Fundamentals Exam 2 Prep

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation

A A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss.

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.

A An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.

What information do anthropometric measurements provide in adults? A) Indirect measure of protein and fat stores B) Direct measure of degree of obesity C) Indication of degree of growth rate D) Reflection of social interaction with others

A Anthropometric measurements are used to determine body dimensions. In children, they are used to assess growth rate; in adults, they give indirect measurements of body protein and fat stores.

While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurses's best response? A) They promote venous blood return to the heart. B) They eliminate peripheral edema. C) They provide a nonslip foot surface to help prevent falls. D) They reduce the risk for impaired skin integrity.

A Anti-embolism stockings are used to promote venous blood return to the heart and help in preventing blood clots. They often do help with edema in the legs, but they do not eliminate edema (nor is this their main goal). They do not provide a nonslip foot surface. If applied incorrectly they can increase the risk for impaired skin integrity.

An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. Which of the following actions should the nurse perform first? A) Explain to the client how the nurse will assist her. B) Position a walker in front of the client to provide stability. C) Enlist the assistance of another nurse or the physiotherapist. D) Have the client stand for 30 seconds prior to walking.

A Any effort to assist a client with mobilization should be preceded by thoroughly explaining the procedure; this optimizes the client's participation and lessens the potential for falls and injuries. The client is unlikely to require a walker or the assistance of multiple care providers, but even if she did, an explanation should still be provided first. It is not necessary to have the client stand for an extended period before ambulating.

A nurse is assessing the activity level of an infant age 5 months. What normal findings would be assessed? A) Ability to sit and head control B) Ability to pick up small objects C) Progress toward running and jumping D) Progress toward unassisted walking

A At 5 months of age, the infant usually has achieved head control and is able to sit alone. Individual variations in activity patterns and neuromuscular development should be expected.

validating data

Confirm the accuracy of data Comparing to normal function Refer to texts, articles, reports Checking consistency Clarifying statements Seeking consensus with colleagues

Ligaments

Connect bone to bone

Ligaments

Connect bone to bone (cartilage)

Tendons

Connect muscle to bone

Effects of applying cold

Constricts peripheral blood vessels Reduces muscle spasms Promotes comfort

Internal girdle

Contracting of abdominal muscles up and gluteal muscles down when stooping, lifting, or pulling

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C)"Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are D) "Assessment data should be collected prior to the physician rounding on the unit."

A Data about the client are collected continuously because the client's health status can change quickly.

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? A) Infection B) Advanced age C) Prolonged fasting D) Long periods of sleep

A Factors that increase a person's basal metabolic rate (BMR) include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones (epinephrine and thyroid hormones). Aging, prolonged fasting, and sleep all decrease BMR.

Cognitive skills

Critical thinking and decision-making skills that use good judgement and sound clinical decision

A nurse is caring for a young adult female client who has a folic acid defiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A) Neural tube deficits in the fetus B) Inadequate absorption of calcium and phosphorus C) Hemolysis of red blood cells D) Impaired neuromuscular functioning

A Folic acid deficiency in pregnant women can lead to neural tube deficits like spina bifida in the fetus. Because fetal neural development begins so early in pregnancy, women in their childbearing years must have adequate folic acid intake. Deficiency in vitamin D intake leads to inadequate absorption of calcium and phosphorus, and a deficiency of mineralization in bones and teeth. Increased hemolysis of red blood cells, poor reflexes, impaired neuromuscular functioning, and anemias are signs of vitamin E deficiency, not folic acid deficiency.

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? A) Fowler's B) Low-Fowler's C) Protective supine D) Semi-Fowler's

A Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following actions will be most effective to transfer the client safely into the chair? A) Have the client sit on the side of the bed for several minutes before moving to the chair. B) Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair. C) Position a friction-reducing sheet under the client. D) Obtain a quad cane for the client to use as a transfer aid.

A Having the client sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

Which of the following are signs and symptoms of poor nutritional status? A) Flaky facial skin, facial edema, pale skin color B) Tongue is a deep red in color with surface papillae present. C) Firm, pink nailbeds D) Firm hair that is resistant to plucking

A Healthy skin is uniform in color and not swollen.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A) Covering the wound area with sterile towels moistened with sterile 0.9% saline B) Closing the wound area with Steri-Strips C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D) Holding the wound together until the physician arrives

A If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.

The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed? A) 45 to 60 degrees B) 15 to 20 degrees C) 30 degrees D) 90 degrees

A In the Fowler's position, the head of the bed is elevated 45 to 60 degrees. Low-Fowler's or semi-Fowler's is positioning of the head of the bed to only 30 degrees. In the high-Fowler's position, the head of the bed is elevated 90 degrees.

Which of the following laboratory results indicates the presence of malnutrition? A) Serum albumin 2.8 g/dL B) Hemoglobin (Hgb) 11.3 g/dL C) Creatinine 1.9 mg/dL D) Hematocrit (Hct) 56%

A Increased Hct indicates dehydration.

The nurse is testing the blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client and turned on the monitor. After removing a test strip from the vial, the nurse should do which of the following? A) Confirm that the strip and the meter share the same code. B) Massage the client's finger toward the selected puncture site. C) Cleanse the client's finger with alcohol. D) Pierce the client's skin with the lancet.

A It is important to confirm that the code on the strip and the meter match. This should precede massaging and cleansing the client's finger or piercing his/her skin.

Which of the following nutritional guidelines should a nurse provide to a client who is entering the second trimester of her pregnancy? A) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." B) "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables." C) "The more food energy you consume, the greater the chances that you will have a healthy pregnancy." D) "Maintain your regular calorie intake, but take some supplements and emphasize organic foods."

A Nutrient needs during pregnancy increase to support growth and maintain maternal homeostasis, particularly during the second and third trimesters. During the last two trimesters, women of normal weight need approximately 300 extra calories per day. Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. It would be inaccurate to encourage the client to maximize calorie intake.

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy? A) Carbohydrates, protein, and lipids B) Vitamins, minerals, and water C) Carbohydrates, protein, and water D) Lipids, vitamins, and minerals

A Of the six classes of nutrients, three supply energy (carbohydrates, protein, and lipids), and three are needed to regulate body processes (vitamins, minerals, and water).

A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan? A) Minimize stress on the wife's joints B) Povide exercise for the husband C) Increase socialization with neighbors D) Maintain self-esteem of the wife

A Older adults often have osteoarthritis, a noninflammatory progressive disorder of the moveable joints, particularly weight-bearing joints. Teaching clients to minimize stress on the joints to prevent possible injury and reduce pain is important.

For which of the following clients should the nurse anticipate the need for a pureed diet? A) A man whose stroke has resulted in difficulty swallowing B) A woman who has required gallbladder surgery C) A man with dementia who is unable to follow instructions D) An obese woman after bariatric surgery

A Pureed diets are indicated for clients who have significant problems chewing and/or swallowing. Surgery and confusion are not indications for this change in the texture and consistency of food.

While performing a physical examination on a client, the nurse observes that the client has scoliosis based on which of the following? A) Lateral deviation of the thoracic spine B) Concave curvature of the cervical spine C) Convex curvature of the thoracic spine D) Concave curvature of the lumbar spine

A Scoliosis is the lateral deviation of the thoracic spine. Concave curvature of the cervical spine, convex curvature of the thoracic spine, and concave curvature of the lumbar spine are the characteristics of a normal spinal alignment.

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute

A Sharp pain in the knee is an example of a subjective cue. Subjective cues are imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a temperature of 102 degrees F, and a pulse rate of 90 beats per minute are examples of objective cues.

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound? A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

A Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned.

D Although various antiseptic cleaning agents could be used to clean a wound, sterile 0.9% normal saline is usually the agent of choice. Other agents may be caustic to skin and tissues.

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem N B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths

D An initial assessment is performed shortly after the client is admitted to a health care agency or service. The purpose of the initial assessment is to establish a complete database for problem identification and care planning.

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A) An infant B) A young adult C) A middle adult D) An older adult

D An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process.

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.

A Strong interviewing skills are needed to obtain the necessary patient data. A common cause of data omission is the nurse's failure to know what information is wanted or not following up on client cues. The nurse only needs to modify the data collection tool if the database is inappropriately organized. If irrelevant or duplicate data is collected, the nurse should determine specific purpose of data collection. Data collection should be ongoing. If the nurse notices that data collection stopped after the initial assessment data were collected, the nurse should update the database.

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following? A) Spreading feet shoulder-width apart to broaden the base of support B) Using the strength of the back muscles during strenuous activities C) Holding the object that you are lifting or moving away from the body D) Pulling equipment, rather than pushing it, when possible

A Techniques that prevent back stress and injury include spreading the feet shoulder-width apart to broaden the base of support; pushing equipment, rather than pulling, whenever possible; holding the object you are lifting or moving close to the body; and using the longest and strongest muscles of the arms and legs to provide power, since the muscles of the back are less strong and more easily injured.

The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate? A) Obtain a mechanical lateral transfer device to move the client onto a stretcher. B) Enlist the aid of two other staff members and pull the client across the bed and onto a stretcher. C) Position a friction-reducing sheet under the client before attempting the transfer. D) Transport the client to the radiology department in the hospital bed.

A The combined weight of the bed and client will be difficult to move safely. Additionally, this strategy does not address the need to transfer the client onto, and off of, equipment in the radiology department.

A nurse performing a nutritional assessment determines that the BMI of a 5'11" (1.8 meters) male client who weighs 81 kilograms is which of the following? A) 25.1 B) 18.5 C) 20.3 D) 28.6

A The formula for calculating BMI is (body weight in kilograms) divided by (body height in meters squared). (weight in kg) (height in meters) * (height in meters)

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the A) situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the C) correct interpretation. Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for D) communication skills.

A The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model

A The nurse is following the Human Needs model based on Maslow's Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.

The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake? A) Encourage his daughter to prepare food at home and bring it to the client. B) Serve large meals and encourage the client to eat as much as possible. C) Provide distractions while the client is fed so that he will eat more. D) Provide bland meals.

A The nurse should solicit food preferences and encourage favorite foods from home, when possible. Be sure the foods look attractive and the eating area is free of odors, clutter, and distractions during mealtime. Provide small, frequent meals to avoid overwhelming the client with large amounts of food.

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position? A) To prevent hyperextension of the neck B) To prevent pressure on the arms C) To lower the client's center of gravity D) To decrease the effort needed to move the client

A The nurse would ask the client to fold the arms across the chest and lift the head with the chin on the chest. Positioning in this manner provides assistance, reduces friction, and prevents hyperextension of the neck.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase

A The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition,a scar forms.

Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how does fiber affect cholesterol? A) Increases fecal excretion of cholesterol B) Decreases fecal excretion of cholesterol C) Facilitates intake and use of trans fat D) Raises blood cholesterol levels

A To help lower serum cholesterol levels, researchers recommend limiting cholesterol intake, eating less total fat, eating more unsaturated fat, and increasing fiber intake. Fiber increases fecal excretion of cholesterol.

A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing one pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response? A) 500 calories/day B) 200 calories/day C) 300 calories/day D) 400 calories/day

A To lose 1 pound (0.45 kg) in a week, daily calorie intake should be decreased by 500 calories a day. One pound of body fat equals about 3,500 calories; 3,500 calories divided by 7 days = 500 calories/day.

A client has been prescribed a clear liquid diet. What food or fluids will be served? A) Milk, frozen dessert, egg substitutes B) High-calorie, high-protein supplements C) Hot cereals, ice cream, chocolate milk D) Jell-O, carbonated beverages, apple juice

D Clear liquid diets contain only foods that are clear liquids at room or body temperature. Included are gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. A full liquid diet includes all fluids and foods that become liquid at room temperature. This would include ice cream, chocolate milk, and liquid dietary supplements.

A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition? A) Unsaturated fats B) Trans fats C) Saturated fats D) Hydrogenated fats

A Unsaturated fat is a healthier form of fat than saturated fat, because it contains less hydrogen, and therefore can be included in the client's diet. Saturated fats are lipids that contain as much hydrogen as their molecular structure can hold, and are generally solid. Most saturated fats are found in animal sources, such as the marbled fat in meat. Saturated fats are responsible for cardiac and vascular diseases. Trans fats are unsaturated fats that have been hydrogenated, a process in which hydrogen is added to the fat. Consumption of trans fats, saturated fats, and hydrogenated fats increases the risk of coronary heart disease.

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe

A When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing).

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed? A) Client restrictions B) Client age C) Client food preferences D) Client restraints

A When attempting to move a client, the nurse would first check the client's chart to see if the client has any physical limitations or restrictions. The nurse would also evaluate the client's condition and determine whether or not the client can help with positioning or understand directions. Lastly, the nurse would evaluate the client's body weight and his or her own strength. Age and food preferences would not affect movement. Clients with restraints still need to be moved and repositioned.

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection

D Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections, because corticosteroids decrease the inflammatory process that may in turn delay healing.

A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly? A) Face the direction of movement. B) Twist body at the waist when lifting. C) Keep body weight higher than center of gravity. D) Keep feet together to provide a base of support.

A When using body mechanics, the nurse should face the direction of movement and avoid twisting the body. Maintaining balance involves keeping the spine in vertical alignment, body weight close to the center of gravity, and feet spread for a broad base of support.

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A) Perform hand hygiene. B) Insert a swab into the wound at 90 degrees. C) Measure the width of the wound with a disposable ruler. D) Assess the condition of the visible wound bed.

A Hand hygiene should precede any wound assessment or wound treatment.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? A) The client's ability to assist B) The client's body weight C) The client's cognitive status D) The client's age

A The nurse assesses several parameters when choosing whether to use a mechanized assistive device for a client transfer. The most important consideration, however, is the client's ability to safely assist with his or her transfer.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following? A) Paralysis of the legs B) Weakness affecting one-half of the body C) Paralysis affecting one-half of the body D) Paralysis of the legs and arms

A Paraplegia is paralysis of the legs, and quadriplegia is paralysis of the arms and legs. Hemiparesis refers to weakness of one half of the body, and hemiplegia is paralysis of one half of the body.

A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which of the following nursing actions is most likely to promote safe handling of this client? A) Provide to the client brief, clear instructions that are phrased positively. B) Post written instructions at the client's bedside to supplement spoken instructions. C) Ask for the client's input on the timing and technique for transfers. D) Ask for the client's feedback frequently during transfers.

A When handling clients who have dementia, clear, short instructions are most effective. These instructions should be phrased positively ("stand up" rather than "don't sit down"). For a client with an advanced state of dementia, asking for feedback during transfers, and input on planning transfers is likely to be ineffective and may be frustrating for both the client and the nurse.

Braden Scale

A tool for predicting pressure ulcer risk

unintentional wound

A wound resulting from trauma

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client'swife B) Medical documents C) Test results D) Assessment data

A' In this case, the primary source of information is the client's wife, as she can provide a detailed description of the incident as well as provide the medical history of the client. The medical files, test results, and assessment data are secondary sources of information.

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A) Secure the heating pad to the client's clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the client if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.

D Guidelines include: Place a heating pad anteriorly or laterally to, not under, the body part. If the heating pad is between the client and the mattress, heat dissipation may be inadequate, leading to burning of the client or the bed linens. Avoid using pins to secure a heating pad because there is a danger of electric shock if a pin touches a wire. Do not cover the heating pad with anything that might be heavy; heat may accumulate and burn the client when it cannot dissipate normally from the pad. Use a heating pad with a selector switch that cannot be turned up beyond a safe temperature

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed

D If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an easy exchange of information. If the nurse stands at the side or foot of the bed and physically looks down at the client, a superior-inferior relationship is communicated and can negatively affect the interview.

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education? A) "I understand the rebound effect of heat." B) "I will put the heat packs only on the sore on my leg." C) "I will only leave the heat packs on for 20 minutes." D) "I will leave the heat packs on for an hour."

D Initially, temperature receptors in the skin are strongly stimulated. This response decreases rapidly for the first few seconds after being stimulated and more slowly for the next 30 minutes as the receptors adapt to the temperature. Be sure to tell clients that increasing the temperature or lengthening the time of application can seriously damage tissues.

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom D) Provide supplies and assist with hard-to-reach areas.

D Morning care is often identified as either self-care, partial care, or complete care. Clients requiring partial morning care most often receive care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach.

A client is discussing weight loss with a nurse. The patient says, "I will not eat for two weeks, then I will lose at least 10 pounds." What should the nurse tell the client? A) "What a good idea. Go ahead. That will jump start your weight loss!" B) "Many people find that to be an ideal way to lose weight quickly and easily." C) "That will increase your metabolic rate and help you lose weight." D) "That will decrease your metabolic rate and make weight loss more difficult."

D Most nutritionists agree that fasting or following a very low-calorie diet defeats a weight-loss plan because the body interprets this eating pattern as starvation, and compensates by slowing down the basal metabolic rate, making it even more difficult to lose weight.

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? A) A client 83 years of age who is mobile B) A client 92 years of age who uses a walker C) A client 75 years of age who uses a cane D) A client 86 years of age who is bedfast

D Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.

Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers

D Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008; Thompson, 2008).

A nurse is discussing infant care with a woman who just had a baby girl. What type of nutrition would the nurse recommend for the infant? A) Solid foods after the first month B) No solid foods until age 1 year C) Bottle feeding with cow's milk D) Breast-feeding or formula with iron

D Nutritional needs per unit of weight are greater in infants than at any other time in the life cycle. Breast-feeding or a commercial formula with iron is recommended as the major source of nutrition for the first 6 to 12 months of life. Cow's milk is not recommended for infants under 1 year. Solid foods are usually not introduced until 6 months.

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."

D Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The only objective data in this question would be that the nurse is unable to palpate a femoral pulse.

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.

D Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria

D Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

Which postural deformity might be assessed in a teenager? A) Kyphosis B) Rickets C) Osteoporosis D) Scoliosis

D Scoliosis, a lateral curvature of the spine, would most likely be assessed in a teenager. Kyphosis and osteoporosis are seen in older adults. Rickets is seen in children.

What is the route of administration for TPN? A) Oral B) Subcutaneous C) Intramuscular D) Intravenous

D TPN meets the client's nutritional needs by way of nutrient-filled solutions administered intravenously through a central line, usually the subclavian or internal jugular veins.

What are the two major processes involved in the inflammatory phase of wound healing? A) Bleeding is stimulated, epithelial cells are deposited B) Granulation tissue is formed, collagen is deposited C) Collagen is remodeled, avascular scar forms D) Blood clotting is initiated, WBCs move into the wound

D The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation.

A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed? A) "I am going to feed you your cereal first, and then your eggs." B) "I wish I had more time so I could feed you all of your meal." C) "I know you don't like me to feed you, but you need to eat." D) "What part of your dinner would you like to eat first?"

D The loss of independence that comes with the inability to self-feed can be a severe blow to a person's self-esteem. Asking the person his or her preference regarding the order of items eaten can help maintain dignity while being fed.

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall? A) The nurse should place his or her feet close together with one foot in front of the other. B) The nurse should rock his or her pelvis out on the opposite side of the client. C) The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D) The nurse should gently slide the client down his or her body to the floor.

D The nurse should place feet wide apart, with one foot in front and rock pelvis out on the side nearest the client. The nurse should grasp the gait belt and support the client by pulling his or her weight backward against his or her body, and then gently sliding the client down his or her body to the floor, protecting the client's head.

What function of the skeletal system is essential to proper function of all other cells and tissues? A) Supporting soft tissues of the body B) Protecting delicate body structures C) Providing storage area for fats D) Producing blood cells

D The production of blood cells (hematopoiesis) is the function of the skeletal system that is essential to all other cells and tissues of the body working properly.

What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care

D Validation is the act of confirming or verifying to plan appropriate nursing care. Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Validation does not identify data to be validated, nor does it establish effective nurse-client communication or relationships with coworkers.

How often would a nurse recommend a client eat or drink a source of vitamin C? A) Once a week B) Once a month C) Three times a week D) Every day

D Vitamin C, a water-soluble vitamin, is usually not stored in the body. Deficiency symptoms are apt to develop quickly when intake is inadequate; a daily intake is recommended.

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information? A) Change the plan of care to include forcing fluids. B) Ask the client to drink more water during the day. C) Post a sign limiting fluids to 1,000 mL every 24 hours. D) Continue with care; this is a normal fluid intake.

D Water intake averages 2,000 to 2,500 mL/day for adults. The nurse would continue with care, because the client has a normal fluid intake.

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A) Do not use irrigation to clean the wound before changing the dressing. B) Hold the fine-mesh gauze over the basin anNd pour the ordered solution over the mesh to saturate it. C) Exert light pressure to pack the wound tightly with moistened dressing. D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

D is the correct step in the procedure. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom, and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The dressing should be gently and loosely packed inside the wound.

objective data

Data that can be measured Vitals Physical Labs DX

Which of the following factors increase BMR? Select all that apply. A) Growth B) Infections C) Fever D) Emotional tension E) Aging

A, B, C, D Feedback: Factors that increase BMR include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones, especially epinephrine and thyroid hormones. Aging, prolonged fasting, and sleep all decrease BMR.

Which of the following clients would be considered at risk for skin alterations? Select all that apply. A) A teenager with multiple body piercings B) A homosexual in a monogamous relationship C) A client receiving radiation therapy D) A client undergoing cardiac monitoring E) A client with diabetes

A, C, E Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory disorders are not risk factors.

Which of the following are functions of the skin? Select all that apply. A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological

A,B,C, E The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination.

When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.

A. Subjective data should be recorded using the client's own words, whenever possible. Quotation marks should be used around the client's statement. The tendency to use nonspecific terms that are subject to individual definition or interpretation should be avoided.

Interpersonal skills

Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family

Effects of applying heat

Dilates peripheral blood vessels. Increases tissue metabolism. Reduces blood viscosity and increases capillary permeability. Reduces muscle tension. Helps relieve pain.

Systemic factors affecting wound healing

Age Etiology Circulation O2 Nutrition Immunosuppression Medications Adherence to TX plan

independent nursing action

An action that does not require a physician's order, but does require critical thinking

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation Documenting and reporting

Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound

B A closed wound results from a blow, force, or strain caused by trauma (such as a fall, an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas. An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment

B A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A) A clean separation of skin and tissue with a smooth, even edge B) A separation of skin and tissue in which the edges are torn and irregular C) A wound in which the surface layers of skin are scraped away D) A shallow crater in which skin or mucous membrane is missing

B A laceration wound can be described as a separation of skin and tissue in which the edges are torn and irregular. An incision wound is described as a clean separation of skin and tissue with a smooth, even edge. An abrasion is a wound in which the surface layers of skin are scraped away. Ulceration is a shallow crater in which skin or mucous membrane is missing.

A nurse has documented that a client has anorexia. What does this term mean? A) Eating more than daily requirements B) Lack of appetite C) Vitamin C deficiency D) Fluid deficit

B Anorexia is lack of appetite. It may be related to multiple factors, including diseases, psychosocial causes, impaired ability to chew and taste, or inadequate income.

Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them. A) True B) False

B Antiembolism stockings may be removed (for example, during morning care to inspect the legs) without the primary care provider writing an order to discontinue them.

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which of the following initial actions by the nurse is appropriate? A) Firmly grasp the client's gait belt. B) Support the client's body against yours and gently slide the client onto the floor. C) Ask the client to lean against the wall while you obtain a wheelchair. D) Apply oxygen and wait several minutes for the weakness to pass. E) Ask the patient, "When was the last time you ate?"

B Assessing for the potential causes of the weakness should occur after the client's safety is assured.

A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs. What is the nurse's best choice of transfer equipment for this client who cannot bear weight on either leg? A) Powered-stand assist B) Transfer chair C) Repositioning lift D) Gait belt

B Chairs that can convert into stretchers are available. These are useful with clients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the client. Powered-stand assist devices and repositioning devices require the client to have weight-bearing capacity in one leg. Gait belts are used to assist clients to ambulate safely.

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to do which of the following? A) Eliminate high-fiber foods B) Eat foods high in folic acid C) Consume saturated fats D) Consume milk products in the last trimester

B Folic acid deficiency in pregnant women can lead to neural tube deficits in the fetus. Women during pregnancy may experience constipation. Increased fiber intake is recommended. Saturated fats are to be eaten only in moderation. Milk products are important during the entire pregnancy.

A nurse is caring for a client with complaints of chest pain. Which of the following test results would indicate whether the client is at risk for cardiac disease? A) Test results of levels of unsaturated fats B) Test results for dyslipidemia C) Test results of levels of balanced proteins D) Test results of levels of calories in each food intake

B Health care providers test for dyslipidemia to assess clients' risks for cardiovascular disease. Measuring levels of protein, calories, or unsaturated fats will not help to assess if a client is at risk for cardiac and vascular disease.

Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device? A) A comatose client who is being taken for x-rays B) An alert client after knee replacement surgery who is being assisted to ambulate C) An obese client who has Alzheimer's disease and is being escorted to the shower room D) A car accident victim with fractures in both legs who is being moved to another room

B Powered stand-assist devices can be used with clients with weight-bearing ability on at least one leg, who can follow directions, and who are cooperative. Clients who are unable to bear partial weight, full weight or who are uncooperative should be transferred using a full body sling lift.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate

B Subjective data are those which the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

Why is it important for the nurse to teach and role model proper body mechanics? A) To ensure knowledgeable client care B) To promote health and prevent illness C) To prevent unnecessary insurance claims D) To demonstrate knowledge and skills

B The correct use of body mechanics is a part of health promotion and illness prevention. The nurse has a major responsibility to teach good body mechanics, both directly and indirectly, by example.

The nurse is preparing to move a patient up in bed with the assistance of another nurse. In what position would the nurse place the patient, if tolerated? A) Reverse Trendelenburg B) Supine C) Sitting D) Semi-Fowler's

B The nurse would adjust the head of the bed to a flat position or slight Trendelenburg, as low as the patient can tolerate. Flat positioning helps to decrease the gravitational pull of the upper body.

Student nurses are turning a client in bed. In order to move the client to the edge of the bed, which positioning instruction is best to give the client when using the friction-reducing sheet? A) Cross the arms across the chest and keep the legs straight. B) Cross the arms across the chest and cross the legs. C) Keep the arms at the sides and the legs crossed. D) Keep the arms folded loosely at the abdomen and the legs straight.

B The nurse would ask the client to cross the arms across the chest, and cross the legs. This facilitates the turning motion and protects the client's arms during the move. Or, if the client is able, the nurse may ask the client to assist by grasping the bed rail on the side toward which the client is turning.

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? A) Every hour B) Every two hours C) Every four hours D) Every shift

B The nurse would turn the client in bed every two hours to avoid complications due to inactivity. The nurse would also include this activity in the client plan of care.

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. N D) If a scar forms over a joint, it may limit movement.

B The proliferative phase of wound healing begins within two to three days of the injury. Collagen synthesis and accumulation continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations.

A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? A) Fever, joint pain, dehydration B) Poor wound healing, apathy, edema C) Sleep disturbances, anger, increased output D) Weight gain, visual deficits, erythema of skin

B The stress of illness, surgery, or prolonged periods of time on simple intravenous therapy without oral intake places hospitalized clients at risk for developing protein-calorie malnutrition. This can result in weakness, poor wound healing, mental apathy, and edema.

Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." N D) "Perhaps we can talk again sometime. Goodbye."

B The successful interview is concluded carefully. After summarizing the data, it is helpful to ask the client if he or she has anything else to tell the nurse. This gives the client the chance to add data the nurse did not think to include.

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A) Change position at least once each shift. B) Implement a turning schedule every two hours. C) Use ring cushions for heels and elbows. D) Do not turn; use pressure-relieving support surface.

B To protect clients at risk from the adverse effects of pressure, implement turning using an every-2-hour schedule in the health care setting. More frequent position changes may be necessary. Never use ring cushions or "donuts."

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family

B Feedback: The nurse should also observe the safety of the immediate environment. Observation is the conscious and deliberate use of the five senses to gather data. Each time a client is observed, the nurse observes current responses, ability to provide self-care, the immediate environment, and the larger environment.

A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply. A) Vitamins B) Proteins C) Fats D) Minerals E) Carbohydrates

B, C,E Of the six classes of nutrients, three supply energy (carbohydrates, proteins, lipids [fats]) and three are needed to regulate body processes (vitamins, minerals, water).

The nurse prepares to administer an intermittent feeding to a client who has a nasogastric feeding tube. Arrange the following steps in the correct order 1. Verify correct tube placement. 2. Position client with head of bed elevated 30 to 45° degrees 3.Aspirate all gastric contents. 4. Flush tube with 30 mL water. 5. Verify that residual volume is less than 400 mL. 6. Administer feeding.

B. 2, 1, 3, 5, 4, 6 The correct order for administering an intermittent feed to a client who has a nasogastric feeding tube is (1) Position client with head of bed elevated 30 to 45° degrees; (2) Verify correct tube placement; (3) Aspirate all gastric contents; (4) Verify that residual volume is less than 400 mL; (5) Flush tube with 30 mL water; and (6) Administer feeding.

When do you check for gastric residual

Before every feeding and every 4-6 hours on continuous feed

How long does planning last?

Begins with first nurse-patient interaction and ends when patient no longer requires care

Fibrinolysis

Breakdown and removal of a clot

Focused assessment

Brief physical at the beginning of shift, in acute care settings, and a specific area of concern

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."

C A possible cause of omission of pertinent data is failing to follow up on cues during data collection. The nurse should ask about what the client uses to self-treat her constipation in order to identify further important information. It is not correct to ignore the statement, ask "why" questions, or make assumptions.

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."

C Avoid questions that impede communication during the interview, including those that can be answered by yes or no, why or how questions, and giving advice.

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."

C Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client communicates that the nurse does not have time or has doubts in the client's ability to communicate.

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

C Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial and may present as a blister or abrasion.

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client? A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin. Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or B) shear. Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or C) cooler as compared with adjacent tissue. Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink D) wound bed, without slough.

C Deep tissue injury may be difficult to detect in individuals with dark skin tones. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client? A) Emaciation B) Cachexia C) Cardiovascular disease D) Anorexia

C Excess abdominal fat may lead to cardiovascular disease, hypertension, and diabetes. Anorexia is the loss of appetite. Emaciation is characterized by excessive leanness. Cachexia is the general wasting away of body tissue.

Which client will have an increased metabolic rate and require nutritional interventions? A) A healthy young adult who works in an office B) A retired person living in a temperate climate C) A person with a serious infection and fever D) An older, sedentary adult with painful joints

C Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing

C Hydrocolloid dressings are used for wounds that are shallow to moderate depth with minimal drainage. Saline-moistened dressing is often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings are recommended for chronic wounds.

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? A) Stage I B) Stage II C) Stage III D) Stage IV

C In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence. In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A) Beta-hemolytic streptococcus B) Age C) V enous insufficiency D) Hemangioma

C Leg and foot ulcers occur from various causes, but the most common are ulcers secondary to venous insufficiency, arterial insufficiency, and neuropathy.

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? A) Milk B) Eggs C) Oatmeal D) Nuts

C Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in diabetics. Milk, eggs, and nuts are proteins.

When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? N A) Allow the client to keep standing for several minutes until balance returns. B) Use the call bell to summon the assistance of another nurse. C) Return the client to the bed. D) Place the client into the wheelchair.

C Once the client is standing, the nurse would assess the patient's balance and leg strength. If the client is weak or unsteady, the nurse would return the client to the bed.

nurse is helping a client design a weight-loss diet. To lose one pound of fat (3,500 calories) per week, how many calories should be decreased each day? A) 100 B) 250 C) 500 D) 1,000

C One pound of body fat equals about 3,500 calories. To gain or lose one pound in a week, daily calorie intake should be reduced by 500 calories per day (3,500 calories divided by 7 = 500 calories per day).

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely affecting the client? A) Thrombophlebitis B) Anemia C) Orthostatic hypotension D) Bradycardia

C Orthostatic hypotension refers to a reduction in blood pressure with position changes from lying to sitting or standing. Blood pooling in the legs increases, thus increasing the postural hypotension. Thrombophlebiits refers to an inflammation of a the veins; it manifests with redness and swelling. Anemia refers to a reduction in hemoglobin. This may present with feelings of weakness. Bradycardia refers to a reduced heart rate.

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

C The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.

A client visits a health care facility with complaints of loss of appetite following a prolonged illness. How should the nurse document the client's condition? A) Emaciation B) Cachexia C) Anorexia D) Nausea

C The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? A) Sitting up B) Lying prone C) Lying flat D) Lying flat with feet raised slightly

C The nurse would position the bed so that the client is lying flat on his/her back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed.

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client? A) Back of the skull B) Elbows C) Sacrum D) Heels

C The sacrum bears the greatest pressure during a sitting position. The back of the skull, elbows, and heels bear pressure in a supine position.

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A) "Oh, for gosh sakes...it doesn't look that bad!" B) "I understand, but you are going to have to look someday." C) "I respect your wish not to look at it right now." D) "You won't be able to go home until you look at it."

C The sight of the wound may disturb a client. If the wound involves a change in normal body functions or appearance, the pclient may not want to look at the wound. With patience and emotional support, clients learn to cope with and adapt to their wounds in time.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest

C The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections.

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency

C The time-lapsed assessment is scheduled to compare a client's current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess health status and to make necessary revisions in the plan of care.

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the patient. What is the rationale for using a transfer board in this procedure? A) To lift the client off the bed. B) To slide the board with the client onto the stretcher. C) To reduce friction as the client is pulled laterally onto the stretcher. D) To protect the client's head from hitting the headboard.

C The transfer board or other lateral-assist device reduces friction, easing work load to move the client. It is positioned partially under the client, across the space between the bed and stretcher.

What independent nursing intervention can be implemented to stimulate appetite? A) Administer prescribed medications. B) Recommend dietary supplements. C) Encourage or provide oral care. D) Assess manifestations of malnutrition.

C There are many methods of stimulating appetite in a client to prevent malnutrition. One independent nursing intervention that is useful is to encourage or provide oral care.

A nurse is placing a client in Fowler's position. What should she teach the family about this position? A) "Use at least two big pillows to support the head." B) "Cross the arms over the client's abdomen." C) "Do not raise the knees with the knee gatch." D) "Keep the hands lower than the rest of the body."

C When positioning the client in Fowler's position, allow the head to rest against the mattress or use only a small pillow. Support the forearms on pillows, with the hand slightly elevated above the forearm. Do not use the knee gatch to raise the knees.

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? A) "I will drink a lot of orange juice and drink milk, too." B) "I will take the zinc supplement the doctor recommended." C) "I will restrict my diet to fats and carbohydrates." D) "I will drink 8 to 10 glasses of water every day."

C Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins C and D, zinc, and adequate fluids are also necessary for wound healing.

A nurse calculates the BMI of a client during a general survey as Under which of the following categories would this 30. client fall? A) Underweight B) Normal C) Overweight D) Obesity Class I

C BMI values are: Underweight <18.5; normal 18.5 to 24.9; overweight 25.0 to 29.9; obesity class I 30.0 to 34.9; obesity class II 35.0 to 39.9; and extreme obesity 40.0+.

Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails

C Subjective data are information perceived only by the affected person. They cannot be perceived or verified by another person. Other terms for subjective data are symptoms or covert data.

The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3. A) 3, 1, 2, 4, 5, 6 B) 1, 2, 4, 3, 5, 6 C) 1, 5, 4, 2, 3, 6 D) 3, 2, 1, 4, 6, 5 E) 1, 3, 2, 4, 5, 6

C) 1, 5, 4, 2, 3, 6

Which of the following activities is normally acquired in the toddler years? Select all that apply. A) Rolling over B) Pulling to a standing position C) Walking D) Running E) Jumping

C, D, E In the toddler, gross and fine motor development continue rapidly; by 15 months, most can walk unassisted, run, and jump. Rolling over and pulling to a standing position are accomplished by the infant.

Nutrients that supply energy

Carbs Proteins Lipids

problem-focused nursing diagnosis

Clinical judgment concerning an undesirable human response to a health condition/life process that exists

risk nursing diagnosis

Clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to a health condition/life process

Hemovac drain

Closed drainage system in which a soft drain is attached to a springlike suction device

Jackson-Pratt drain

Closed system Hollow bulb-like device used to collect drainage

Time-lapses assessment

Compare to baseline and is used in residential settings and patients receiving long periods of care

Evaluating

Comparing observations and data to reach a conclusion about the patient and shows effectiveness of care plan

Walking with crutches

1-2 inches below armpits Hand grips even with hips Weight rests on hands Move crutches first, then injured leg. Follow with strong leg

Protein intake

10-35% of total daily calories 0.8 g/kg daily

Normal

18.5-24.9

Overweight

25-29.9

Obesity 1

30-34.9

Obesity 2

35-39.9

Underweight

<18.5

Extreme obesity

>40

The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing

A A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.

Sensory deprivation

Environment with decreased or monotonous stimuli Impaired ability to receive environmental stimuli Inability to process environmental stimuli

subjective data

Feelings/concerns of the patient Symptoms Health history

Maturation

Final stage Occurs about 3 weeks post injury Can last months to years

Weight

Force exerted on a body from gravity

How do you position the bed during gastric feeds

HOB 30-45 degrees and for at least one hour after feeding is administered

Fowler's position

HOB elevated to 45-60 degrees

Phases of wound healing

Hemostasis Inflammatory Proliferation Maturation

Hemostasis

Immediate Blood vessels constrict and clotting begins Exudate is formed and causes swelling/pain Platelets arrive

propriceptors

Informs brain of location of a limb

Labyrinthine sense

Inner sense of position

Problem focused assessment

Judgement and undesirable human response to a health condition/life process Contains label, related factors, and defining characteristics.

Inflammatory

Lasts 2-3 days WBC, leukocytes, and macrophages move to wound Patient has generalized body response

Proliferation

Lasts several weeks New tissue is built Capillaries grow Epithelial cells grow Granulation and scar tissue form

Going down stairs

Move crutches and affected leg first

role of skeletal system

Movement Mineral storage Support Protection Blood cell formation

stage 2 pressure injury

Partial thickness skin loss with exposed dermis. The wound bed is pink or red and moist, may appear as an intact or ruptured blister.

Local factors affecting wound healing

Pressure Edema Infection Dehydration Maceration Trauma Bleeding Tissue death Biofilm

working phase

Problem Solve

Nursing Diagnosis

Problems nurses can treat independently - they are within the RN Scope of Practice

collaborative problems

Problems that are managed by both physician and nursing prescribed interventions

medical diagnosis

Problems that require physicians to direct the primary treatment

Community interventions

Promote and preserve the health of populations Education Risk factor modification Placing infants on back for sleeping Being current on EBP

functions of the skin

Protection Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption and excretion Production of vitamin D Sensation

Direct care

Reassessment Activities of daily living Physical care Informal counseling Teaching

Physical assessment steps

Review Dx results Provide privacy Gather equipment Hand hygiene Collect objective data

flat bones

Ribs and skull

Abrasion

Rubbing or scraping of epidermal layer of skin

How are compression socks worn?

Should be removed daily and washed at least every 3 days.

Visual/optic reflex

Spatial relationships

Goals should be

Specific, Measurable, Attainable, Realistic, Time-bound

Walking with a cane

Supports weight on stronger side Advances the weaker limb first and followed by unaffected limb

Signs of infection to a wound

Swelling Redness Heat Drainage Odor Pallor

Emergency assessment

TX is immediate and categorized by urgency of coordination

laceration

Tearing of skin and tissue with blunt or irregular instrument

partial thickness wound

The dermis and epidermis of the skin are broken

termination phase

The final, integral phase of the nurse-patient relationship.

dermis

The inner layer of the skin, containing hair follicles, sweat glands, nerve endings, and blood vessels.

Sensory overload

Too much stimuli received Brain is unable to respond meaningfully or ignores stimuli

Going up stairs with crutches

Unaffected leg and crutches first

Related factors

Underlying cause and terms used is "AEB or as evidenced by"

Nutrients that regulate body processes

Vitamins Minerals H2O

heart failure (HF)

a condition in which the heart muscle fails to adequately pump blood around the cardiovascular system, leading to a backup or congestion of blood in the system

cardiomyopathy

a disease of the heart muscle that leads to an enlarged heart and eventually to complete heart muscle failure and death

patient interview

a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories

Penrose drain

a surgical device placed in a wound, cavity or infected area to drain fluid

closed wound

a type of wound in which the skin's surface is not broken

open wound

a type of wound in which the skin's surface is not intact

chronic wound

a wound that does not heal easily

intentional wound

a wound that is the result of a planned surgical or medical intervention

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply. A) Constricts peripheral blood vessels B) Reduces muscle spasms C) Increases blood flow to tissues D) Increases the local release of pain-producing substances E) Reduces the formation of edema and inflammation

a, b, e The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues and decreases the local release of pain-producing substances such as histamine, serotonin, and bradykinin. This action in turn reduces the formation of edema and inflammation. Decreased metabolic needs and capillary permeability, combined with increased coagulation of blood at the wound site, facilitate the control of bleeding and reduce edema formation. Cold also reduces muscle spasms, alters tissue sensitivity (producing numbness), and promotes comfort by slowing the transmission of pain stimuli.

Short-term goals

achievable in less than 1 week

preload

amount of blood that is brought back to the heart to be pumped throughout the body

Flexion

bending

Dorsiflexion

bending of the foot or the toes upward toward the ankle

plantar flexion

bends the foot downward at the ankle. point toes

hemoptysis

blood-tinged sputum, seen in left-sided heart failure when blood backs up into the lungs and fluid leaks out into the lung tissue

sanguineous drainage

bloody drainage

gliding joint

carpals and tarsals

Etiology

cause of disease

contusion

caused by a blunt instrument may result in bruising or hematoma

Maceration

caused by overhydration related to incontinence that causes impaired skin integrity

Y=yellow

cleanse

serous drainage

clear, watery plasma

Assessment Phase

collect data analyze data organize data validate data document data

Animal proteins

complete

necrosis

dead tissue in the wound

B=black

debride

orthopnea

difficulty breathing when lying down pt sleeps with 3 or more pillows

dyspnea

discomfort with respirations, often with a feeling of anxiety and inability to breathe, seen with left-sided heart failure

blood vessels in the skin dilate to

dissipate heat

positive inotropic

effect resulting in an increased force of contraction

hinge joint

elbow and knee

cardiomegaly

enlargement of the heart, commonly seen with chronic hypertension, valvular disease, and heart failure

extension

extending

saturated fats

fats that are solid at room temperature

stage 4 pressure injury

full thickness skin and tissue loss

stage 3 pressure injury

full-thickness skin loss; not involving underlying fascia

nocturia

getting up to void at night

Planning

having a mutual end goal with the patient

cardiac muscle

heart contraction

Why is vitamin D important?

helps absorb calcium and promote bone growth

Plant proteins

incomplete

primary data

information directly from the patient

secondary data

information from family and others

subcutaneous layer

innermost layer of the skin, containing fat tissue

Psychomotor skills

integration of cognitive and motor skills

smooth or visceral muscle

involuntary muscle; around organs, GI tract, blood vessels

unsaturated fats

liquid at room temperature

Prone position

lying face down

Supine position

lying face up

lithotomy position

lying on back with legs raised and feet in stirrups

Sims position

lying on stomach with one leg flexed

dorsal recumbent position

lying on the back with the knees flexed

skeletal muscle

move the body

Abduction

movement away from the midline of the body

Adduction

movement toward the midline of the body

isokinetic

muscle contraction with resistance (lifting weights)

Isometric

muscle contraction without shortening (yoga pose)

Isotonic

muscle shortening and active movement (jogging, swimming, bicycling)

stage 1 pressure injury

non-blanchable erythema of intact skin

Informal counseling

nurses provide support and intervene with patients; nurses use professional guidance to address personal conflicts or emotional problems

indirect care

nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients Communication and collaboration Referrals Research Advocacy Delegation Community interventions

unstageable pressure injury

obscured full-thickness skin and tissue loss

Epidermis

outermost layer of skin

Defining cause

patient problem caused and term used is "r/t or related to"

Label

pattern of related, clustered data

Maslow's Hierarchy of Needs

physiological, safety, love/belonging, esteem, self-actualization

Desiccation

process where the cells dehydrate and die

Evisceration

protrusion of viscera through an incision

gait belt

provide stability have to have leg strength

Document

provide written evidence evidence based

tachypnea

rapid and shallow respirations, seen with left-sided heart failure

erothema

redness

metformin can interact with contrast and cause

renal insufficency

dependent nursing action

requires a physicians order

afterload

resistance against which the heart has to beat

Five Rights of Delegation

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

Animals fats

saturated

First step in planning

setting priorities

pulmonary edema

severe left-sided heart failure with backup of blood into the lungs, leading to loss of fluid into the lung tissue

ball and socket joint

shoulder and hip

Three types of muscles

skeletal, cardiac, smooth

Goal Setting Theory

specific measurable attainable relevant time-bound

irregular bones

spinal column and jaw

Hyperextension

straightening beyond normal

edema

swelling

Long-term goals

takes weeks or months to achieve

Avulsion

tearing of a structure from anatomic position

Complex wound

the dermis and underlying subcutaneous fat tissue are damaged or destroyed

full thickness wound

the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved

Implementation

the process that is carried out

purulent drainage

thick green, yellow, or brown drainage

serosanguineous drainage

thin, watery drainage that is blood-tinged

Circumduction

think arm circles

saddle joint

thumb

documentation has to be

timeliness, safe, confidentiality, clear information

R=red

to protect

health promotion nursing diagnosis

trying to get the person to a healthier state

Vegetable fats

unsaturated

long bones

upper and lower extremities

acute wound

usually heal within days to weeks

cardiac output

volume of blood being pumped by the heart

Extensor/stretch reflex

when muscles overstretched, causes reflex contraction

orientation phase

when the nurse and the patient meet and get to know each other

condyloid joint

wrist and fingers

pivotal joint

wrist at proximal radius/ulna

short bones

wrists and ankles