EXAM 2 PREP U
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A. a surgical incision with sutured approximated edges B. a large wound with considerable tissue loss allowed to heal naturally C. a wound left open for several days to allow edema to subside D. a wound healing naturally that becomes infected.
A. a surgical incision with sutured approximated edges
The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client's A. apical pulse. B. breath sounds. C. jugular veins. D. carotid arteries.
A. apical pulse ----emphysema: is a lung condition in which the alveoli of the lungs are damaged making it hard to breathe----
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? A. contusion B. incision C. avulsion D. puncture
A. contusion ---> BRUISE AVULSION IS the action of pulling or tearing away.
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? A, "Dehiscence is not anything that you need to worry about." B."Dehiscence is when a wound has partial or total separation of the wound layers." C. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." D. "Dehiscence is the softening of tissue due to excessive moisture."
B. "Dehiscence is when a wound has partial or total separation of the wound layers." -----Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed--------
In which order should a nurse perform the appropriate physical assessment techniques to assess the carotid artery? A. Inspect then auscultate B. Auscultate then palpate C. Palpate then auscultate D. Inspect then palpate
B. Auscultate then palpate
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? A. "I should keep this on my ankle until it is numb." B. "I must wait 15 minutes between applications of cold therapy." C. "I will put a layer of cloth between my skin and the ice pack." D. "I can let this stay on my ankle an hour at a time."
C. "I will put a layer of cloth between my skin and the ice pack."
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? A. supine B. prone C. Sims' D. Fowler's
C. Sims ---PRONE IS LAYING ON YOUR STOMACH--
The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? A. "I may have staples in place for a number of days." B. "I will not remove the staples myself." C. "After delivery, I will have sutures in place." D. "Reinforced adhesive skin closures will hold my wound together until it heals."
D. "Reinforced adhesive skin closures will hold my wound together until it heals."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? A. "To preserve the client's functional ability to grasp and pick up objects." B. "To prevent foot drop." C. "To avoid contractures." D. "To prevent the legs from rotating outward."
D. "To prevent the legs from rotating outward."
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect? A. vitamin A B. vitamin B C. vitamin C D. vitamin D
D. vitamin D
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon True OR False
TRUE
A client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment? A. "Do not douche for 24-48 hours before the procedure." B."Douching is recommended so that you are clean for the examination." C. "Plan to begin douching routinely immediately after your procedure." D. "The Pap procedure includes application of a douche."
A. "Do not douche for 24-48 hours before the procedure." ---DOUCHE MEANS WASH---
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? A. "Your wound will heal slowly as granulation tissue forms and fills the wound." B. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." C. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." D ."As soon as the infection clears, your surgeon will staple the wound closed."
A. "Your wound will heal slowly as granulation tissue forms and fills the wound."
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? A. Adduction B. Abduction C. Circumduction D. Extension
A. Adduction
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. An infant's skin and mucous membranes are easily injured and at risk for infection. B. In children younger than 2 years, the skin is thicker and stronger than in adults. C. A child's skin becomes less resistant to injury and infection as the child grows. D. An individual's skin changes little over the life span.
A. An infant's skin and mucous membranes are easily injured and at risk for infection.
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? A. Angina B. Musculoskeletal C. Gastrointestinal D. Crushing
A. Angina ----angina is ischemic chest pain which only last for about 20 minutes----
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? A. Bruits B. Murmurs C. Normal findings D. Gallops
A. Bruits
A nurse is teaching an adolescent client about nutrition following a hospital admission. What should the nurse understand about adolescent nutrition? A. Childhood nutrition problems may worsen during adolescence. B. Nutritional needs decrease during adolescence. C. Adolescents tend to eat meals at home. D. Adolescents eat their food slowly.
A. Childhood nutrition problems may worsen during adolescence.
A nurse is caring for a client who reports frequent nausea. Which food should the nurse recommend to the client when the nausea is relieved? A. Clear fruit juices B. Boiled vegetables C. Mashed potatoes D. Carbonated beverages
A. Clear fruit juices
Which symptom is a known side effect of antibiotics? A. Diarrhea B. Constipation C. Fecal impaction D. Abdominal bloating
A. Diarrhea
What nursing diagnosis would be most appropriate for a client admitted with heart failure? A. Ineffective tissue perfusion B. Acute pain C. Risk for denial D. Impaired gas exchange
A. Ineffective tissue perfusion
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? A. Local capillary pressure must be lower than external pressure. B. The heart must be able to pump adequately. C. The volume of circulating blood must be sufficient. D. Arteries and veins must be patent and functioning well.
A. Local capillary pressure must be lower than external pressure. -----Local capillary pressure must be higher than external pressure for adequate skin perfusion.----- (GAS EXCHANGE BETWEEN TISSUE AND THE BLOOD)
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? A. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. B. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. C. Carefully pick the crusts off the sutures with the forceps before removing them. D. Do not attempt to remove the sutures because the wound needs more time to heal.
A. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.
Symptoms of complete arterial occlusion include which of the following? Select all that apply. A. Numbness B. Color change C. Pain D. Erythema F. Heat
A. Numbness B. Color change C. Pain
A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? A. Shortness of breath B. Painful breathing C. Rapid breathing D. Inability to breathe
A. Shortness of breath
A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition? A. Total parenteral nutrition (TPN) B. Partial or peripheral parenteral nutrition (PPN) C. Percutaneous endoscopic gastrostomy tube (PEG) D. Percutaneous endoscopic jejunostomy tube (PEJ)
A. Total parenteral nutrition (TPN)
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet? A. a diet lacking in fruits and vegetables B. a diet lacking in glucose and water C. a diet consisting of whole grains, seeds, and nuts D. a diet lacking in meat and poultry products
A. a diet lacking in fruits and vegetables -----FRUITS AND VEGS ARE HIGH IN FIBER---
The older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What actions will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply. A. assess the client's skin prior to the application of heat B. ensure that the aquathermia unit contains water to the appropriate level C. apply the heating pad to the client's back for intervals of 1 hour D.instruct the client to lie on the pad to keep the pad in its proper position E. set the temperature on the unit to the maximum heat setting
A. assess the client's skin prior to the application of heat B. ensure that the aquathermia unit contains water to the appropriate level
A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply. A. insufficient protein and vitamin C intake B. compromised peripheral circulation C. weak tissue and muscular support due to obesity D. serous fluid accumulation preventing skin tissue approximation E.distention of the abdomen from accumulated intestinal gas
A. insufficient protein and vitamin C intake C. weak tissue and muscular support due to obesity E.distention of the abdomen from accumulated intestinal gas
While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem? A. left-sided heart failure B. palpitations C. hypertension D. dextrocardia
A. left-sided heart failure
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? A. preventing the client from sliding in bed B. lubricating the area with skin oil C. Improving the client's hydration C. pulling the client up from under the arms
A. preventing the client from sliding in bed
The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? A. transparent film B. 2 × 2 in (5 × 5 cm) gauze C. hydrocolloid dressing D. hydrogel sheet
A. transparent film
A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as: A. tremor B. athetosis C. dystonia D. ataxia
A. tremor ---INVOLUNTARY SHAKING--- - Athetosis is movement characterized by slow, irregular, twisting motions. - Dystonia is similar to athetosis but usually involves larger areas of the body. - Ataxia is a general term used to describe impaired muscle coordination.
A client birthed twins via cesarean and is learning to care for her incision. Which teaching will the nurse include? A. "You only need a binder to hold your incision together." B. "It is important to keep your sutured incision clean." C. "Reinforced adhesive skin closures can be peeled off after 48 hours." D. "You will have staples in place for several weeks."
B. "It is important to keep your sutured incision clean."
A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? A. Size B. Depth C. Tunneling D. Direction
B. Depth
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A. Pasta salad B. Fish C. Banana D. Green beans
B. Fish -----YOU WANT A DIET HIGH IN PROTEIN-----
A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply. A. Measure each leg and take an average to determine size to order. B. Order at least two pairs of stockings. C. Plan to put the stockings on the client right before bedtime. D.Remove the stockings and massage the legs once each day. E.Launder the stockings at least every three days.
B. Order at least two pairs of stockings. E.Launder the stockings at least every three days.
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient? A. Calcium B. Vitamin K C. Potassium D. Vitamin C
B. Vitamin K
The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area? A. percussion B. auscultation C. light palpation D. deep palpation
B. auscultation
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? A. increase in the movement of secretions in the respiratory tract B.increase in circulating fibrinolysin B. predisposition to renal calculi C. increased metabolic rate
B. predisposition to renal calculi ---> KINDEY STONES In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria;
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? A. gauze B. transparent C. hydrocolloid D .bandage
B. transparent
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? A. elevate the head of the bed 90 degrees B. use pillows to maintain a side-lying position as needed C. provide incontinent care every 4 hours as needed D. place a foot board on the bed
B. use pillows to maintain a side-lying position as needed
The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next? A. Move the opposite arm forward to above the head of the client. B.Return the arm to the starting position at the side of the body. C.Rotate the lower arm and hand so the palm is up. D. Move the arm across the body as far as possible.
B.Return the arm to the starting position at the side of the body.
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? A. "You will receive medication through this device." B. "This drain minimizes the chance for bacteria to enter the surgical site." C. "It provides a way to remove drainage and blood from the surgical wound." D. "The bulb-like system will stay in place permanently after your mastectomy."
C. "It provides a way to remove drainage and blood from the surgical wound."
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A. Use clean technique to clean the wound. B. Clean the wound in a circular pattern, beginning on the perimeter of the wound. C. Clean the wound from the top to the bottom and from the center to outside. D. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.
C. Clean the wound from the top to the bottom and from the center to outside.
Which laboratory test is the best indicator of a client in need of TPN? A. Hemoglobin B. Hematocrit C. Serum albumin D. Creatinine
C. Serum albumin --Assessment of serum albumin level is the best indicator of a client in need of total parenteral nutrition (TPN). Clients whose levels are 2.5 g/dL (25 g/L) or less are at severe risk for malnutrition. Creatinine is used to assess kidney function. Hemoglobin and hematocrit assess the red blood cells of a client--
A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? A. Tearing of the skin and tissue with some type of instrument; tissue not aligned B. Cutting with a sharp instrument with wound edges in close approximation with correct alignment C. Tearing of a structure from its normal position D. Puncture of the skin
C. Tearing of a structure from its normal position
The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed? A. The client uses the arms of the chair as support when standing up to use the walker. B. The client steps into the walker before moving the walker forward. C. The client pushes the walker ahead, following behind it. D. When arising from a chair, the client puts one hand at a time on the walker.
C. The client pushes the walker ahead, following behind it. ----This makes the client and walker unstable and may result in a fall.-----
What is a benefit of regular exercise over time? A. increased risk for blood clots B. increased work of breathing C. decreased heart rate D. decreased venous return
C. decreased heart rate
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation? A. high intake of fiber B. constant urges to defecate C. inadequate intake of liquid D. constant physical activity
C. inadequate intake of liquid ---Primary constipation results from lifestyle factors such as insufficient fluid intake, inadequate intake of fiber, inactivity, or ignoring the urge to defecate.----
A nurse is caring for a client with chronic anemia. What should be included in the diet of this client? A. dairy products B. citrus fruits C. red meat D. yellow vegetables
C. red meat
At what period of life do nutrient needs stabilize? A. Infancy B. Adolescence C. Pregnancy D. Adulthood
D. Adulthood
The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? A. Avoid using irrigation to clean the wound before changing the dressing. B. Apply dry gauze to the wound and carefully apply saline to saturate it. C. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. D. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.
D. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.
A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: A. decubitus ulcers. B. pooling of blood. C. blood pressure changes. D. Foot drop.
D. Foot drop.
The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition? A. Potassium B. Sodium C. Magnesium D. Iodine
D. Iodine
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? A. The nurse uses a safety pin to attach the pad to the bedding. B. The nurse covers the heating pad with a heavy blanket. C. The nurse places the heating pad under the client's neck. D. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
D. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? A. puncture B. laceration C. contusion D. avulsion
D. avulsion
The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of A. pulmonary emphysema. B. diastolic murmurs. C. patent ductus arteriosus. D. increased central venous pressure.
D. increased central venous pressure.