Chapter 38 + 40: Skin integrity/ Surgery

How will the nurse obtain a culture of the patient's wound? a. Obtain a sample from the patient's wound drainage bag. b. Obtain a sample of the drainage around the edge of the wound. c. Obtain a sample of the drainage from the dressing on the wound. d. Gently swab the center of the wound after irrigating with sterile saline.

d. Gently swab the center of the wound after irrigating with sterile saline.

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger. Which term will the nurse use to describe this area? a. Reactive hyperemia b. Secondary erythema c. Blanchable hyperemia d. Nonblanchable erythema

d. Nonblanchable erythema

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.) a. Dehiscence b. Evisceration c. Debridement d. Hemostasis e. Hemorrhage

A,B,E

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday. Which are the appropriate actions of the nurse? (Select all that apply.) a. Assist the patient to sit up in the chair and ambulate in the hallway. b. Watch the patient use the incentive spirometer and ensure hourly usage. c. Teach the patient to splint the incision when coughing to minimize pain. d. Dim the lights, provide warm blankets, and maintain a quiet environment. e. Maintain patient privacy and use therapeutic touch as desired by the patient.

A,B,C

Which assessment findings indicate increased risk of infection following hip replacement surgery? (Select all that apply.) a. The patient has been a type 2 diabetic for the last 5 years. b. The patient had an indwelling urinary catheter during surgery. c. The patient takes adalimumab for rheumatoid arthritis. d. The patient received two units of packed red blood cells after surgery. e. The patient's platelet count has been 300,000 to 350,000/mm3 after surgery

A,B,C

On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.) a. Mobility b. Nutrition c. Infection d. Activity e. Friction

A,B,D,E

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness? (Select all that apply.) a. The patient's skin will remain intact without redness or ulceration. b. The nurse will assess the patient's skin daily for any sign of breakdown. c. The patient will verbalize at least two methods to prevent skin breakdown. d. The patient's wounds will be kept clean and will not develop signs of infection. e. The nurse will reposition the patient every 2 hours and pad bony prominences.

A,C

Which interventions are appropriate for the postoperative patient with the nursing diagnosis risk for ineffective peripheral tissue perfusion related to venous thromboembolism from immobility after surgery? (Select all that apply.) a. Apply graduated compression stockings after measuring the patient's legs. b. Encourage weight loss in order to minimize risk of chronic venous insufficiency. c. Carefully assess for any swelling or redness in the patient's upper and lower legs. d. Apply sequential compression devices to the patient's legs when resting in bed. e. Carefully assess the patient for dyspnea, tachycardia, and low pulse oximetry. f. Teach the patient to inspect the legs daily for dry skin, coolness, and hair loss.

A,C,D,E

The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone, tendon, or muscle. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

c. Stage 3

Which is the first intervention of the nurse for changing the dressing to a painful burn? a. Administer pain medication 30 minutes beforehand. b. Gently irrigate the wound using sterile normal saline. c. Loosen the tape gently by pressing the skin away from it. d. Observe the wound bed for presence of granulation tissue.

a. Administer pain medication 30 minutes beforehand

The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department? a. 1 year b. 3 years c. 5 years d. 10 years

d. 10 years

The patient just sustained a deep laceration that is bleeding profusely. Which stage of healing describes the current state of the patient's wound? a. Hemostasis phase b. Proliferative phase c. Inflammation phase d. Remodeling phase

a. Hemostasis phase

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery? a. Ineffective breathing pattern related to incisional pain and anesthesia b. Deficient diversional activity related to boredom from hospitalization c. Readiness for enhanced comfort related to desire for rest after surgery d. Risk for suffocation related to emotional and cognitive stress after surgery

a. Ineffective breathing pattern related to incisional pain and anesthesia

The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours. Which term will be used to document the patient's condition in the medical record? a. Maceration b. Dehiscence c. Evisceration d. Debridement

a. Maceration

What is the primary advantage of a hydrogel dressing for wound healing? a. Provide moisture needed for wound healing. b. Act as an absorbent to collect wound drainage. c. Provide negative pressure to promote healing. d. Provide protection from the external environment.

a. Provide moisture needed for wound healing.

Which surgery is classified as a palliative procedure? a. Release of bowel obstruction in a patient with end-stage colon cancer b. Thoracotomy to determine if a patient's lung nodule is cancerous or benign c. Tummy tuck and repair of umbilical hernia after the patient gave birth to triplets d. Removal of the donor's heart, lungs, and cornea for transplant in recipient patients

a. Release of bowel obstruction in a patient with end-stage colon cancer

Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury? a. Serum total protein level of 4.6 g/dL b. Braden Scale score of 22 c. Cetirizine 5 mg PO daily d. Fasting serum glucose level 84 mg/dL

a. Serum total protein level of 4.6 g/dL

The patient has a nonblanchable area of redness on the right malleolus. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

a. Stage 1

Which assessment charting indicates that the wound is healing by primary intention? a. The 4-inch incision edges are well approximated with intact sutures. b. Ulcerated 3-inch x 1-inch area has thick yellow slough present in the center. c. Incision is 5 inch long x 1 inch deep x 1 inch wide with granulation tissue present. d. Superficial 3-inch x 3-inch abrasion has no active bleeding, drainage or debris.

a. The 4-inch incision edges are well approximated with intact sutures.

Which is the priority outcome for the patient with the nursing diagnosis fluid volume deficit related to ongoing postoperative bleeding? a. The patient's urine output will be at least 30 mL/hour. b. The patient's temperature will remain within normal limits. c. The patient's surgical incision will remain intact with sutures. d. The patient will verbalize measures to reduce fluid volume loss.

a. The patient's urine output will be at least 30 mL/hour.

The nurse is caring for a patient who will be having emergency surgery in a few minutes for appendicitis. Which preoperative teaching is most important? a. What to expect when waking up in the postanesthesia care unit b. Interventions to minimize risk of postoperative wound infection c. Demonstration of incentive spirometer and deep-breathing exercises d. Importance of early ambulation to prevent pneumonia and atelectasis

a. What to expect when waking up in the postanesthesia care unit

The patient will be having knee-replacement surgery at 2:00 p.m. What is the latest time that the patient can have a cup of coffee with cream? a. 6:00 a.m. b. 8:00 a.m. c. 10:00 a.m. d. 12:00 noon

b. 8:00 a.m.

The nurse is caring for a patient with a necrotic wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement? a. Transparent film b. Hydrogel dressing c. Dry nonstick gauze d. Hydrocolloid dressing

b. Hydrogel dressing

Which is the highest priority nursing diagnosis for the patient undergoing a lengthy surgery in the operating room? a. Powerlessness related to unconscious state from general anesthesia b. Hypothermia related to cool ambient temperature in the operating room c. Risk for impaired oral mucus membranes related to prolonged NPO status d. Risk for caregiver role strain related to lengthy waiting period for family members

b. Hypothermia related to cool ambient temperature in the operating room

Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action of the nurse? a. Notify the surgeon immediately and prepare the patient for emergency surgery. b. Keep the patient NPO and document the finding in the patient's medical record. c. Allow the patient to have clear liquids as tolerated to help bowel function return. d. Provide meticulous oral care and allow the patient to have ice chips for dry mouth.

b. Keep the patient NPO and document the finding in the patient's medical record.

The patient's wound has thick creamy yellow drainage present on the dressing. How will the nurse document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

b. Purulent drainage

The patient's incision is fading to a pale pink following surgery 2 months previously. Which stage of the healing describes the current status of the patient's wound? a. Hemostasis phase b. Remodeling phase c. Proliferative phase d. Inflammation phase

b. Remodeling phase

The patient has a large red, blistered area on the left hip. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. Stage 2

The nurse is teaching the patient about postoperative exercises including incentive spirometry. How can the nurse best determine that the teaching was effective? a. The patient states that the preoperative anxiety has decreased significantly. b. The patient correctly demonstrates the exercises and how to use the spirometer. c. The patient senses a caring presence of the nurse in the therapeutic relationship. d. The patient explains to the nurse why the exercises and spirometer are important.

b. The patient correctly demonstrates the exercises and how to use the spirometer.

Which assessment finding leads the nurse to question the order to remove the patient's indwelling urinary catheter? a. The patient does not wish to get out of bed and ambulate to the toilet. b. The patient just underwent radical prostatectomy surgery 2 days ago. c. The drainage bag contains 300 mL of clear yellow urine from the last 4 hours. d. The patient is to be discharged home after a final assessment by the surgeon.

b. The patient just underwent radical prostatectomy surgery 2 days ago.

The postanesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first? a. Foley catheter and surgical fluid intake b. Intravenous lines for patency or redness c. Airway, lung sounds, and pulse oximetry d. Nasogastric tube and presence of bowel sounds

c. Airway, lung sounds, and pulse oximetry

Which surgical procedure may be performed using conscious sedation? a. Knee-replacement surgery b. Coronary artery bypass surgery c. Cataract removal with lens implant d. Modified radical mastectomy surgery

c. Cataract removal with lens implant

Which type of anesthesia will the patient receive during surgery on the cervical spine? a. Local b. Spinal c. General d. Epidural

c. General

Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery? a. Mental status and orientation b. Hourly fluid intake and output c. Lung sounds and pulse oximetry d. Presence of peripheral pedal pulses

c. Lung sounds and pulse oximetry

Which nursing diagnosis is the highest priority for a patient who had spinal anesthesia for hysterectomy surgery? a. Nausea related to side effect of spinal anesthesia b. Constipation related to manipulation of bowel during surgery c. Risk for falls related to impaired motor function from anesthesia d. Impaired oral mucus membranes related to NPO status before surgery

c. Risk for falls related to impaired motor function from anesthesia

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism? a. The patient's platelet count was 45,000/mm3 this morning. b. The patient's last bowel movement was before surgery, 4 days ago. c. The patient has refused enoxaparin injections after surgery d. The patient required transfusion of two units of packed red blood cells.

c. The patient has refused enoxaparin injections after surgery

Which assessment finding leads the nurse to include risk for ineffective airway clearance to the surgical patient's care plan? a. The patient is extremely anxious about the upcoming surgery. b. The patient will be receiving a local anesthetic for the procedure. c. The patient sleeps poorly and wakes up every morning with a headache. d. The patient speaks no English and requires the services of an interpreter.

c. The patient sleeps poorly and wakes up every morning with a headache.

Which is the most appropriate outcome for the postoperative patient with the nursing diagnosis ineffective breathing pattern related to side effects of pain medication? a. The patient will correctly demonstrate how to use pursed-lip breathing. b. The patient will report the ability to breathe comfortably without anxiety. c. The patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute. d. The patient will rest comfortably and rate pain no higher than 4 on 0-to-10 scale.

c. The patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute.

Which intervention will the nurse use for an abscessed leg wound? a. Warm water sitz baths b. Cold moist compresses c. Warm moist compresses d. Epsom salt solution soaks

c. Warm moist compresses

Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle? a. "I will take the bandage off if my toes start to tingle." b. "I need to make sure the bandage is applied smoothly." c. "I need to watch my toes for swelling and feeling cold." d. "I will to wrap the bandage from my shin toward my toes."

d. "I will to wrap the bandage from my shin toward my toes."

Which patient would benefit from soaking in a sitz bath? a. A patient with an abscessed tooth b. A patient with a fractured right arm c. A patient with painful back muscle spasms d. A patient who just had hemorrhoid surgery

d. A patient who just had hemorrhoid surgery

Which nursing diagnosis is the highest priority for a patient who just underwent hip replacement surgery? a. Risk for perioperative positioning injury related to anesthesia, immobilization b. Dressing/grooming self-care deficit related to inability to bend over or cross legs c. Impaired walking related to toe-touch weight bearing to operative lower extremity d. Risk for injury related to dislodgement of prosthesis, unsteadiness with ambulation

d. Risk for injury related to dislodgement of prosthesis, unsteadiness with ambulation

Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed? a. Momentum b. Acceleration c. Applied force d. Shearing force

d. Shearing force

The patient's sacral pressure injury is open with exposed bone. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

d. Stage 4

The nurse is caring for a patient undergoing a surgical procedure that will take 7 to 8 hours to complete. Which is the appropriate outcome for the diagnosis risk for perioperative positioning injury related to prolonged immobilization? a. The patient's skin will be assessed prior to surgery to identify areas at risk. b. The patient's privacy and dignity will be maintained throughout the procedure. c. The patient's bony prominences will be padded with pressure-reducing cushions. d. The patient's skin will be free of redness or breakdown when surgery is complete.

d. The patient's skin will be free of redness or breakdown when surgery is complete.

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue. Which term will the nurse use to describe the ulcer in the patient's medical record? a. Fluctuant b. Indurated c. Macerated d. Unstageable

d. Unstageable