Quiz 2 Tissue Integrity & Gas Exchange

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider (HCP) immediately? A. The stoma is dark red to purple B. The stoma is slightly edematous C. The stoma oozes a small amount of blood D. The stoma does not expel stool

A. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

Which steps help to manage infection control with PICC line dressing changes? Select all that apply A. Ensure the client and nurse wear a mask prior to the beginning the dressing change B. Don sterile gloves after removing previous dressing C. Scrub skin with chlorhexidine using sterile gauze to hold the line in place D. Use soap and water to clean skin around Statlock

A, B, C These answers are correct because sterile gloves should be donned after removing the previous PICC line dressing. Steps to help prevent infection when changing a PICC line may include: masking the client and the nurse prior to starting the dressing change; don sterile gloves after removing the previous PICC line dressing; and scrub the skin with chlorhexidine (antimicrobial) using sterile gauze to hold the line steady and in place. The dressing is a sterile dressing change

The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply A. Pressure redistribution turn every 1-2 hour B. Encourage a diet high in protein and calories C. Keep clients clean and dry by managing incontinence D. Rub and massage the clients pressure injuries

A, B, C These answers are correct because pressure redistribution and turning every 1-2 hours helps prevent pressure injuries. This answer is correct because a diet high in protein and calories will help prevent skin breakdown and pressure injuries. When a client has a low albumin and protein is low, the client has a much higher risk of skin breakdown. The client should be checked every 1-2 hours and changed if incontinent. Mild soaps and skin moisturizers should be utilized to help prevent breakdown. . Dry intact skin breaks down much faster than dry intact moisturized skin.

Which of the following describes the function of wound dressings? Select all that apply. A. Protects surgical incision from infection B. Absorbs excess drainage C. To dry out the incision D. Creates a sterile field for the incision E. Allows for wound friction

A, B, D These answers are correct because the dressing acts as a barrier to prevent the client from contracting an infection. Without the dressing, the client is a risk for cross contamination as well. The nurse must follow the orders of the healthcare provider to properly take care of the clients needs. This answer is correct because the dressing absorbs excess drainage. The dressing helps to promote healing by keeping the incision moist. Without the dressing it causes the incision to become dry and hinders the healing process and causes the client excess pain. This answer is correct because a sterile dressing protects the incision and promotes healing. The dressing protects the incision from trauma and infection. The nurse will use aseptic technique when taking care of the clients incision

Which of the following are primary risk factors for pressure ulcers? Select all that apply. A. Fever B. Low-protein diet C. Insomnia D. Sleeping on a waterbed E. Lengthy surgical procedures

A, B, E Protein is needed for adequate skin health and healing. During surgery the patient is on a hard surface for a long period of time and their body is not well protected from pressure on bony prominences. Fever causes diaphoresis so the patient's skin is moist leading to skin breakdown, and the stress on the body can cause their circulation to be impaired leading to a decrease in skin integrity.

When drawing blood from a patient's peripherally inserted central catheter (PICC), what should the nurse do to minimize the pressure on the device during flushing? A. Use a 10-mL syringe for the flush B. Cleanse the catheter hub with an alcohol swab C. Clamp the device D. Use 3-mL syringe for the flush

A. A 10-mL syringe would be used during the flush to minimize pressure on the device. Clamping the device would hinder the nurse's ability to flush the catheter. A 3-mL syringe would not reduce pressure on the device during the flush.

Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk? A. 30-degree side lying B. 90-degree side lying C. Sitting with the head of the bed elevated 75-degrees D. Lying supine with the bed flat at all times

A. A 30-degree side lying position puts the least amount of pressure on bony prominences. The others will increase pressure in at risk areas for a pressure ulcer to form.

A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient? A. A gauze dressing placed over catheter exit site B. Antibacterial ointment applied at the exit site and covered with a gauze dressing C. A transparent dressing placed over the gauze dressing at the catheter exit site D. A transparent dressing applied over catheter exit site

A. A gauze dressing should be used with a patient who perspires excessively because it wicks the moisture away from the catheter exit site.

Which skin preparation would be best to apply around the client's colostomy? A. adhesive skin barrier B. petroleum jelly C. cornstarch D. antiseptic cream

A. An adhesive skin barrier is effective for protecting the skin around a colostomy to keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag.

What is the nurse's initial action when preparing to change a patient's colostomy pouching system? A. Applying clean gloves B. Draping the patient appropriately C. Assessing the surrounding skin for signs of irritation D. Emptying the colostomy

A. Applying gloves first will protect the nurse while checking the stoma for leakage and assessing the patient's skin for irritation. Although it is appropriate to drape the patient, FIRST put on gloves. The nurse will need to empty the pouch, but this is not the best initial action. Although it is appropriate to assess the skin, doing so would not be the nurse's first action.

A nurse is teaching a new nurse how to remove a midline catheter. The nurse asks the new nurse what the minimum amount of time is to hold pressure on the site after the catheter is removed. Which of the following responses would indicate the new nurse understood the teaching? A. 30 seconds B. 15 seconds C. 1 minute D. 2 minutes

A. Applying pressure for 30 seconds is an adequate amount of time for clotting to occur and stop bleeding. Pressure should be held longer in patients taken anti-coagulants or anti-platelets.

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? A. Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention. B. Thoroughly explain the procedure to the patient C. Position the patient comfortably before the intervention. D. Use a distraction technique to divert the patient's attention during the procedure.

A. By pre-medicating the patient before the intervention, it allows for the patient's pain to be controlled and for a comfortable state during dressing change. Distracting, re-positioning and explaining the procedure to the patient does not prevent or diminish the patient's pain.

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's peripherally inserted central catheter (PICC) site? A. Discard the first 6-9 mL of blood drawn. B. Allow fluid infusions to continue to flow right up to the time of the sample. C. Flush the catheter after aspirating for blood return. D. Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample.

A. Discarding the first sample reduces the risk of drug concentrations or a diluted specimen. Allowing fluid infusions to continue to flow right up to the time of the sample could alter the sample. Flushing the catheter after aspirating for blood return would have no effect on the quality of the sample. The patient need not be asked to rest before the sample is taken.

A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the drain is to; A. promote drainage of wound exudates B. provide access for wound irrigation C. minimize development of scar tissue D. decrease postoperative discomfort

A. JP Drains are inserted postoperatively in appendectomies when an abscess was present, or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

When pouching a patient's colostomy, which action reduces the patient's risk for injury? A. Protecting the skin from irritation caused by fecal drainage B. Measuring output when emptying the contents of the pouch C. Maintaining the patient's bowel elimination function D. Promoting the patient's autonomy with bowel elimination care

A. Protecting the skin from irritation caused by fecal drainage ensures correct pouching and prevents injury associated with skin breakdown.

A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching? A. Central parental nutrition B. Fresh frozen plasma C. Long-term antibiotic therapy D. RBC's

A. Rationale: Central parenteral nutrition needs to be given through a central line. Administering through a midline line will cause phlebitis due to the osmolality of the CPN.

When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next? A. Notify the practitioner B. Discontinue the catheter and start a peripheral IV line C. Flush each catheter lumen with 10 ml of normal saline followed by an antibiotic flush solution D. Swab the site with antiseptic solution, apply povidone-iodine ointment, and apply a gauze dressing

A. Redness, swelling, and drainage at the catheter exit site are signs of infection, and the practitioner should be notified to make a decision regarding blood and catheter exit site cultures for further evaluation.

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. B. Apply skin protectant while the stabilization device is off C. Cleanse the insertion site quickly and gently in concentric circles D. Lower the patient's head during the dressing change

A. The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change. Skin protectant should be applied before placing a new catheter stabilization device.

An 89-year-old client had right hip surgery a week ago. The rehab nurse assesses a purple maroon-colored blood-filled blistered area to the client's right heel. How should the nurse document her findings? A. A right heel deep tissue injury B. A stage 1 right heel pressure injury C. A stage 2 right heel pressure injury D. A stage 3 right heel pressure injury

A. This answer is correct because a deep tissue injury involves tissue loss to the muscle and appears as a maroon, purple or red injury that may be a blood-filled blister or bulla. The tissue damage may not be visible at first, but the tissue damage is extensive and involves bone, tendon, and ligament

Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)? A. Use a sterile technique when changing the PICC dressing. B. Take blood pressure in the arm with the PICC line C. Change the IV tubing every 72 hours D. Use only macro-drip tubing with IV infusions through the PICC line.

A. Using sterile technique is the most important to include because it decreases risk of bacteria entering the body, going directly to heart, and causing infection (endocarditis or myocarditis). Changing IV tubing is important but not a priority over maintaining a sterility during dressing change. You would NOT place a blood pressure cuff on the arm with the PICC line.

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? A. Wear clean gloves to remove soiled dressings B. Using a circular motion to cleanse the wound before collecting the specimen. C. Sending the specimen to the lab within 30 minutes of collecting it D. Completing the lab requisition form in a timely manner after collecting the specimen

A. Wearing clean gloves to remove soiled dressings minimizes the risk of cross contaminating the wound. The proper procedure is to wipe away old exudate by swabbing outward from the wound.

Why should PICC lines be changed every 7 days and prn? A. The dressing begins to irritate the skin of the client after a week B. The client is at a high risk for infection at the insertion site C. Tests have proven that no infection will begin before a week D. The nurse supervisor mandates a weekly dressing change

B. This answer is correct because the client is at a high risk of infection at the insertion site. PICC lines should be changed weekly due to the risk of infection that can get into the bloodstream of the client. Signs/symptoms of infection may include redness, edema at the site, pain at the site, pyrexia, rigors, and fluid leaking from the site. Infection may occur within 48-72 hours after insertion.

A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B. This answer is correct because a stage 2 pressure injury is skin damage through two layers of skin, the epidermis and the dermis. A stage 2 pressure injury is open, red, and moist extending to the dermis of the skin.

A client had a central venous line placed 15 minutes ago. What priority intervention should the nurse implement next? A. Administer ordered IV fluids B. Order a state chest x-ray C. Administer IV antibiotics ordered D. Order a stat ultrasound of the chest

B. This answer is correct because when a central venous catheter is inserted, placement must be confirmed before using the line. Placement is confirmed by a stat chest x-ray. The tip of the catheter should lie in the superior vena cava.

Which area of the body will the client have an increased risk of developing a pressure injury? Select all that apply A. Knees and thighs B. Wrists and hands C. Heels and ankles D. Scrum and coccyx E. Bilateral hip bones

C, D, E These answers are correct because sacrum and coccyx are areas of the body that have an increased risk of developing pressure injury. A pressure injury occurs when there is damage to the skin and the underlying soft tissue. This occurs as a result of the compression of the skin and skin tissue between a bony prominence and an external surface. The most common areas this can occur include the sacrum, coccyx, hips, heels, and ankles

A nurse is assessing a sacral pressure injury on a client and evaluates that the wound base has yellow stringy slough noted. How should the nurse document this assessment? A. The client has a stage 3 B. The client has a stage 4 C. The client has an unstable able pressure injury D. The client has a deep tissue injury

C. This answer is correct because an unstageable pressure injury is a full-thickness injury where the base of the wound is covered by slough or necrotic tissue. Once the slough is removed, the tissue damage will likely be a stage 3 or 4 pressure injury.

While changing the client's dressing, the nurse observes the wound's drainage is pale red/pinkish. What does the nurse describe the drainage as? A. Sanguineous B. Serous C. Serosanguineous D. Purulent

C. This answer is correct because pale red/pinkish drainage from the surgical wound is serosanguineous. This is a normal drainage in the healing process of the surgical incision. If the drainage becomes redder, it is a sign of active bleeding

When assessing the client that presents with a pressure injury, what description best describes an unstageable pressure injury? A. A wound that is full thickness through to the bone, muscle and tendon B. A wound that appears red, shiny, and dry with injury to the dermis C. Dark purple tissue with injury to the subcutaneous tissue D. A wound that presents with full thickness loss as well as Escher and sloughing

D. This answer is correct because a wound that presents with full thickness loss as well as eschar and sloughing is a presentation of an unstageable pressure injury. The wound is classified as unstageable when there is full skin thickness loss and there is a presence of eschar and sloughing, as these will interfere with the ability to objectively determine the stage.

True or False The nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding.

False Bloody drainage 7 hours after surgery is still normal so the provider does not need to be contacted. If drainage increases and dressings become heavily saturated, then the surgeon should be notified as internal bleeding could be present.