NUR 1018 Final Exam PPT

Which statement made by the caregiver of a home care client indicates the need for more teaching regarding pressure ulcer prevention? A. "I help him shift his position every 15 to 30 minutes when he sits up in a chair." B. "I massage his tailbone every morning because it is red." C. "I apply lotion to his arms and legs daily because they are dry." D. "He drinks a nutritional supplement between meals to maintain his weight."

"I massage his tailbone every morning because it is red"

Vacuum assisted wound dressing is best defined as which of the following? A Term used when sterile maggots are placed on the wound to digest the necrotic tissue of the wound B. A compression bandage used to seal the wound and promote moist to dry debridement. C. A cellular therapy used to introduce stem cells into the wound bed and promote healing. D. A negative pressure dressing used to remove excess fluid from the wound.

A negative pressure dressing used to remove excess fluid from the wound

What are the steps of evidence-based practice. Select all that apply: A. Cultivate a spirit of inquiry B. Ask a clinical question in PICOT format C. Clinically appraise the evidence D. Ask a patient for their preferences on care E. Get permission to implement your study

ABCD

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? SELECT ALL THAT APPLY: A. An older adult who is bed-ridden B. A client with a peripheral vascular disorder C. A client who is obese D. A client who eats a diet high in vitamins A and C E. A client who is taking corticosteroid medication F. A 10 year old client with a surgical incision

ABCE

A nurse is standing beside the patient's bed and the following exchange occurs. Nurse: How are you doing? Patient: I don't feel good. Which element will be identified as feedback? A. How are you doing? B. Patient C. Nurse D. I don't feel good.

I don't feel good

The patient is at risk of shearing forces on the skin. Which interventions would the nurse provide for this patient? Select all that apply. A. Maintain head of bed below 30 degrees unless contraindicated. B. Turn the patient from side to side every two hours. C. Have the patient use the trapeze for moving up in bed. D. Have the patient sit in a bedside chair as much as possible.

Maintain head of bed below 30 degrees unless contraindicated. Have the patient use the trapeze for moving up in bed.

What does NCLEX stand for? A. National Council of Legendary Executives B. National Council Licensure Examination C. National Coalition Licensure Examination D. National Center for License and Examination

National Council Licensure Examination

The nurse asks a patient where their pain is located, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? A. Verbal B. Intonation C. Vocabulary D. Nonverbal

Nonverbal

A patient is admitted with a wound over his left trochanter. It measures 4 cm deep and 5 cm in diameter and the bone is exposed. How would you document this finding? A. Stage I pressure ulcer B. Stage II pressure ulcer C. Stage III pressure ulcer D. Stage IV pressure ulcer

Stage IV pressure ulcer

The staff is having difficulty getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? A. Ask the patient for explanations B. Allow the patient to reminisce C. Involve only the patient in conversations D. Try changing topics often

allow the patient to reminisce

What is an advantage to following a clinical pathway for a specific set of medical diagnoses? A. Allows for sequencing of care on a specific day B. Allows for nursing diagnosis to link together with a physical assessment C. Allows the nurse to plan their own care for the patient D. Provides a map to allow for data to be assessed in a specific manner.

allows for sequencing of care on a specific day

The client has a wound that is in need of debridement. The nurse expects to perform which intervention? A. Application of a dry gauze dressing. B. Application of a continuously moist dressing. C. Application of wet to dry dressing changes. D. Application of antibiotic ointment.

application of wet to dry dressing changes

Which description best fits that of sanguineous drainage? A. Fresh Bleeding B. Thick and Yellow C. Clear and Watery D. Mixed clear and blood tinged

fresh bleeding

Which of the following increase the risk of an elderly client developing a pressure injury (ulcer)? A. Adequate Nutrition B. Actinic keratosis C. Immobility D. WBC count of 10,000

immobility

The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article? A. Literature Review B. Results C. Introduction D. Methods

introduction

The nurse reviews the documentation in the client's chart, and reads an entry that says the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to find on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial thickness skin loss

partial thickness skin loss

Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? A. Preinteraction B. Termination C. Working D. Orientation

preinteraction

Categories of the Braden scale include which of the following? Select all that apply: A. Sensory Perception B. Moisture C. Mobility D. Perfusion E. Nutrition

sensory perception, moisture, mobility, nutrition

The patient is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. The patient is at risk for developing a pressure injury on his coccyx because of. A. Maceration B. Shearing Force C. Impaired Peripheral Circulation D. Nutrition

shearing force

What does the "T" stand for in PICOT? A. Time B. Terminate C. Texture D. Trending

time