adult health 1 ati quiz- week 5

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.) A. Bradycardia B. An increase in neutrophils C. An increase in RBCs D. An increase in platelets E. Localized edema

B. An increase in neutrophils E. Localized edema Rationale: Bradycardia is incorrect. Tachycardia, not bradycardia, is an indication of infection.An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms.An increase in RBCs is incorrect. An increase in the RBC count reflects polycythemia, not infection.An increase in platelets is incorrect. An increase in the platelet count can reflect malignancies, not infection.Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? A. Kidney beans B. Grilled salmon C. Peanut butter D. Raw spinach

B. Grilled salmon Rationale: Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing

A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching? A. "Black cohosh should not be taken during pregnancy." B. "Black cohosh helps relieve headache pain." C. "Black cohosh increases the risk for bleeding." D. "Black cohosh is a stimulant."

A. "Black cohosh should not be taken during pregnancy." Rationale: Black cohosh has estrogenic properties and should not be taken during pregnancy.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify the usual flora.

A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. Rationale: The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? A. Cover the wound with a sterile saline-soaked dressing. B. Place the client in high-Fowler's position. C. Auscultate all quadrants of the abdomen for bowel sounds. D. Gently reinsert the protruding tissue.

A. Cover the wound with a sterile saline-soaked dressing. Rationale: The nurse should cover an eviscerated wound with sterile saline-soaked gauze to prevent damage and infection.

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area? A. Montgomery straps B. Enzymes C. Alcohol swabs D. A transparent dressing

A. Montgomery straps Rationale: Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Poor nutritional state B. Altered mental status C. Obesity D. Pain medication administration E. Wound infection

A. Poor nutritional state C. Obesity E. Wound infection Rationale: Poor nutritional state is correct. A client who is in a poor nutritional state is at risk for dehiscence due to impaired healing.Altered mental status is incorrect. Altered mental status is not a risk factor for dehiscence. Obesity is correct. A client who is obese is at risk for dehiscence due to poor healing abilities of adipose tissue and the constant strain placed on the incision. Pain medication administration is incorrect. A client who is taking pain medication is not at risk for dehiscence.Wound infection is correct. A client who has a wound infection is at risk for dehiscence due to delayed healing.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D

A. Protein Rationale: Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.

A. Use a transfer device to lift the client up in bed. Rationale: Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? A. Instruct the client about home disposal of contaminated dressings. B. Schedule a follow-up visit by a home health nurse for dressing changes. C. Provide a dietary list of foods which promote wound healing. D. Establish a follow-up appointment with the client's provider.

B. Schedule a follow-up visit by a home health nurse for dressing changes. Rationale: The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention? A. "Does your skin condition keep you awake at night?" B. "Have you had any changes in your diet?" C. "How do you handle stress?" D. "How does your skin condition make you feel?"

C. "How do you handle stress?" Rationale: Although stress can play a role in creating or exacerbating a skin condition, this question does not obtain specific information that relates to the skin condition.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? A. Abrasion B. Contusion C. Laceration D. Puncture

C. Laceration Rationale: Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound.

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? A. Massage the client's red bony prominences. B. Assess the client's skin for increased coolness. C. Reposition the client every 2 hr. D. Keep the client's skin moist.

C. Reposition the client every 2 hr. Rationale: The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? A. Exposed bone B. Blood filled blisters C. Partial-thickness skin loss. D. Necrotic subcutaneous tissue

D. Necrotic subcutaneous tissue Rationale: Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous

D. Serosanguineous Rationale: Watery red drainage should be documented as serosanguineous.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. BUN B. Potassium C. RBC count D. WBC count

D. WBC count Rationale: An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. Wet-to-dry gauze dressing C. Hydrogel dressing D. Alginate dressing

A. Transparent dressing Rationale: A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? A. Serum albumin 3.2 g/dL B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. PTT 1.8

A. Serum albumin 3.2 g/dL Rationale: A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.) A. A client who is ambulatory following a cardiac catheterization 4 hr ago B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has protein calorie malnutrition D. A client who has right-sided heart failure and 4+ edema to the lower extremities E. A client who has postoperative delirium

C. A client who has protein calorie malnutrition D. A client who has right-sided heart failure and 4+ edema to the lower extremities E. A client who has postoperative delirium Rationale: A client who is ambulatory following a cardiac catheterization 4 hr ago is incorrect. Because this client is ambulatory, there is no identified risk for the development of a pressure ulcer.A client who has type1 diabetes mellitus and is hyperglycemic is incorrect. The nurse should identify the client who has hyperglycemia as being at risk for long-term complications such as renal failure. However, this client has no identified risk for the development of a pressure ulcer.A client who has protein calorie malnutrition is correct. A client who has poor nutritional status is at risk for the development of pressure ulcers.A client who has right-sided heart failure and 4+ edema to the lower extremities is correct. A client who has poor skin perfusion resulting from a condition such as peripheral edema is at risk for the development of pressure ulcers.A client who has postoperative delirium is correct. A client who has a decreased level of consciousness, such as delirium, is at risk for the development of pressure ulcers

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? A. Place the head of the client's bed in the flat position. B. Gently reinsert the bowel back into the client's wound. C. Apply moistened sterile gauze to the site. D. Position the client on his left side.

C. Apply moistened sterile gauze to the site. Rationale: The nurse should apply moistened sterile gauze to the site to reduce the risk for further injury and infection.