Unit 6: Practice Questions

An appendectomy is considered which classification of surgery based on purpose? A. Diagnostic B. Ablative C. Palliative D. Reconstructive

*Answer: B. Ablative* Rationale: Ablative surgery is performed to remove a diseased part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery is performed to relieve or reduce intensity of an illness. Reconstructive surgery is performed to restore function to tissue

Which type of anesthesia would be the best choice for an older adult undergoing surgery of the lower abdomen? A. General anesthesia B. Topical and local anesthesia C. Moderate sedation/analgesia D. Regional anesthesia

*Answer: D. Regional anesthesia* Rationale: Regional anesthesia is appropriate for lower abdomen surgery. Research has proven that regional anesthesia is especially useful in reducing postsurgical pain, bowel dysfunction, and length of hospital stay for older adult patients.

A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select all that apply. A. Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. B. Verbally ask the client to state his or her name, surgical site, and procedure. C. Verify the correct client with the correct operative site from medical records and diagnostic reports. D. Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. E. Show the client an anatomic model of the surgery site.

A, B, C, D: The root cause of wrong-site surgery involves a breakdown in communication between the client and family and the healthcare team. Information retrieved from the client in the preoperative assessment, such as the client's name, surgical site, and procedure, should be verbally assessed and verified with medical records and radiographic diagnostic reports. This information should be compiled in a checklist that the intraoperative team can recheck, thus avoiding unnecessary distraction and delay in the operating room. The nurse in the operating room is responsible for calling a "time-out" so that every surgical team member can double-check the correct site of surgery, verify the site using the operative consent form, and verify that the surgeon has marked the operative site on the client. Showing the client an anatomic model will assist the client in understanding the location of the surgery, but it will not prevent anyone from identifying the wrong site on the client.

A client has vertigo. Which goal would be most appropriate to prevent injury related to altered immobility and gait disturbances? Select all that apply. A. The client assumes a safe position when dizzy. B. The client experiences no falls. C. The client performs vestibular/balance exercises. D. The client demonstrates family involvement. E. The client keeps the head still when dizzy.

A, B, C, E: Assessment of vertigo, including history, onset, description of attacks, duration, frequency, and associated ear symptoms, is important. Vestibular/balance therapy or exercises should be taught and practiced. The client needs to be instructed to sit down when dizzy and decrease the amount of head movement. The client will benefit from recognizing whether he or she experiences an "aura" before an attack so appropriate action can be taken. Finally, it is recommended that the client keep the eyes open and look straight ahead when lying down. These expected outcomes will prevent the problem of injury.

The nurse has been assigned to a client who is hearing impaired and reads speech. Which strategies should the nurse incorporate when communicating with the client? Select all that apply. A. Avoid being silhouetted against strong light. B. Do not block out the person's view of the speaker's mouth. C. Face the client when talking. D. Have bright light behind so the individuals can see. E. Ensure the client is familiar with the subject material before discussing. F. Talk to the client while doing other nursing procedures.

A, B, C, E: When working with a client who is hearing impaired and reads speech, the presenter must face the person directly and devote full attention to the communication process. In addition, it will be useful for the client that the speaker not be too silhouetted against strong light, that the speaker's mouth not be blocked from the client's view, and there there are no objects in the mouth of the speaker. Finally, it is recommended that the presenter provide the client with the needed information to study before reviewing. This will provide the client with the ability to use contextual clues in speech reading

What should the nurse instruct a client who has cerumen buildup in the ear to do? Select all that apply. A. Wash the external ear with a washcloth. B. Instill cerumenolytic drops in the ear canal. C. Use cotton-tipped applicators to remove the wax from the ear canal. D. Use small forceps to extract the wax. E. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.

A, B, E: The nurse can advise the client with cerumen that is impacted in the ear to use a washcloth to clean the exterior part of the ear. The client can also instill cerumenolytic drops to soften the earwax. The client can then irrigate the ear canal with sterile water using a small bulb syringe. The client should not use cotton-tipped applicators as they often push the cerumen further into the ear canal. The client should never put forceps in the ear.

The nurse is discharging a client who just had cataract removal and intraocular lens implantation. The nurse is confident the client understands discharge instructions when the client states (select all that apply): A. "I understand the schedule for my eyedrops and will use the medications." B. "I feel good and am ready to drive home now." C. "I will call in the morning if I cannot see clearly." D. "I will wear the eye shield at night to protect my eye." E. "I will avoid lifting or pulling anything over 15lb." F. "I will call if I still have eye pain after taking acetaminophen."

A, D, E, F: To promote success of lens implant without complication (infection, inflammation, hemorrhage), it is important for the client to instill eyedrops as prescribed, protect the eye, and avoid placing any stress on the eye by lifting, pulling, or pushing objects that weigh more than 15 pounds. Pain should be minimal and relieved with acetaminophen; if not, the client should notify the health care provider. Clients should not expect to drive or see clearly immediately following lens implant; it may take several days for vision to clear, and limitations will be discussed at the follow-up appointment.

Which complications can occur following cataract surgery? Select all that apply. A. acute bacterial endophthalmitis B. retrobulbar hemorrhage C. rupture of the posterior capsule D. suprachoroidal hemorrhage E. vision loss

A, E: Acute bacterial endophthalmitis can occur in about 1 out of 1,000 cases. Organisms that are typically involved include Staphylococcus epidermidis, Staphylococcus aureus, and Pseudomonas and Proteus species. Vision loss is one result of acute bacterial infection. In addition, vision loss can be the result of malposition of the intracoular lens implant or opacification of the posterior capsule. Retrobulbar hemorrhage is a complication that may occur right before surgery and is a result of retrobulbar infiltration of anesthetic agents. Rupture of the posterior capsule and suprachoroidal hemorrhage are both complications that can result during surgery.

A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to: A. reduce rapid eye movements B. decrease the irritation caused by light entering the damaged eye C. protect the injured eye from infection D. minimize eye strain on the uninvolved eye

A: Patching the eyes helps decrease random eye movements that could enlarge and worsen retinal detachment. Although clients with eye injuries frequently are light sensitive, and preventing infection is important, the specific goal is to reduce rapid eye movements. Using the uninvolved eye would not cause eye strain, but random movements of one eye will involve the other eye.

A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply. A. atrial fibrillation B. advancing age C. type 2 diabetes mellitus D. hypertension E. smoking

B, C, E: Advancing age, type 2 diabetes mellitus and smoking are risk factors for delayed healing. Advanced age slows collagen synthesis by fibroblasts, impairs circulation, and requires a longer time for epithelialization of the skin. Type 2 diabetes mellitus reduces supply of oxygen and nutrients secondary to vascular complications. Nicotine is a potent vasoconstrictor and impedes blood flow, which reduces the supply of oxygen and nutrients necessary for healing. Atrial fibrillation causes venous stasis in the atria, but does not have an effect on wound healing. Hypertension does not have an effect on healing.

To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid: A. lying supine B. coughing C. deep breathing D. ambulation

B: Coughing is contraindicated after cataract extraction because it increases intraocular pressure. Other activities that are contraindicated because they increase intraocular pressure include turning to the operative side, sneezing, crying, and straining. Lying supine, ambulating, and deep breathing do not affect intraocular pressure.

A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do? A. Tell the client that at age 75 years, it is inevitable that there will be hearing loss. B. Report the hearing loss to the healthcare provider. C. Schedule the client for audiometric testing and a hearing aid. D. Tell the client that the hearing loss is only temporary; when the body adjusts to the furosemide, hearing will improve.

B: Furosemide may cause ototoxicity. The nurse should tell the client to promptly report the hearing loss, dizziness, or tinnitus to help prevent permanent ear damage. Hearing loss is not inevitable, and it is inappropriate to make assumptions about the cause of symptoms without a thorough evaluation. The client's system will not "adjust," and hearing loss will not resolve.

The nurse is to instill drops of phenylephrine hydrochloride into the client's eye prior to cataract surgery. Which is the expected outcome? A. dilation of the pupil and blood vessels B. dilation of the pupil and constriction of blood vessels C. constriction of the pupil and constriction of blood vessels D. constriction of the pupil and dilation of blood vessels

B: Instilled in the eye, phenylephrine hydrochloride acts as a mydriatic, causing the pupil to dilate. It also constricts small blood vessels in the eye.

A client with glaucoma is to receive 3 gtts (drops) of acetazolamide in the left eye. What should the nurse do? A. Ask the client to close the right eye while administering the drug in the left eye. B. Have the client look up while the nurse administers the eyedrops. C. Have the client life the eyebrows while the nurse positions the hand with the dropper on the client's forehead. D. Wipe the eyes with a tissue following administration of the drops.

B: The client should look up while the nurse instills the eyedrops. The client will need to keep both eyes open while the nurse administers the drug. If the client raises the eyebrows while the nurse's hand is positioned on the eyebrows, the movement of the forehead may cause the dropper to move and injure the eye. The client should gently blink the eyes after the eyedrops have been instilled. Using a tissue to wipe the eyes could remove some of the medication; excess fluid can be removed with a cotton ball.

Which statement indicates the client understands the expected course of Meniere's disease? A. "The disease process will gradually extend to the eyes." B. "Control of the episodes is usually possible, but a cure is not yet available." C. "Continued medication therapy will cure the disease." D. "Bilateral deafness is an inevitable outcome of the disease."

B: There is no cure for Meniere's disease, but the wide range of medical and surgical treatments allows for adequate control in many clients. The disease often worsens, but it does not spread to the eyes. The hearing loss is usually unilateral.

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information? A. Stand in front of the client, and slowly explain the instructions. B. Provide instructions to the spouse, and have the spouse explain them to the client. C. Give the client written material to read, and follow up with time for questions. D. Show the client a DVD with instructions.

C: A client who is deaf benefits most from reading information and then having an opportunity to ask questions and follow up. Verbal communication, while appropriate, may not be sufficient. The spouse can be included in the teaching, but the nurse is responsible for ensuring that the client understands the instructions. DVDs may be helpful, but unless they have close captioning, key points may be missed in the audio portion.

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to: A. apply a moist to moist dressing, being careful to pack just the wound bed. B. consult with a wound-ostomy-continence nurse specialist. C. reposition the client off of the reddened skin and reassess in a few hours. D. complete and document a Braden skin breakdown score for the client

C: A stage I ulcer presents as an area of intact, nonblanchable redness, usually over a bony prominence, caused by pressure. If a reddened area blanches and refills with fingertip pressure, it indicates that there is still some blood flow to the injured area, and the redness may be reversible. It may be appropriate to complete and document a Braden score or consult a wound nurse specialist, but it is imperative to reposition the client off the reddened skin area first. Since there is no break in the skin, it is not appropriate to apply a moist to moist dressing.

A client has a history of macular degeneration. While in the hospital, the priority nursing goal will be to: A. provide education regarding community services for clients with adult macular degeneration (AMD) B. provide health care related to monitoring the eye condition C. promote a safe, effective care environment D. improve vision

C: AMD generally affects central vision. Confusion may result related to the changes in the environment and the inability to see the environment clearly. Therefore, providing safety is the priority goal in the care of this client. Educating him regarding community resources or monitoring his AMD may have been done at an earlier date or can be done after assessing his knowledge base and experience with the disease process. Improving his vision may not be possible.

During preadmission testing for same-day surgery, a client states that she has added two cloves of garlic each day to her diet to help control her blood pressure. The nurse should further inquire about: A. the type of surgery the client is having. B. what her blood pressure has been running. C. the amount of garlic she is eating. D. her preference for the type of anesthesia.

C: Garlic has anticoagulant properties and may pose a problem with bleeding if enough has been taken too close to surgery. Therefore, the nurse must obtain more quantifiable details about the client's statement. The nurse should check the surgical procedure, anesthesia preference, and blood pressure status with the client. However, the part of the client's statement that needs further investigation concerns intake of a herb with anticoagulant properties before a surgical procedure.

When the nurse asks the client who is having abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I am just not sure." The nurse should: A. teach the client all the details of the planned procedure. B. utilize a second witness when the client signs for consent. C. notify the surgeon of the client's expressed lack of understanding. D. administer the prescribed preoperative narcotics and/or sedatives.

C: It is the surgeon's responsibility to discuss the planned procedure and review the risks, benefits, and alternatives to the planned procedure. If the client verbalizes that he or she does not understand the procedure that is planned, it is the nurse's responsibility to notify the surgeon of this lack of understanding right away, prior to any other/additional nursing actions. In this case, when the client verbalizes a lack of understanding, the nurse should not teach about he procedure; the surgeon needs to do this. The nurse cannot assist the client to sign for consent and should not administer narcotics or sedatives until the client understands and agrees to the procedure.

Which approach is the best way for the nurse to begin the preoperative interview? A. Walk in the client's room and ask, "Are you Mrs. Smith?" B. Walk in the client's room, sit down, and take the client's blood pressure. C. Walk in the client's room, sit down, maintain eye contact, and make an introduction. D. Walk in the client's room, and ask the client's name.

C: Nurses should provide the preoperative client individual and sincere attention by meeting the client at eye level and introducing themselves by name and role. The nurse should ask the client to tell her full name rather than asking if she is Mrs. Smith because there might be another client by that name on the schedule. Nurses should not start the physical assessment or ask the client's name without first identifying themselves and their role out of courtesy and to relieve the client's anxiety in the new environment of the surgical experience.

The nurse assesses that a client is restless in the immediate postoperative period. The nurse should first: A. administer a sedative B. offer ice chips C. administer oxygen D. apply wrist restraints

C: Restlessness in the immediate postoperative period may be a sign of *cerebral hypoxia as a result of depression* on the central nervous system from anesthetic agents and sedatives. Administering sedatives would depress the central nervous system further. A client may aspirate ice chips when he or she is restless. *Wrist restraints may increase agitation and cannot be used without justification.*

To ensure safety for a hospitalized blind client, the nurse should: A. require that the client has a sitter for each shift. B. request that the client stays in bed until the nurse can assist. C. orient the client to the room environment. D. keep the side rails up when the client is alone.

C: The priority goal of care for a client who is blind is safety and preventing injury. The initial action is to orient the client to a new environment. Taking time to identify the objects and where they are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at all times or for the client to stay in bed until the nurse can assist. Using side rails creates unnecessary barriers and may be a safety hazard.

A client uses timolol maleate eyedrops. The expected outcome of this drug is to control glaucoma by: A. constricting the pupils B. dilating the canals of Schlemm C. reducing aqueous humor formation D. improving the ability of the ciliary muscle to contract

C: Timolol maleate is commonly administered to control glaucoma. The drug's action is not completely understood, but it is believed to reduce aqueous humor formation, thereby reducing intraocular pressure. Timolol does not constrict the pupils; miotics are used for pupillary constriction and contraction of the ciliary muscle. Timolol does not dilate the canal of Schlemm.

One day after cataract surgery, the client is having discomfort from bright light. The nurse should advise the client to: A. dim lights in the house and stay inside for 1 week. B. attach sun shields to existing eyeglasses when in direct sunlight. C. use sunglasses that wrap around the side of the face when in bright light. D. patch the affected eye when in bright light.

C: To prevent discomfort from bright light, the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye.

The nurse is assessing a client with dark skin for the presence of a stage I pressure ulcer. The nurse should: A. use a fluorescent light source to assess the skin. B. inspect the skin only when the Braden score is above 12. C. look for skin color that is darker than the surrounding tissue. D. avoid touching the skin during inspection.

C: When assessing a client with dark skin, the nurse should observe for skin that is darker, brownish, purplish, or bluish compared to surrounding skin. Fluorescent light casts a blue light, making skin assessment difficult; natural or halogen light sources help to accurately assess the skin. Risk assessment using the Braden Scale should be performed on all clients. A Braden score of 12 indicates a high risk for pressure ulcer, and the lower the Braden score, the higher the risk (no risk 19-23, at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below). The nurse should touch to skin to assess consistency and temperature differences.

Which clinical manifestation should the nurse assess when a client has acute angle-closure glaucoma? A. gradual loss of central vision B. acute light sensitivity C. loss of color vision D. sudden eye pain

D: Acute angle-closure glaucoma produces abrupt changes in the angle of the iris. Clinical manifestations include severe eye pain, colored halos around lights, and rapid vision loss. Gradual loss of central vision is associated with macular degeneration. The loss of color vision, or achromatopsia, is a rare symptom that occurs when as stroke damages the fusiform gyrus. It most often affects only half of the visual field.

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I have been asked the question over and over!" What is the nurse's best response? A. "I am sorry! I just have to ask that question for the record." B. "It is an important question, and we just have to check." C. "You will hear it again and again as you go through surgery." D. "This question is asked for verification and safety with each new phase of treatment."

D: Clients should be made aware that some questions are asked for verification and safety with each new phase of treatment. Indicating that the nurse is sorry, or needs to check several times, or telling the client that the question will be asked again does not tell the client why it is necessary to continue to verify information essential to the client's safety.

An older adult has vertigo accompanied with tinnitus as the result of Meniere's disease. The nurse should instruct the client to restrict which dietary element? A. protein B. potassium C. fluids D. sodium

D: Meniere's disease is commonly seen in older women; the disorder is caused by pressure within the labyrinth of the inner ear as a result of excess endolympha resulting in swelling in the cochlea. Therefore, the nurse should instruct the client about dietary restrictions of sodium to reduce fluid retention. Pharmacologic treatment includes antivertiginous drugs and diuretics. If the client is prescribed a diuretic, the fluid and electrolytes are monitored. The amount of protein does not have a direct influence in this disease process.

A client tells the nurse on admission that she is uneasy about having to leaver her children with a relative while being in the hospital for surgery. What should the nurse do? A. Reassure the client that her children will be fine and she should stop worrying. B. Contact the relative to determine his/her capacity to be an adequate care provider. C. Encourage the client to call the children to make sure they are doing well. D. Gather more information about the client's feelings about the childcare arrangements.

D: The health history is conducted to ascertain a client's state of wellness or illness. A personal dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client. The therapeutic communication must be adapted to the responses, problems, and needs of the client. Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the client's needs.

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? A. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. B. Tell the client that a nurse will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up. C. Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she will not need to hear. D. Call the surgery unit to explain the client's concern, and ask if she can wear her hearing aid to surgery.

D: The nurse serves as a client *advocate* when helping in addressing a client's concern. The nurse should call the operating room and inform the intraoperative nurse about the client's request. A special container with correct identification can be prepared so that when the client is anesthetized and her hearing aid is removed, it will not be lost or broken. *It is usual policy not to send personal belongings to surgery because they are easily broken or lost in the transfer of an anesthetized client with higher priority needs*, but special needs do exist. In some instances, the nurse does bring a client's personal belongings to the postanesthesia care unit, but in this case, the item involves the client's ability to communicate. Because the trend is to use little premedication, clients are more alert and may want to talk with their surgical team before going to sleep. Decreasing teh client's anxieties preoperatively effects the amount of medication used to induce the client and her overall psychological and physiologic sttus. Telling the client that she will not need to hear is insensitive.

Which measure should the nurse teach the client with adult macular degeneration (AMD) as a safety precaution? A. Wear a patch over one eye. B. Place personal items on the sighted side. C. Lie in bed with the unaffected side toward the door. D. Turn the head from side to side when walking.

D: To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. A patch does not address the problem of hemianopsia. Appropriate client positioning and placement of personal items will increase the client's ability to cope with the problem but will not affect safety.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? A. Activity is resumed gradually; the client an resume usual activities in 5 to 6 weeks. B. Activity level is determined by the client's tolerance; clients can be as active as they wish. C. Activity level will be restricted for several months; the client should plan on being sedentary. D. Activity level can return to normal; clients can resume regular aerobic exercises.

Post op positioning is CRITICAL. Can take months to a year to fully heal; When the patient has this kind of surgery, they have to lay on tummy and will be sent home with special bed for them to put head into; lay flat; minimal movement; NO SUN; they stay in this position for at least 23 hours a day.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statemenst accurately describe a characteriistic of wound drainage? Select all that apply. a.) Serous drainage is composed of the clear portion of the blood and serous membranes. b.) Sanguineous drainage is composed of a large number of RBCs and look like blood. c.) Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d.) Purulent drainage is composed of WBCs, dead tissue, and bacteria. e.) Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f.) Serosanguineous drainage can be dark yellow or green depending on the causative organism

a, b, c, d Serious drainage is composed primarily of the clear, serous portion of blood and serous membranes. Serous drainage is clear and watery. Sanguineous drinage consists of large numbers of RBC and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of WBCs, 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. Serosanguineous drainage is a mixture of serum and RBCs. It is light pink to blood tinged.

A nurse who is chancing dressing is postoperative patients in the hospital documents various phases of wound healing on the patient charts .Which statements accurately describe these stages? Select all that apply. a.) Hemostasis occurs immediately after the initial injury. b.) A liquid called exudate is formed during the proliferation phase c.) WBCs move to the wound in the inflammatory phase d.) Granulation tissue forms in the inflammatory phase e.) During the inflammatory phase, the patient has generalized body response. f.) A scar forms during the proliferation phase.

a, c, e Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. WBCs, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of WBCs in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation of scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

36 hours after surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a.) document the findings and continue to monitor the patient. b.) administer antipyretics, as prescribed. c.) increase the frequency of assessment to every hour and notify the patient's primary care provider. d.) Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription

a.) document the findings and continue to monitor the patient. Assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has the generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: a.) Stage 1 b.) Stage 2 c.) Stage 3 d.) Stage 4

b Stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/rupture serum-filled blister.

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? a.) Keeping the head of the bed elevated as often as possible. b.) Massage over bony prominence c.) Re-positioning bed-bound patients every 4 hours d.) Using a mild cleansing agent when cleansing the skin.

d. To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agents with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominence should not be massaged, and bed-bound patients should be re-positioned every 2 hours.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a.) Using sterile dressing supplies b.) Suggesting dietary supplements c.) Applying antibiotic ointment d.) Performing careful hand hygiene

d.) Performing careful hand hygiene