2. "I will exhale slowly through the mouth." 3. "I will always be in a sitting position." 4. "I will inhale slowly and evenly through the nose until the greatest chest expansion is achieved."

1. "I will hold my breath for 6 to 8 seconds." Rationale: The client should hold his or her breath for 2 to 3 seconds. The client should be in a sitting position. The client should exhale slowly through the mouth. The client should inhale slowly and evenly through the nose until the greatest chest expansion is achieved.

A nurse is is evaluating a nursing student who is applying anti embolic stockings to a client. Which of the following actions demonstrates a need for further teaching? 1. Assists the client to a sitting position in bed 2. Reaches inside the stocking from the top and, grasping the heel, turns the upper portion of the stocking inside out so the foot portion is inside the stocking leg. 3. Has the client point his or her toes, then positions the stocking on the client's foot 4. Eases the stocking over the toes, taking care to place the toe and heel portions of the stocking appropriately

1. Assists the client to a sitting position in bed Rationale: The student nurse should assist the client to a lying position in bed. Reach onside the stocking from the top and, grasping the heel, turn the upper portion of the stocking inside the stocking leg. Have the client point his or her toes, then position the stocking on the client's foot. Ease the stocking over the toes, taking care to place the toe and heel portions of the stocking appropriately.

When irrigating a gastrointestinal tube for a client, which of the following would be appropriate? The nurse: 1. Attaches the syringe to the nasogastric tube 2. Aspirates the solution harshly 3. Draws up 90 mL of irrigating solution into the syringe 4. Quickly injects the solution

1. Attaches the syringe to the nasogastric tube Rationale: Draw up the ordered volume of irrigating solution in the syringe; 30 mL of suction per instillation is usual, but up to 60 mL may be given per instillation if ordered. Attach the syringe to the nasogastric tube and slowly inject the solution. Gently aspirate the solution. Forceful withdrawal could damage the gastric mucosa.

A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury? 1. Barrier creams 2. Antifungal ointment 3. Chemical debridement agent 4. Antibiotic agent

1. Barrier creams Rationale: Barrier creams and ointments are used for clients that are prone to skin breakdown from pressure, shear, or incontinence. Therefore, the nurse should plan to apply barrier creams for a client who has a stage 1 pressure injury. Option 2: An antifungal agent is typically prescribed to treat rashes caused by fungus infections. Option 3: A chemical debridement agent is used to treat pressure injuries that have slough or eschar, or for infected wounds with poor wound edges. Option 4: An antibiotic agent is used to treat infected wounds.

Which of the following is NOT a correct action to reduce the risk of postoperative wound infection? 1. Clean the surgical site only 2. Remove hair from the surgical site only when necessary 3. Document surgical skin preparation in the client's record 4. Prepare the surgical site with an antimicrobial agent

1. Clean the surgical site only Rationale: Clean the surgical site and surrounding areas. This can be accomplished before the surgical prep by having the client shower and shampoo or wash the surgical site in the surgical setting immediately before applying an antimicrobial agent. Prepare the surgical site and surrounding area with an antimicrobial agent when indicated. A nontoxic antimicrobial agent with a broad range of germicidal action is used to inhibit the growth of microorganisms during and following the surgical procedure. The agent selected depends on the client's history of hypersensitivity reactions, the location of the surgical site, and the skin condition. The area prepared needs to be large enough to accommodate an extension of the incision and and potential drain sites or additional incisions if needed. Remove hair from the surgical site only when necessary or according to the primary care practitioner's orders or institutional policies and procedures. Document surgical skin preparation in the client's record. Document surgical skin preparation in the client's record. Documentation should include the skin condition, including any growths, abrasions, or rashes; hair removal and the techniques use, if performed; the skin preparation, including cleansing and antimicrobial agent applied; who performed the preoperative skin preparation; and any adverse or hypersensitivity responses noted.

Proper technique for performing a wound culture include which of the following: 1. Cleansing the wound prior to obtaining the specimen 2. Swabbing for the specimen in the area with the largest collection of drainage. 3. Removing the crusts or scabs with sterile forceps and then culturing the site beneath 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen

1. Cleansing the wound prior to obtaining the specimen Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of deriding. The nurse does not generally decried the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms.

Which is the most common dietary prescription the nurse can anticipate after a client who had abdominal surgery exhibits a return of intestinal peristalsis? 1. Clear liquids 2. Full liquids 3. Low fiber 4. Regular

1. Clear liquids Rationale: The molecules in clear liquids are less complex and easier to ingest, tolerate, and digest that those in a full-liquid diet or food.

A nurse is assessing a client who has spinal anesthesia? For which common response should the nurse assess the client? 1. Headache 2. Neuropathy 3. Lower back discomfort 4. Increased blood pressure

1. Headache Rationale: Leakage of cerebrospinal fluid from the needle insertion site recedes cerebrospinal fluid pressure, which causes a headache

Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client: 1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). 2. It will be acceptable to leave the pad in place if the temperature is reduced. 3. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed. 4. It will be acceptable to leave the pad in place as long as it is moist heat

1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect, resulting in vasoconstriction. Lowering the temperature, but still delivering heat-dry or moist- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.

Which client having emergency surgery should the nurse anticipate to be at the highest risk for postoperative mortality? 1. Individual who has alcoholism 2. Person who has epilepsy 3. Middle-age adult 4. Infant

1. Individual who has alcoholism Rationale: Chronic alcoholism disrupts the structure and function of the liver. A decrease in the synthesis of the bile salts prevents the absorption of vitamin K, which is essential for the production of clotting factors II, VII, IX, and X. Therefore, clients with alcoholism are at risk for hemorrhage. In addition, malnutrition results in decreased protein synthesis, anemia, and vitamin deficiencies, all of which interfere with fluid and electrolyte balance and wound healing. Finally, the client will have to be medically managed to minimize the responses to alcohol withdrawal.

Which factor places a client at the highest risk for postoperative nausea and vomiting after receiving general anesthesia? 1. Obesity 2. Inactivity 3. Hypervolemia 4. Unconsciousness

1. Obesity Rationale: Obese people have excess adipose tissue that exerts pressure on the abdominal cavity, which raises intra-abdominal pressure. Increased intra-abdominal pressure exerts pressure on the gastrointestinal tract, increasing the risk of nausea and vomiting.

A nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion? 1. Oliguria 2. Cachexia 3. Yellow sclera 4. Suprapubic distention

1. Oliguria Rationale: Oliguria is diminished urine secretion in relation to fluid intake, which is indicated by a negative balance in the intake and output record or an hourly urin output of less than 30 mL. Oliguria is caused by decreased renal perfusion or kidney disease.

A postoperative client experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude that the client most likely experienced? 1. Pulmonary embolus 2. Hemorrhage 3. Heart attack 4. Pneumonia

1. Pulmonary embolus Rationale: These are the classic clinical manifestations of a pulmonary embolus. Chest pain results from local tissue hypoxia, tachycardia from systemic hypoxia, and hypotension from decreased cardiac output. A pulmonary embolus is caused by an embolus lodging in a vessel in the pulmonary circulation, occluding blood supply to the capillary side of the alveolar-capillary membrane.

Which client responses best support the decision to discharge the client from the post anesthesia care unit? 1. SaO2 of 95%, vital signs stable for 30 minutes, active gag reflux 2. Tolerable pain, ability to move extremities, dry intact dressing 3. Urinary output of 30 mL/hr, awake, turning from side to side 4. Afebrile, adventitious breath sounds, ability to cough

1. SaO2 of 95%, vital signs stable for 30 minutes, active gag reflux Rationale: These clinical findings are essential for discharge from the post anesthesia care unit because they reflect the body's vital functions, such as airway, breathing, and circulation.

A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage? 1. Serosanguineous 2. Sanguineous 3. Serous 4. Purulent

1. Serosanguineous Rationale: This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color. Option 2: Sanguineous exudate is thin in consistency but bright red in color. This does not correlate with the nurse's assessment findings. Option 3: Serous exudate is thin in consistency but clear in color. This does not correlate with the nurse's assessment findings. Option 4: Purulent exudate can be thin or thick in consistency, but it is tan to yellow in color. This does not correlate with the nurse's assessment findings.

The nurse is assessing a wound and notes that the exudate is purulent. What would you expect the exudate to look like? 1. The exudate is thick with the presence of pus and is yellow in color 2. The exudate is clear and appears blood tinged 3. The exudate is red to pink and watery 4. The exudate is bright red and bloody

1. The exudate is thick with the presence of pus and is yellow in color Rationale: A purulent exudate is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquified dead tissue debris, and dead and living bacteria. A serosanguineous (consisting of clear and blood-tinged drainage) exudate is commonly seen in surgical incisions. A serous exudate consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membrane of the body, such as the peritoneum. It looks watery and has few cells. A sanguineous (hemorrhagic) exudate consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This type of exudate is frequently seen in open wounds.

A nurse is caring for two clients. One of the clients has a Jackson-Pratt drain and the other client has a Hemovac drain. Which does the nurse understand is the difference between these two drains? 1. The size of the containers 2. How the pressure within the collection container is needed 3. The type of pressure that promotes drainage to the collection container 4. Where the collection container should be placed in relation to the insertion site

1. The size of the containers Rationale: A Hemovac is designed to accommodate 100, 400, or 800 mL of drainage, depending on the system used, whereas a Jackson-Pratt system accommodates volume of less than 100 mL of drainage.

A client is being admitted for right total knee replacement tells the nurse that he is afraid because a friend of his needed eye surgery and they operated on the wrong eye. Which statement(s) could the nurse make to address the client's fear? Select all that apply. 1. "Don't worry. Nothing like this has ever happened at this hospital." 2. "You will be asked to write "YES" with a permanent marker on your right knee to indicate it is the correct knee." 3. "Before the surgery begins the surgical team takes a time-out to conduct a final verification of the correct client, procedure, and sit." 4. "An 'X' will be marked on your left knee to indicate that it is not the correct knee." 5. "Your surgeon will verify the correct knee by writing his initials on the right knee."

2, 3, and 5 Rationale: Options 2, 3, and 5 are all part of safety protocols to avoid wrong site, wrong procedure, and wrong person surgery. The Joint Commission does not specify the type of mark, but whatever mark is used, it must be consistently throughout the facility. Option 1 is giving false reassurance and does stoa address the client's fear. Placing an X on the wrong knee is confusing and could result in wrong-site surgery (option 4).

A nurse compares the advantages and disadvantages of a central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following foes the nurse conclude is the reason why a peripheral catheter is more desirable? 1. Because it will not be in the superior vena cava 2. Because it will not cause a tension pneumothorax 3. Because it will not prevent the development of an infection 4. Because it will not allow large volumes of fluid to be administered

2. Because it will not cause a tension pneumothorax Rationale: A tension pneumothorax is not a concern with a peripherally inserted central venous catheter. Pneumothorax is a complication of a central venous catheter inserted into a subclavian vein because of the close proximity of its insertion site to the apex of the lung.

A postoperative client is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for a client with a Penrose drain? 1. Removing the excess external portion until drainage stops 2. Changing the soiled dressing carefully 3. Maintaining the negative pressure 4. Pinning the drain to the dressing

2. Changing the soiled dressing carefully Rationale: Changing a soiled dressing carefully is necessary to prevent inadvertent removal of the Penrose drain because it is placed between several layers of guaze 4x4s to absorb drainage

The nurse is preparing to obtain a wound drainage specimen for culture from a client. Which of the following is part of the preparation? 1. Check the progress notes to determine if the specimen is to be collected for an aerobic (growing only in the presence of oxygen) culture. 2. Check the medical orders to determine if the specimen is to be collected for an anaerobic (growing only in the absence of oxygen) culture. 3. Administer an analgesic 90 minutes before the procedure if the client is complaining of the pain at the wound site. 4. Administer an analgesic 5 minutes before the procedure if the client is complaining of pain at the wound site.

2. Check the medical orders to determine if the specimen is to be collected for an anaerobic (growing only in the absence of oxygen) culture. Rationale: Check the medical orders, not the progress notes, to determine if the specimen is to be collected for an aerobic (growing only in the presence of oxygen) or anaerobic (growing only in the absence of oxygen) culture. Aerobic organisms are generally found on the surface of the wound, whereas anaerobic organisms would be found in deep wounds, tunnels, and cavities. Administer an analgesic 30 minutes before the procedure if the client is complaining of pain at the wound site.

A nurse is to apply a transparent wound barrier over a client's incision. Which nursing action is appropriate? 1. Stretch the transparent dressing snuggly over the entire wound 2. Clean the skin with normal saline before applying the dressing 3. Cover the transparent wound barrier with a guaze dressing a secure with paper tape 4. Ensure the reinforcing tape extends several inches beyond the edges of the transparent wound barrier

2. Clean the skin with normal saline before applying the dressing Rationale: Cleansing the skin with normal saline before applying the dressing removes exudate and ensures adhesion of the dressing. Transparent adhesive films are semipermeable (allows oxygen exchange) and nonabsorbent (impermeable to water and bacteria)

A nurse is caring for a client who has multiple sclerosis and a chronic non healing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? 1. Tricyclic antidepressants 2. Corticosteroids 3. Beta blockers 4. Anticholinergics

2. Corticosteroids Rationale: Corticosteroids suppress the immune system and can therefore delay wound healing. Option 1: Delayed wound healing is not an adverse effect of this medication. Option 3: Delayed wound healing is not an adverse effect of this medication. Option 4: Delayed wound healing is not an adverse effect of this medication.

A nurse is considering the commonalities and differences of equipment used for gastric depression. Which is the major advantage to using a double-lumen tube? 1. Minimizes the risk of bowel obstruction 2. Ensures drainage of the intestine 3. Prevents gastric mucosal damage 4. Promotes gastric rest

2. Ensures drainage of the intestine Rationale: A double-lumen tube has two lumens: one allows stomach secretions to be removed by suction (first lumen) and the other allows air to be drawn into the stomach (second lumen). The second lumen (blue pigtail) is open to environmental (atmospheric) air, which is drawn into the stomach to equalize the outside pressure with the pressure inside the stomach. This prevents the catheter tip from attaching to the gastric mucosa when the drainage lumen is attached to suction, limiting mucosal damage

A nurse is evaluating the effectiveness of nursing interventions for meeting the nutrient needs of clients during the first 2 days after abdominal surgery. Which outcome is most important? 1. Nausea and vomiting have not occurred 2. Fluid and electrolytes are balanced 3. Wound healing is progressing 4. Oral intake is reestablished

2. Fluid and electrolytes are balanced Rationale: Fluid is the most basic nutrient of the body, and it contain compounds such as electrolytes. Electrolytes help maintain fluid balance, contribute to acid-base balance, and facilitate enzyme and neuromuscular reactions. The narrow safe limits of the volumes and composition of fluid compartments are essential for the life-sustaining processes of nutrition, metabolism, and excretion.

Which of the following indicates a proper principle of bandaging? 1. Apply the bandage as tightly as possible without causing pain 2. Gauze bandages are used to hold absorbent dressings in place 3. Elastic bandages must be sterile when applies 4. The bandage should always occur at least one joint of the limb

2. Gauze bandages are used to hold absorbent dressings in place Rationale: Gauze bandages are used to hold absorbent dressings in place. How tight the bandage is applied depends on the purpose (option 1). Elastic bandages are generally not sterile because they are used to support a body part and not cover a wound (option 3). The bandage may or may not cover at least one joint of the limb (option 4).

A client who is having a mastectomy expresses sadness about losing her breast. Based on this information, the nurse would identify that the client is at risk for which diagnosis? 1. Altered body image 2. Grieving 3. Fear 4. Impaired coping

2. Grieving Rationale: Grieving is the state in which an individual experiences reactions in response to an expected significant loss and is often characterized by negative responses such as shame, embarrassment, guilt, or revulsion. Option 3, fear, is usually characterized by feelings of dread, fright, apprehension, or alarm. Impaired coping, option 4, is usually characterized by verbalization of inability to cope or ask for help, inappropriate use of defense mechanisms, or inability to meet role expectations.

The nurse assesses a postoperative client who has a rapid, weak pulse; urine output of less than 30 mL/h; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect? 1. Thrombophlebitis 2. Hypovelmic shock 3. Pneumonia 4. Wound dehiscence

2. Hypovelmic shock Rationale: The symptoms describe decreased cardiac output and not any of the other listed complications.

Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2. Implement a turning schedule; the client is at increased risk for skin breakdown. Rationale: A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment is indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to clients with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

Surgery is a unique experience of a planned physical alteration encompassing three phases. Which phase begins when the client is transferred to the operating table and ends when the client is admitted to the post anesthesia care unit (PACU)? 1. Preoperative 2. Intraoperative 3. Postoperative 4. Perioperative

2. Intraoperative Rationale: The intraoperative phase begins when the client is transferred to the operating table and ends when the client is admitted to the post anesthesia care unit (PACU), also called the post anesthesia room or recovery room. Th preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating room table. The postoperative phase begins with the admission of the client to the post anesthesia area and ends when healing is complete. Surgery is a unique experience of a planned physical alteration encompassing three phases: preoperative, intraoperative, and postoperative. These three phases are together referred to as the perioperative phase.

Any at-risk client confined to bed, even when a special support mattress is used, should be repositioned at least every 2 hours, depending on the client's need, to allow another body surface to bear the weight. The nurse should NOT place the client in which position? 1. Prone 2. Knee-chest 3. Supine 4. Sims'

2. Knee-chest Rationale: Any at-risk client confined to bed-even when a special support mattress is used-should be repositioned at least every 2 hours, depending on the client's need, to allow another body surface to bear weight. Six body positions can usually be used: prone, supine, right and left lateral (side-lying), and right and left Sims positions. When a lateral position is used, the nurse should avoid positioning the client directly on the trochanter and instead position the client on a 30 degree angle. A written schedule should be established fro turning and repositioning. A knee-chest position would not be appropriate.

There are discharge criteria for clients in the postanesthesia care unit (PACU) regardless of the type of anesthesia used and additional criteria for specific types of anesthesia. Which is the criterion specific for the client who has received spinal anesthesia? 1. Oxygen saturation reaches the pre surgical baseline 2. Motor and sensory function returns 3. Nausea and vomiting are minimal 4. Headache is reported as tolerable

2. Motor and sensory function returns Rationale: The ability to move and feel sensations in all four extremities is especially important after receiving spinal anesthesia (subarachnoid block) because it indicates that nerve damage has not occurred because of the lumbar puncture necessary for the introduction of the anesthetic agent into the subarachnoid space.

The spouse of a client is preparing to apply a sterile dressing. Which of the following indicates a need for further teaching? The spouse: 1. Puts on sterile gloves 2. Places the bulk of the dressing along the edges of a wound 3. Secures the dressing with tap or ties 4. Applies the sterile dressings one at a time over the drain and the incision

2. Places the bulk of the dressing along the edges of a wound Rationale: The proper techniques is to place the bulk of the dressing over the drain area and below the drain, depending on the client's usual position. Sterile gloves must be worn during the procedure. The dressing should be secured with tape or ties. The sterile dressing are applied one at a time over the drain and the incision.

A client has a pressure injury with a shallow, partial skin thickness, and eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry guaze 3. Hydrocolloid 4. No dressing is indicated

3. Hydrocolloid Rationale: Hydrocolloid dressings protect shallow injuries and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry guaze (option 2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

A nurse is documenting data about a deep necrotic wound on a client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissues formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document? 1. Keloid 2. Slough 3. Granulation 4. Eschar

2. Slough Rationale: Slough is stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed. The nurse should document this finding for the client. Option 1: Keloids are hypertrophic scar tissue resulting from excessive collagen formation following a wound injury. Option 3: Granulation has a granular, moist, shiny, beefy, red appearance within the wound bed. This does not correlate with the nurse's assessment findings. Option 4:Eschar is hard or soft necrotic tissue that is tan, black, or brown in color and is firmly attached to the wound bed. This does not correlate with the nurse's assessment findings.

A nurse is performing postoperative teaching a week before surgery. The client is taking 650 mg of aspirin twice daily for arthritis. Which instruction should the nurse expect the surgeon to have the nurse include in the preoperative teaching? 1. Continue to take the aspirin indefinitely 2. Stop taking the aspiring 5 days before surgery 3. Withhold the dose of aspirin on the morning of surgery 4. Reduce the dose of aspirin to 81 mg a day until after surgery

2. Stop taking the aspiring 5 days before surgery Rationale: Acetylsalicylic acid (aspirin) is a salicylate that inhibits thromboxane, which binds platelet molecules together. Ot has a half-life of 15 to 30 hours. It should be discontinued at least 5 days before surgery. Some providers advocate discontinuing aspirin 7 days before surgery.

How many days after surgery should the nurse anticipate that a postoperative client will begin to exhibit signs and symptoms of a wound infection if it should occur? 1. Fifth day 2. Third day 3. Ninth day 4. Seventh day

2. Third day Rationale: Microorganisms introduced into a surgical site take 72 hours to multiply and present local adaptation of pain, swelling, erythema, warmth, and purulent discharge and systemic adaptation of fever and tachycardia.

A client arrives in the post anesthesia care unit. Which is the most important information that the nurse needs to know? 1. Anxiety level before surgery 2. Type and extent of the surgery 3. Type of intravenous fluids administered 4. Special requests that were expressed by the client

2. Type and extent of the surgery Rationale: The type and extent of the surgery are significant pieces of information because there are unique stressors and expected responses to various types of surgery that may direct the plan of care for the client.

When should the nurse initiate planned interventions regarding a client's perioperative management? 1. When the consent is signed 2. When the decision for surgery is made 3. When the client is admitted for surgery 4. When the client is transferred to the operating room

2. When the decision for surgery is made Rationale: The surgical experience begins as soon as the decision for surgery is made. Perioperative nursing responsibilities begin immediately and continue throughout the preoperative, intraoperative, and postoperative phases.

A client had a tonsillectomy and is on a soft diet. Which of the following should the nurse encourage this client to have during the first 24 hours after surgery? Select all that apply. 1. Warm pudding 2. Milk shakes 3. Apple juice 4. Ice pops 5. Gelatin

3, 4, and 5 Rationale: 3; Apple juice is a clear liquid that, when cool, will promote vasoconstriction and limit bleeding from the operative site 4; An ice pop is a frozen clear liquid that promotes vasoconstriction and limits bleeding from the operative site. However, flavors that have a red color are contraindicated because they complicate assessing for bleeding 5; Cool gelatin desserts promote vasoconstriction, limiting bleeding from he operative site. Flavors that have a red color are contraindicated because they complicate assessing for bleeding.

Which of the following actions can the nurse assign to the assistive personnel (AP)? Select all that apply. 1. Teaching preoperative information 2. Managing GI Suction 3. Reinforcing preoperative teaching 4. Reapplying anti emboli stockings 5. Emptying GI suction drainage

3, 4, and 5 Rationale: Preoperative teaching (option 1) includes assessment of the client's learning needs and determining the teaching content and strategies that require professional knowledge and cannot be assigned. However, the AP can reinforce what the nurse has taught the client (option 3). Managing GI suction (option 2) requires application of knowledge and problem-solving and is not assigned to the AP. The AP, however, can assist with emptying the drainage receptacle and reporting changes in amount and color of the drainage to the nurse (option 5). AP frequently remove and apply anti emboli stockings (option 4).

During discharge planning, the nurse is teaching a client how to apply an electric heat pad to his back. Which of the following statements indicates that the patient requires further teaching? 1. "I will not insert any sharp objects into the electric heating pad because the pin could damage the wire and cause an electric shock." 2. "I will ensure tear my back is dry unless there is a waterproof cover on the electric heating pad because electricity in the presence of water can cause a shock." 3. "I do not need to use an electric heating pad with a preset heating switch." 4. "I will not lie on top of the electric heating pad because the heat will not dissipate, and I may be burned."

3. "I do not need to use an electric heating pad with a preset heating switch." Rationale: In applying electric pads, the nurse needs to teach the client the following guidelines: Do not insert any sharp objects (e.g., pins) into the pad. The pin could damage a wire and cause an electric shock. Ensure that the body area is dry unless there is a waterproof cover on the pad. Electricity in the presence of water can cause a shock. Use pads with a preset heating switch so a client cannot increase the heat. Do not place the pad under the client. Heat will not dissipate, and the client may be burned.

Which statement, if made by the client or family member, would indicate the need for further teaching? 1. "If a skin area gets red but then the red goes away after turning, I should report it to the nurse." 2. "Putting foam pads under my heals or other bony areas can help decrease pressure." 3. "If my father cannot turn himself in bed, I should help him change position every 4 hours." 4. "The skin should be washed with only warm water (not hot) and lotion put on while It is still a little wet."

3. "If my father cannot turn himself in bed, I should help him change position every 4 hours." Rationale: Immobile and dependent clients should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a form pad to help relieve pressure.

During a discharge teaching session with a client, which statement by the client indicates a need for further teaching? 1. "Transparent dressings act as a temporary skin." 2. "Transparent dressings are nonporous, nonabsorbent, and self-adhesive." 3. "Transparent dressings cannot be places over a join without disrupting mobility." 4. "Transparent dressings adhere only to the skin area around the wound and not to the wound itself because they keep the wound moist."

3. "Transparent dressings cannot be places over a join without disrupting mobility." Rationale: Transparent dressings are often applied to wounds including ulcerated or burned skin areas. These dressings offer several advantages: they are elastic, they can be placed over a joint without disrupting the client's mobility; they act as temporary skin; and they are nonporous, nonabsorbent, self-adhesive dressings that do not require changing as other dressings do. They often left in place until healing has occurred or as long as they remain intact, and adhere only to the akin area around the wound and not to the wound itself because they keep the wound moist.

The client is most likely to require the greatest amount of analgesia for pain during which period? 1. Immediately after surgery 2. 4 hours after surgery 3. 12 to 36 hours after surgery 4. 48 to 60 hours after surgery

3. 12 to 36 hours after surgery Rationale: Options 1 and 2 are incorrect because the client is still recovering from the anesthesia used during surgery. Option 4 is incorrect because pain usually decreases after the second or third postoperative day.

Which test is the best resource for determining the preoperative status of a client's liver function? 1. Serum electrolytes 2. Blood urea nitrogen (BUN), creatinine 3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin 4. Serum albumin

3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin Rationale: These tests are specific to liver function. Option 1 evaluates fluid and electrolyte status. Option 2 evaluates renal status; option 4 evaluates nutritional status.

A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressing should the nurse select to help promote hemostasis? 1. Transparent 2. Hydrogel 3. Alginate 4. Dry gauze

3. Alginate Rationale: Alginate dressings help establish hemostasis while providing a moist environment for healing and absorption of exudate. They do not adhere to the wound, so removal is unlikely to cause further bleeding. Option 1: Transparent film dressings are used for clients who have a stage 1 pressure injury with minimal drainage. Option 2: Hydrogel dressings are used for clients who have a dry wound and minimal exudate. Option 4: Dry gauze can disrupt angiogenesis, the development of the vascular bed in the wound, thereby causing further bleeding of the wound when removed.

The nurse is caring for a client who has a wound covered with thick necrotic tissue, or eschar, and it requires debridement. What color would this wound most likely be? 1. Red 2. Yellow 3. Black 4. Blue

3. Black Rationale: Black wounds are covered with thick necrotic tissue, or eschar. Black wounds require debridement (removal of necrotic material). Removal of nonviable tissue from a wound must occur before the wound can be staged or heal. Wounds that are red are usually in the late regeneration phase of tissue repair (i.e., developing granulation tissue). They need to be protected to avoid disturbance to regenerating tissue. Yellow wounds are characterized primarily by liquid to semiliquid "slough" that is often accompanied by purulent drainage or previous infection. The nurse cleanses yellow wounds to remove nonviable tissue.

A client received conscious sedation during a colonoscopy. Which should the nurse expect regarding the client's experience with this procedure? 1. Client will be unresponsive and pain free 2. Client will be at risk for malignant hyperthermia 3. Client will be sleepy but able to follow verbal commands 4. Client will be positioned in the supine position to prevent headache

3. Client will be sleepy but able to follow verbal commands Rationale: Conscious sedation involves the use of IV opioids and sedatives to decrease the level of consciousness to a degree where the person can still maintain an airway, can respond to verbal commands, and cannot remember the procedure.

A nurse is caring for a postoperative client. Which action is effective in preventing postoperative urinary tract infections? 1. Eating foods with roughage 2. Taking site baths twice a day 3. Drinking an adequate amount of fluid 4. Increasing the intake of citrus fruit juices

3. Drinking an adequate amount of fluid Rationale: Adequate (2,000 to 3,000 mL/day) fluid intake daily promotes a dilute urine and more frequent emptying of the bladder, both of which limit the development of a urinary tract infection. The stasis of concentrated urine promotes microbial growth.

During discharge planning, the nurse is teaching the client how to maintain comfort, promote healing, and restore wellness. Which of the following actions is NOT correct? 1. Instruct the client to use pain medications as ordered, not allowing pain to become severe before taking the prescribed dose. 2. Teach the client to avoid using alcohol or other central nervous system depressants while taking narcotic analgesics 3. Instruct the client to report promptly to the primary care provider any decreased redness, swelling, pain, or discharge from the incision or drain sites. 4. Emphasize the importance of adequate rest for healing and immune function

3. Instruct the client to report promptly to the primary care provider any decreased redness, swelling, pain, or discharge from the incision or drain sites. Rationale: Instruct the client to report promptly to the primary care practitioner any increasing redness, swelling, pain, or discharge from the incision or drain sites. Instruct the client to use pain medications as ordered, not allowing pain to become severe before taking the prescribed dose. Teach the client to avoid using alcohol or other central nervous system depressants while taking narcotic analgesics. Emphasize the importance of adequate rest for healing and immune function.

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? 1. Utilization of compression stockings at night 2. Deep breathing and coughing exercises daily 3. Leg exercises 10 times per hour when awake 4. Elevation of the legs on 2 pillows

3. Leg exercises 10 times per hour when awake Rationale: Leg exercises are an active intervention by the client that contracts the muscles of the legs. This rhythmically compresses the veins, which promotes venous return and prevents venous stasis.

A client's perineal area must be examined by the primary health-care provider prior to surgery. In which position should the nurse place the client for this physical assessment? 1. Sims 2. Supine 3. Lithotomy 4. Trendelenburg

3. Lithotomy Rationale: The lithotomy position, back-lying with the hips and knees flexed and the legs supported in stirrups, provides optimal visualization of and access to the perineal area for a physical examination.

Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to a nurse, "My incision feels funny all of a sudden." Which should the nurse do first? 1. Take the vital signs 2. Apply the abdominal binder immediately 3. Place the client in low-Fowler position 4. Encourage slow deep breathing by the client

3. Place the client in low-Fowler position Rationale: The low-Fowler position, back-lying position, permits inspection of the operative site and promotes retention of abdominal viscera by gravity if dehiscence has occurred. Also, slight flexion of the hips reduces tension on the abdominal musculature.

A nurse is planning a seminar on dressing wounds. Which of the following is NOT correct information about the purpose of dressing wounds? Dressings are applied to: 1. Protect the wound from mechanical injury 2. Prevent hemorrhage 3. Prevent thermal insulation 4. Protect the wound from microbial contamination

3. Prevent thermal insulation Rationale: Dressings are applied for the following purposes: to protect the wound from mechanical injury, to prevent hemorrhage (when applied as a pressure dressing or with elastic bandages), to provide thermal insulation, and to protect the wound from microbial contamination.

A nurse is to position a client in the post anesthesia care unit. Which factor is most important for the nurse to consider? 1. Allow for skeletal deformities 2. Prevent pressure on bony prominences 3. Provide for adequate thoracic expansion 4. Avoid stretching of neuromuscular tissue

3. Provide for adequate thoracic expansion Rationale: Maintaining an airway and facilitating respirations and oxygenation always are the priorities in the post anesthesia care unit.

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive? 1. Placing a transparent dressing over the pressure injury 2. Applying hydrocolloids to the wound bed 3. Pulsating lavage 4. Using a topical enzyme solution in the wound bed

3. Pulsating lavage Rationale: Pulsating lavage or irrigations provides mechanical debridement by dislodging exudate, debris, and necrotic tissue in the wound bed. Option 1: A transparent film dressing protects a healing stage 1 pressure injury. Option 2: Hydrocolloids are an autolytic debridement using occlusive dressings. Option 4: Topical enzyme solution is a form of chemical enzymatic debridement.

An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the client? 1. Constipation 2. Urinary retention 3. Shallow breathing 4. Inability to provide self-care

3. Shallow breathing Rationale: After abdominal surgery, clients frequently have shallow respirations because when the diaphragm contracts with a deep breath, it increases intra-abdominal pressure, which causes pain at the operative site. Shallow breathing may result in atelectasis, hypostatic pneumonia, or both.

Which is the next most important assessment made by the nurse after ensuring a postoperative client has a patent airway? 1. Condition of drains 2. Level of consciousness 3. Stability of the vital signs 4. Location of the surgical dressing

3. Stability of the vital signs Rationale: Assessment in acute situations always follow the ABCs: airways, breathing, and circulation. Respirations and pulse reflect the cardiopulmonary status of the client.

A primary health-care provider prescribes anti embolism stockings for a client. Place the following steps in the order in which they should be implemented when applying these stockings. 1. Asses the client for contraindications to the use of antiembolism stockings. 2. Apply the antiembolism stockings before getting the client out of bed in the morning. 3. Ensure that the applied stockings are 1 to 2 inches below the popliteal fold (bend) in the back of the knee. 4. Explain that antiembolism stockings are prescribed by the primary health-care provider and what is to be done and why. 5. Measure the smallest circumference of the ankle, the largest circumference of the calf, and the length from the heel to 1 to 2 inches below the popliteal fold (bend) in the back of the knee 6. Turn the stocking inside out so that the foot portion is inside the stocking leg, stretch Esch side of the stocking and ease it over the toes, center the heel, and pull the stocking over the heel and up the legs

4, 1, 5, 2, 6, 3 Rationale: 4; Clients have a right to know what is going to be done and why. 1; Antiembolism stockings should not be applied to a client with such conditions as excessive peripheral edema or lower extremity arterial disease because doing so may make these conditions worse. 5; Antiembolism stockings must fit the size of the client for compression to be effective. If the stockings are too loose, they will not provide adequate compression to facilitate venous return, and if they are too tight, they will have tourniquet effect. 2; The supine position facilitates venous return via gravity, thereby limiting trapping of pooled blood in the lower extremities. When the legs are dependent, they can develop dependent edema. Antiembolism stockings should be applied before the client gets out of bed in the morning before dependent edema has a chance to occur. Antiembolism stockings are elastic garments worn around the legs, thus reducing the diameter of the veins. When the diameter of veins is reduced, the volume and velocity of blood flow increase, preventing venous stasis. Venous stasis promotes the formation of a thrombus. 6; Turning the stocking inside out and stretching each side make it easier to get the elastic over the toes and heel. Centering the heel keeps the stocking straight, providing for even compression 3; Avoiding placement of antiembolism stockings over the popliteal fold prevents damage to the nerves and blood vessels in the popliteal area.

The nurse is assessing a student nurse's knowledge of bandages. Which of the following statements from the student nurse indicates a need for further teaching? 1. "Bandages can be used to support a wound." 2. "Bandages can be used to immobilize a wound." 3. "Bandages an be used to apply pressure to a wound." 4. "Bandages can be firm and tight."

4. "Bandages can be firm and tight." Rationale: The bandage should be firm, but not too tight. Ask the client if the bandage feels comfortable. A tight bandage can interfere with blood circulation, whereas a loose bandage does not provide adequate protection. Bandages can be used to support a wound (e.g., a fractured bone). Bandages can also be used to immobilize a wound (e.g., a strained shoulder). Bandages can be used to apply pressure (e.g., elastic bandages on the lower extremities to improve venous blood flow).

Which statement by the client indicates that the preoperative teaching regarding gallbladder surgery has been effective? 1. "I cannot eat or drink anything after midnight." 2. "I'm not going to cough after surgery because it might open my incision." 3. "I might have a stroke if I stop taking my anticoagulant." 4. "The nurse showed me how to contract and relax my calf muscles."

4. "The nurse showed me how to contract and relax my calf muscles." Rationale: Option 1 is incorrect because of the ASA guidelines for preoperative fasting. Option 2 is incorrect because the clients are taught how to cough and also how to split their incision to prevent complications. Option 3 is incorrect because anticoagulants are discontinued a few days before surgery to avoid excessive bleeding postoperatively.

The regular use of certain medications can increase surgical risk. Which of the following would NOT increase surgical risk as much as the others? 1. Anticoagulants 2. Tranquilizers 3. Diuretics 4. Antibiotics

4. Antibiotics Rationale: Antibiotics would not be as much of a risk as the other medications listed. The regular use of certain medications can increase surgical risk. Consider these examples: Anticoagulants increase blood coagulation. Tranquilizers may interact with anesthetics, increasing the risk of respiratory depression. Diuretics may affect fluid and electrolyte balance. Corticosteroids may interfere with wound healing and increase the risk of infection. Clients may be unaware of the potential adverse interactions of medication and may fail to report the use of medications for conditions unrelated to the indication for surgery. The astute nurse interviewer should question the client and family about the use of commonly prescribed medications, over-the-counter preparations, and any herbal remedies for specific conditions mentioned during the nursing history.

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care? 1. Leave nonbleeding wounds open to the air. 2. Administer a corticosteroid medication. 3. Initiate mechanical debridement. 4. Apply oxygen at 2 L/min via nasal cannula.

4. Apply oxygen at 2 L/min via nasal cannula. Rationale: Following an acute injury, the body responds best by increasing oxygen to improve perfusion, which is essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in clients who have a lack of oxygen or poor perfusion. Option 1: Except for minor superficial scratches, wounds should be covered with sterile dressings to help prevent infection. Infection can delay all phases of wound healing. Option 2: The inflammatory process is decreased when corticosteroids are administered, thereby prolonging the healing process. Option 3: Unless the client has an immediate need for skin restoration, such as with significant burns, debridement is not typically needed during the inflammatory (initial) phase of wound healing.

A nurse is planning a seminar on potential postoperative problems. Which of the following describes a condition in which alveoli collapse and are not ventilated? 1. Thrombophlebitis 2. Pulmonary embolism 3. Pneumonia 4. Atelectasis

4. Atelectasis Rationale: Atelectasis is a condition in which alveoli collapse and are not ventilated. Thrombophlebitis is inflammation of the vein, usually of the legs and associated with a blood clot. Pulmonary embolism is a blood clot that has moved to the lungs and blocks a pulmonary artery, thus obstructing blood flow to a portion of the lung. Pneumonia is inflammation of the alveoli.

A client has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative ileus in this client after surgery? 1. Identify the time of the first bowel movement 2. Monitor the tolerance of a clear liquid diet 3. Palpate the abdominal distention 4. Auscultate for bowel sounds

4. Auscultate for bowel sounds Rationale: Expected bowel sounds are high-pitches gurgling sounds that vary in frequency, intensity, and pitch; they are caused by the propulsion of intestinal contents throughout he lower alimentary tract. These sounds are the first indication that intestinal mortality is returning. Signs and symptoms of a postoperative ileum include a silent abdomen or minimal peristaltic sounds; abdominal distention; nausea; vomiting; anorexia; feeling of fullness; vague abdominal discomfort or cramping; and obstipation/constipation, passage of slight amounts of watery stool, or both.

One hour after the reduction of a compound fracture of the ulna and radius and application of a cast, the nurse observes a centimeter circle of drainage on the client's cast. Which should the nurse do first? 1. Inform the surgeon immediately 2. Reinforce the cast with a guaze dressing 3. Monitor the area frequently for expansion 4. Circle the spot with a pen and date, times and initial the area

4. Circle the spot with a pen and date, times and initial the area Rationale: Circling the spot with a pen and indicating the date, time and initials is appropriate. This determines objectively the time and extent of the bleeding and the person who performed the assessment. The extent of progression of the bleeding can be established objectively using the original circle as a standard.

A client has negative pressure wound therapy (vacuum-assisted closure [VAC]) after the amputation of a toe. The tubing is connected to intermittent negative pressure. What should the nurse do when the film over the wound collapses when negative pressure is exerted? 1. Notify the primary health-care provider. 2. Decrease the extent of negative pressure. 3. Apply a new transparent film over the wound. 4. Continue to observe the functioning of the device.

4. Continue to observe the functioning of the device. Rationale: The device is functioning appropriately. The transparent film will collapse or wrinkle as negative pressure is applied to the wound. This indicted that there are no leaks in the dressing and the negative pressure is functioning.

A nurse is caring for several clients who received general anesthesia. A client with which concurrent health problem poses the highest risk for the development of a postoperative complication? 1. Gastroesophageal reflux disease 2. Reduced reflexes 3. Hypothyroidism 4. Emphysema

4. Emphysema Rationale: Respiratory problems complicate the administration of inhalation anesthesia. Emphysema is characterized by destruction of alveoli, loss of elastic recoil, and narrowing of bronchioles, which result in alveolar hyperinflation and increased airflow resistance.

A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressing should the nurse select to help minimize the pain of dressing changes? 1. Wet-to-dry 2. Abdominal pads (ABD) 3. Dry gauze 4. Hydrogel

4. Hydrogel Rationale: The nurse should select hydrogel for this client because hydrogel does not adhere to the wound bed and maintains moisture, which results in decreased pain. Option 1: Wet-to-dry dressings are usually painful to remove because, as the dressing dries, exudate, necrotic tissue, and healthy tissue adhere to the dressing and are pulled out when it is removed. Option 2: ABD dressings are used over other dressings to absorb excess drainage and should not be place directly over a wound. This type of dressing can cause increased pain on removal when it is placed directly over an open wound. Option 3: Gauze fibers can shed and adhere to the wound bed, causing painful removal.

A client spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection? 1. Intestines 2. Bladder 3. Wound 4. Lungs

4. Lungs Rationale: When postoperative pneumonia (an inflammation of the lung with consolidation and exudation) occurs, client symptoms are evident usually any time within 36 hours after surgery

A hospitalized client who has been receiving medications via a variety of routes for several days is scheduled for surgery at 10 a.m. Which should the nurse plan to do on the day of surgery? 1. Use an alternative route for oral medications 2. Withhold all the previously prescribed medications 3. Withhold the oral medications and administer the other drugs 4. Obtain directions from the primary health-care provider regarding the medications

4. Obtain directions from the primary health-care provider regarding the medications Rationale: This intervention meets the client's needs and adheres to the laws that govern the practice of nursing. A change in the route of medication delivery requires a prescription because medication administration is a dependent function of the nurse.

A nurse is caring for a client who had abdominal surgery. Which type of incisional drainage should the nurse expect 4 hours after surgery? 1. Serous wound drainage 2. Purulent wound drainage 3. Sanguineous wound drainage 4. Serosanguineous wound drainage

4. Serosanguineous wound drainage Rationale: Serosanguineous exudate, a combination of serous and sanguineous drainage, consists of plasma and red blood cells and is pale red and watery. This is the initial drainage expected after surgery.

A nurse is caring for a client with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? 1. Using sterile technique when irrigating the tube 2. Recording intake and output every 2 hours 3. Providing oral hygiene every 4 hours 4. Setting suction at the prescribed level

4. Setting suction at the prescribed level Rationale: The level of suctioning is part of the primary health-care provider's prescription for nasogastric decompression. Low suction pressure is between 80 and 100 mmHg, and high suction pressure is between 100 and 120 mmHg. Suctioning must be maintained continuously with a double-lumen (e.g., Salem sump) to prevent reflux of gastric secretions into the vent lumen, which will obstruct its functioning and result in mucosal drainage. A single-lumen tube requires low intermittent suction to prevent the tube from adhering to the stomach mucosa

A nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following? 1. Unstageable 2. A suspected deep tissue injury 3. Stage 4 4. Stage 3

4. Stage 3 Rationale: The nurse should identify that this client has a stage 3 pressure injury indicated by full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. Stage 3 pressures can have slough, but it is not necessary. Option 1: Unstageable refers to pressure injuries whose stage cannot be determined because eschar or slough obscures the wound. This wound has no eschar or slough. Option 2: A suspected deep tissue injury refers to tissue that is discolored due to underlying tissue damage, boggy, and warm to the touch. If the skin is intact the injury appears as a blood-filled blister. If the skin in nonintact the wound bed will appear very dark in color. Option 3: A stage 4 pressure injury has full-thickness tissue loss with destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, and some eschar and slough.

A client is admitted to the post anesthesia care unit. Which nursing action is most important during the client's stay in this unit? 1. Monitoring urinary output 2. Assessing level of consciousness 3. Ensuring patency of drainage tubes 4. Suctioning mucus from respiratory passages

4. Suctioning mucus from respiratory passages Rationale: Maintaining a patent airway always is the priority to prevent respiratory distress and hypoxia. This follows the ABCs (airway, breathing, circulation) of client care.

Which of the following actions taken by a client self-administering a hot water bottle to his back indicates to the nurse the need for further teaching? 1. The client fills the bag two thirds full with water 2.After filling the bag with water, the client dries the bag and holds it upside down to test for leakage 3. The client expels the remaining air out of the bag before securing the top 4. The client fills the bag with water at a temperature at 135F

4. The client fills the bag with water at a temperature at 135F Rationale: The following temperatures of the water in the bag are considered safe in most situation and provide the desired effect: normal adult and child over 2 years, 46C to 52C (115F to 125F); debilitated or unconscious adult, or client under 2 years, 40.5C to 46C (105F to 115F). The client fills the bag two thirds full with water. After filling the bag with water the client dries the bag and holds it upside down to test it for leakage. the client expels the remaining air out of the bag before securing the top.

Which of the following actions is appropriate for the nurse removing skin sutures? 1. Th nurse puts on exam gloves 2. The nurse removes the skin sutures without an order 3. The nurse grasps the suture at the know with a pair of clamps 4. The nurse cuts the suture as close to the skin as possible

4. The nurse cuts the suture as close to the skin as possible Rationale: The nurse wears sterile gloves, not exam glove. Before removing skin sutures, the nurse needs to verify the orders for suture removal (in many instances, only alternate interrupted sutures are removed one days and the remaining sutures are removed a day or two later) and whether a dressing is to be applied following the suture removal. The nurse will grasp the suture at the knot with a pair of forceps. Sutures are cut as close to the skin as possible on one side of the visible part because the suture material that is visible to the eye is on contact with resident bacteria of the skin and must not be pulled beneath the skin during removal. Suture material that is considered free form bacteria.