Chapter 48: Skin Integrity and Wounds and Chapter 45: Nutrition

3. What will the nurse do to protect the peristomal skin of a patient with a urostomy? Clean the skin around the stoma with soap and hot water. Apply lotion to the skin around the stoma. Wipe the skin with alcohol swabs before applying the device. Clean the skin with warm water and pat dry.

Clean the skin with warm water and pat dry.

4. Which statement best illustrates correct interpretation of a positive gastric occult blood test? "We don't need to retest the patient right now, because the sample turned green after about 60 seconds." "If the test sample turns blue, it is positive for blood." "The monitor area needs to turn blue within 30 seconds." "Because it was positive, I notified the patient's physician."

"If the test sample turns blue, it is positive for blood."

4. Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly? "Wear sterile gloves when holding the specimen." "Take this specimen to the lab immediately." "Borrow a specimen collection kit from another unit if we're out of them." "Keep the specimen tube horizontal."

"Take this specimen to the lab immediately."

3. Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in carrying out a gastric occult blood test for a patient with a low hemoglobin and hematocrit? "Have you used the new Gastroccult testing system?" "The next time the patient vomits, please test it for occult blood." "Is the patient capable of assisting with the specimen collection?" "Remember to tell me the results of the test immediately."

"The next time the patient vomits, please test it for occult blood."

7. What does the Braden Scale evaluate? Skin integrity at bony prominences, including any wounds Risk factors that place the patient at risk for skin breakdown The amount of repositioning that the patient can tolerate The factors that place the patient at risk for poor healing

Risk factors that place the patient at risk for skin breakdown

3. What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound 4, 3, 2, 5, 1 3, 4, 2, 1, 5 4, 2, 3, 5, 1 2, 3, 4, 5, 1

4, 3, 2, 5, 1

5. The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? Osteoarthritis Glaucoma Deafness Diabetes mellitus

Diabetes mellitus

8. Which statement made by a patient of a 2-month-old infant requires further education? I'll continue to use formula for the baby until he is a least a year old. I'll make sure that I purchase iron-fortified formula. I'll start feeding the baby cereal at 4 months. I'm going to alternate formula with whole milk starting next month.

I'm going to alternate formula with whole milk starting next month.

4. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? Binder Ice bag Elastic bandage Absorptive dressing

Ice bag

1. What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? Ask another nurse to attempt the insertion. Document the attempts in the patient's medical record. Notify the physician that the attempts were unsuccessful. Allow the patient to rest for 30 minutes before resuming the process.

Notify the physician that the attempts were unsuccessful.

3. Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A 28-year-old patient who fractured a femur after heavy drinking A 73-year-old patient who is on anticoagulation therapy. A 54-year-old patient who broke a cheekbone in a fall A 67-year-old patient with a history of unexplained nosebleeds

A 28-year-old patient who fractured a femur after heavy drinking

5. Which of the following describes a hydrocolloid dressing? A seaweed derivative that is highly absorptive Premoistened gauze placed over a granulating wound A debriding enzyme that is used to remove necrotic tissue A dressing that forms a gel that interacts with the wound surface

A dressing that forms a gel that interacts with the wound surface

3. What will the nurse need before removing a patient's nasogastric tube? Evidence of hypoactive bowel sounds in all quadrants Absence of abdominal pain and distention Assurance that the patient can pass flatus A health care provider's order

A health care provider's order

3. Which measurements would the nurse use to calculate the surface area of a patient's pressure ulcer? Height and weight Length and width Length and depth Width and depth

Length and width

1. The nurse evaluates which laboratory values to assess a patient's potential for wound healing? Fluid status Potassium Lipids Nitrogen balance

Nitrogen balance

4. Which action would be the nurse's priority when caring for a patient with a urostomy who had no urine output for 4 hours? Change the ostomy device. Document the output. Catheterize the patient. Notify the health care provider.

Notify the health care provider.

3. When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? Occlusion alarm sounds on infusion pump Patient's oral temperature gradually increases Patient's neck veins become distended The nurse cannot achieve blood return

Patient's oral temperature gradually increases

1. 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? Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. Use a distraction technique to divert the patient's attention during the procedure. Position the patient comfortably before the intervention. Thoroughly explain the procedure to the patient.

Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.

4. When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? After performing hand hygiene at the start of the procedure Before removing the inner dressing After removing the original dressing materials and performing hand hygiene a second time Just before cleansing the wound with sterile water

After removing the original dressing materials and performing hand hygiene a second time

4. Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? Attach the tubing to the patient's gown with a safety pin. Tape the tubing to the patient's bed. Attach the tubing to the nearest side rail. Loop the tubing through the bed frame.

Attach the tubing to the patient's gown with a safety pin.

2. Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture? Collect the specimen while wearing sterile gloves. Collect the specimen after washing the wound with sterile water. Collect the specimen before cleansing the wound. Collect the specimen after administering prescribed pain medication.

Collect the specimen after administering prescribed pain medication.

2. What is the nursing action to set up suction for a hemovac drainage system? Set the suction to lowest level possible. Hemovacs are always set to medium suction. Connect to the wall on intermediate suction. Compress the hemovac, creating suction.

Compress the hemovac, creating suction.

5. Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? Pinning the tubing to the patient's hospital gown Compressing the bulb while replacing the port cap Emptying the drainage container only when it is 90% full Placing the drainage container below the wound site

Compressing the bulb while replacing the port cap

5. Which nursing action is appropriate when feeding gastric residual is 50 mL? Return it to the stomach via the feeding tube. Dispose of the residual contents down the commode. Discard the stomach contents as a liquid biohazard. Return half of the volume to the stomach, and discard the rest. SubmitSave Answers

Return it to the stomach via the feeding tube.

14. Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) Use a transfer device, e.g. transfer board Have head of bed elevated when transferring patient Have head of bed flat when re positioning patients Raise head of bed 60 degrees when patient positioned supine Raise head of bed 30 degrees when patient positioned supine

Use a transfer device, e.g. transfer board Have head of bed flat when re positioning patients Raise head of bed 30 degrees when patient positioned supine

1. Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer? Begin antibiotic therapy before the dressing change. Use appropriate personal protective equipment. Adhere to sterile technique during the intervention. Complete the dressing change in an effective, efficient manner.

Use appropriate personal protective equipment

2. Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? Begin antibiotic therapy before the dressing change. Use appropriate personal protective equipment (PPE). Adhere to sterile technique during the intervention. Complete the dressing change in an effective, timely way.

Use appropriate personal protective equipment (PPE)

5. Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? Cleansing the wound with sterile water Blotting the incision with dry gauze Wearing sterile gloves to cleanse the wound Using a new gauze pad for each stroke while cleansing the wound

Using a new gauze pad for each stroke while cleansing the wound

5. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy? "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch." "Alert me immediately if you see any blood in the fecal matter in the pouch." "Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the stoma." "Remember to change your gloves after cleaning the stoma and the surrounding skin."

"Alert me immediately if you see any blood in the fecal matter in the pouch."

5. Which instruction might the nurse give to nursing assistive personnel (NAP) caring for a patient with a newly established urostomy? "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch." "Alert me immediately if you see any blood in the urine that has collected in the pouch." "Using the stoma guide, cut the pouch opening about an eighth of an inch larger than the stoma." "Remember to use warm water when cleaning the stoma and the surrounding skin."

"Alert me immediately if you see any blood in the urine that has collected in the pouch."

3. Which question might the nurse ask the patient when an aerobic wound culture has been ordered? "Do you have any pain at the wound site?" "Have you ever collected a specimen from your wound before?" "Have you had any trouble breathing?" "Have your blood counts been high recently?"

"Have your blood counts been high recently?"

6. What is the removal of devitalized tissue from a wound called? Debridement Pressure reduction Negative pressure wound therapy Sanitization

Debridement

1. Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? "Assess the site frequently for signs of inflammation." "Be sure to change the transparent dressing on the site once every 7 days." "Let me know immediately if the patient's dressing becomes damp." "Make sure the patient knows to notify me if the site becomes painful or swollen."

"Let me know immediately if the patient's dressing becomes damp."

4. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a CVAD? "Assess the site frequently for signs of inflammation." "Be sure to change the transparent dressing on the site once every 7 days." "Let me know immediately if the patient's dressing becomes damp." "Make sure the patient knows to notify me if the site is painful or swollen."

"Let me know immediately if the patient's dressing becomes damp."

3. Which device is used for wound irrigation? 19-gauge needle attached to a 10-mL syringe 19-gauge needle attached to a 35-mL syringe Sterile container held 30.5 cm (12 inches) above the wound Foley irrigating syringe

19-gauge needle attached to a 35-mL syringe

5. The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. What is the correct order of steps to perform this procedure? 1. Place patient in high-Fowler's position. 2. Have patient flex head toward chest. 3. Assess patient's gag reflex. 4. Determine length of the tube to be inserted. 5. Obtain radiological confirmation of tube placement. 6. Check pH of gastric aspirate for verifying placement. 7. Identify patient with two identifiers. 7, 1, 3, 4, 2, 5, 6 1, 3, 4, 7, 2, 6, 5 7, 1, 3, 2, 4, 6, 5 1, 7, 3, 2, 4, 5, 6

7, 1, 3, 4, 2, 5, 6

1. Which action will the nurse perform first when preparing to change a patient's urostomy pouching system? Apply clean gloves. Drape the patient appropriately. Position absorbent padding beneath the patient. Apply sterile gloves.

Apply clean gloves.

4. How would the nurse safely apply an enzyme debridement ointment? Daub ointment on dead tissue at the wound edges. Put ointment on a tongue blade, and gently spread it on the center of the wound. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. Apply a gauze dressing to ensure contact with the ointment.

Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

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

Applying clean gloves

3. Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? Taking the patient's temperature Applying clean gloves Assessing the wound for drainage Assessing the dressing for drainage

Applying clean gloves

14. The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) Avoid grapefruit and grapefruit juice, which impair drug absorption. Increase the amount of carbohydrates for energy. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein. Limit fluids to decrease the risk of edema.

Avoid grapefruit and grapefruit juice, which impair drug absorption. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein.

3. When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma? Using adhesive remover Emptying the ostomy bag only when full Avoiding unnecessary changes of the pouching system Wearing clean gloves

Avoiding unnecessary changes of the pouching system

1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A local skin infection requiring antibiotics Sensitive skin that requires special bed linen A stage III pressure ulcer needing the appropriate dressing Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present.

Category Stage 1

Partial thickness skin loss or intact blister with serosanginous fluid.

Category Stage II

Full thickness skin loss, subcutaneous fat may be visible. May include undermining

Category Stage III

Full thickness tissue loss, muscle and bone visible. May include undermining.

Category Stage IV

5. What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? Change the dressing every 48 hours. Apply sterile gloves to remove the original dressing. Cleanse the catheter and insertion site with sterile saline. Label the dressing with the date and time of application and the nurse's initials.

Change the dressing every 48 hours.

1. How would the nurse assess a patient's central venous access device (CVAD) for damage or breakage? Assess the patient's neck veins for distention. Palpate the patient's arm. Check the catheter for pinholes and tears. Palpate the area around the insertion site.

Check the catheter for pinholes and tears.

4. How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? Elevate the head of the patient's bed to at least 30 degrees. Use an intravenous fluid infusion set. Check the gastric residual volume. Monitor the amount of intake the patient tolerates in an 8-hour period.

Check the gastric residual volume.

7. The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? Recheck by performing another blood glucose test. Call the primary health care provider. Check the medical record to see if there is a medication order for abnormal glucose levels. Monitor and recheck in 2 hours.

Check the medical record to see if there is a medication order for abnormal glucose levels.

10. A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? Institute isolation precautions Clean the central line port through which the TPN is infusing with alcohol Change the TPN tubing every 24 hours Monitor glucose levels to watch and assess for glucose intolerance

Clean the central line port through which the TPN is infusing with alcohol

2. When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? Necrotic tissue Wound drainage Wound circumference Cleansed wound

Cleansed wound

5. After drawing blood from a central venous access device (CVAD), which action would minimize the patient's risk for infection when reconnecting prescribed intravenous fluids? Wearing clean gloves Changing the IV tubing Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab Aspirating for blood return before flushing the catheter

Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab

4. Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? White blood cell count Complete blood count X-ray of left foot Culture and sensitivity test

Culture and sensitivity test

3. Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's central venous access device (CVAD) site? Allow fluid infusions to continue to flow right up to the time of the sample. Flush the catheter after aspirating for blood return. Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample. Discard the first 4 to 5 mL of blood drawn.

Discard the first 4 to 5 mL of blood drawn.

6. A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 1200. What is the appropriate nursing action? Assess bowel sounds Raise the head of the bed to at least 45 degrees Position the patient on his or her right side to promote stomach emptying Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

5. A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? Drainage that was not present previously Redness at the abdominal suture line Granulation tissue in the wound bed The patient reports less pain SubmitSave Answers

Drainage that was not present previously

1. Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? Elevating the head of the bed reduces the risk for aspiration. Proper elevation of the head of the bed promotes the patient's digestion. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. Nutrients are absorbed more efficiently when the head of the bed is elevated.

Elevating the head of the bed reduces the risk for aspiration.

5. Which nursing action addresses the risk for infection related to gastric occult blood testing? Maintaining aseptic technique while handling the Gastroccult slide Performing the test in the patient's bathroom Assessing the patient's history of previous gastrointestinal (GI) bleeding Ensuring appropriate hand hygiene before and after testing

Ensuring appropriate hand hygiene before and after testing

4. What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? Examine each naris for patency and skin breakdown. Place the patient in the high-Fowler's position. Anesthetize the throat. Have the patient take a few sips of water.

Examine each naris for patency and skin breakdown.

4. After drawing blood from a patient's central venous access device (CVAD), what would the nurse do to ensure that the device resumes proper functioning? Discard the initial 5 mL of aspirated blood. Apply an antiseptic to the injection cap. Wear clean treatment gloves during the procedure. Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.

Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.

1. When irrigating a wound, how would the nurse know the right amount of pressure to apply? Calculate the wound size. Follow the general rule of keeping the pressure between 4 and 15 psi. Keep the pressure strong enough to cause moderate pain. Gentle enough that is does not create a splash off of the wound.

Follow the general rule of keeping the pressure between 4 and 15 psi.

11. Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) Frequent position changes. Keeping the buttocks exposed to air at all times Using a large absorbent diaper, changing when saturated Using an incontinence cleaner Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel Applying a moisture barrier ointment

Frequent position changes. Using an incontinence cleaner Applying a moisture barrier ointment

3. What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? Notify the surgeon of the bleeding. Remove the dressing, and assess the wound. Assess the patient for signs of shock. Further assess the patient and the wound.

Further assess the patient and the wound.

4. Which initial nursing action would best help the patient learn self-care of a colostomy pouching system? Giving the patient handouts on self care of a colostomy Allowing the patient to examine an ostomy device Identifying a family member who can participate in the ostomy appliance process Giving the patient a mirror to watch the nurse provide care

Giving the patient a mirror to watch the nurse provide care

2. The wound bed of a patient's pressure ulcer is red. What does this finding indicate to the nurse? Necrotic tissue Presence of slough Granulation tissue Development of an infection

Granulation tissue

3. A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? Have the patient perform a Valsalva procedure Clamp the intravenous (IV) tubing to prevent more air from entering the line Have the patient take a deep breath and hold it Notify the health care provider immediately

Have the patient perform a Valsalva procedure

2. Which wound would be allowed to heal by secondary intention? Cleft lip repair Infected hysterectomy incision Exploratory laparoscopy incision Facial laceration caused by a pocket knife

Infected hysterectomy incision

10. After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) Notify the surgeon Allow the area to be exposed to air until all drainage has stopped Place several cold packs over the area, protecting the skin around the wound Cover the area with sterile, saline-soaked towels and immediately. Cover the area with sterile gauze and apply an abdominal binder

Notify the surgeon Cover the area with sterile, saline-soaked towels and immediately.

3. After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? Flush the tube with ginger ale. Use apple juice to flush the tube. Obtain a product designed to unclog NG tubes. Force-flush the system with sterile normal saline.

Obtain a product designed to unclog NG tubes.

2. The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? Check for blood return. Palpate the skin for coiling. Listen for gurgling sounds. Assess for pain at the site.

Palpate the skin for coiling.

13. The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) Repositioning and retaping a patient's nasogastric tube Performing glucose monitoring every 6 hours on a patient Documenting PO intake on a patient who is on a calorie count for 72 hours Administering enteral feeding bolus after tube placement has been verified Hanging a new bag of enteral feeding

Performing glucose monitoring every 6 hours on a patient Documenting PO intake on a patient who is on a calorie count for 72 hours

9. The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? Fastening tube to the gown with new tape Placing patient supine while giving a bath Hanging a new container of enteral feeding Ambulating patient with enteral feedings still infusing

Placing patient supine while giving a bath

2. What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? Recalculate the present drip factor for accuracy. Terminate the fluid, and prepare to hang a new bag of formula. Plan to check the feeding for completion within the next 3 hours. Check with the pharmacy to see if the formula has been hanging too long.

Plan to check the feeding for completion within the next 3 hours.

5. Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? Positioning the patient in a high-Fowler's position Assessing the patient's abdomen for bowel sounds Determining any history of unexplained nosebleeds Educating the patient about the need for the intervention

Positioning the patient in a high-Fowler's position

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

Protecting the skin from irritation caused by fecal drainage

2. When pouching a patient's urostomy, which nursing action reduces the risk for injury? Collecting all urinary drainage from the urostomy Maintaining the patient's urinary elimination function Promoting the patient's autonomy with urinary elimination care Protecting the skin from irritation caused by urinary drainage

Protecting the skin from irritation caused by urinary drainage

1. How might the nurse minimize the patient's anxiety when removing a nasogastric tube? Administer a mild sedative prescribed by the patient's health care provider. Ask the patient's caregiver to emotionally support the patient during the removal. Provide reassurance of what will happen during the procedure and talk the patient through the process. Instruct the patient to take deep, calming breaths while revisiting a pleasant memory.

Provide reassurance of what will happen during the procedure and talk the patient through the process.

12. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) Collection of wound drainage Provides support to abdominal tissues when coughing or walking Reduction of abdominal swelling Reduction of stress on the abdominal incision Stimulation of peristalsis (return of bowel function) from direct pressure

Provides support to abdominal tissues when coughing or walking Reduction of stress on the abdominal incision

4. What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed? Assessing the patient for abdominal distention Providing the patient with mouth care Documenting tube removal Checking for bowel sounds

Providing the patient with mouth care

4. What will the nurse do after removing the soiled dressing from a patient's CVAD device? Cleanse the site with soap and water. Use 2% chlorhexidine swabs to cleanse the site. Apply a skin protectant. Remove the catheter stabilization device, if present.

Remove the catheter stabilization device, if present.

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

Remove the transparent dressing or tape and gauze in the direction of catheter insertion.

4. Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound? Assessing the site for signs of redness or swelling Reporting the presence of wound odor Removing a soiled outer dressing Opening sterile dressings during the dressing change

Reporting the presence of wound odor

5. Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient? Reposition the patient at least every 2 hours. Assess the patient's bony prominences every shift. Educate the family about the importance of healthy skin. Assist the patient in the selection of high-protein foods.

Reposition the patient at least every 2 hours.

1. What is the initial step in preparing to perform a gastric occult blood test for a patient with recurrent vomiting? Determine the patient's ability to help obtain the specimen. Gather a Gastroccult slide and developing solution. Review the medications the patient is currently taking. Perform hand hygiene, and apply treatment gloves.

Review the medications the patient is currently taking.

1. The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first? Explain the purpose of the test to the patient. Assess the level of the patient's pain at the wound site. Assess the patient for signs and symptoms of infection. Review the order to determine the type of specimen to be collected.

Review the order to determine the type of specimen to be collected.

11. The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (Select all that apply.) Heart disease. Sepsis. Pleural effusion. Cardiac arrhythmias. Diarrhea.

Sepsis. Pleural effusion. Cardiac arrhythmias.

5. While palpating the skin around a patient's CVAD insertion site, the nurse elicits a crackling sound. What might this finding indicate? Catheter occlusion Infection Skin erosion Subcutaneous emphysema

Subcutaneous emphysema

2. The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? Suction her mouth and throat Turn her on their side Put on oxygen at 2-L nasal cannula Stop feeding her and place on NPO

Suction her mouth and throat

3. When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? The drainage is odorless. The drainage is straw colored. The patient doesn't like looking at the drainage tubing. The amount of drainage was greater today than yesterday.

The amount of drainage was greater today than yesterday.

2. When drawing blood from a central venous access device (CVAD) in which all ports are patent, it is recommended that the nurse select which lumen? The shortest The longest The proximal port The distal port

The distal port

15. Which patients are at high risk for nutritional deficits? (Select all that apply.) The divorced computer programmer who eats precooked food from the local restaurant The middle-age female with celiac disease who does not follow her gluten-free diet The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal

The middle-age female with celiac disease who does not follow her gluten-free diet The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements

12. The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (Select all that apply.) The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. The fat emulsion will help control hyperglycemia during periods of stress. The parenteral nutrition will help your wounds heal. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours.

The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. The fat emulsion will help control hyperglycemia during periods of stress. The parenteral nutrition will help your wounds heal.

2. Why might the nurse delegate to nursing assistive personnel (NAP) the skill of performing a gastric occult blood test for a patient who has vomited? The task is easy to demonstrate to NAP. The likelihood of a positive result is minimal. This skill may be delegated if performed on vomited stomach contents. The agency trains NAP to perform only NG tube testing.

This skill may be delegated if performed on vomited stomach contents.

5. Why does the nurse kink the nasogastric tube before removing it from a patient? To suppress the cough reflex To keep any fluid from flowing out To hinder the gag reflex To prevent transmission of microorganisms

To keep any fluid from flowing out

13. When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) To relieve edema To reduce shivering To improve blood flow to an injured part To protect bony prominences from pressure ulcers To immobilize area

To relieve edema To improve blood flow to an injured part

8. On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? Category/Stage II Category/Stage IV Unstageable Suspected deep tissue damage

Unstageable

1. When drawing blood from a patient's central venous access device (CVAD), what can the nurse do to minimize pressure on the device during flushing? Clamp the device. Use a 3-mL syringe for the flush. Use a 10-mL syringe for the flush. Cleanse the catheter hub with an alcohol swab.

Use a 10-mL syringe for the flush.

2. Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? Use sterile technique throughout the process. Apply a stabilization device if the initial sutures are no longer intact. Apply a mask to the patient during the procedure. Change the transparent dressing every 48 hours

Use sterile technique throughout the process.

1. A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound? Remove the dressing, inspect the wound, and reapply a new dressing. Inspect the wound and reapply the surgical dressing every 2 hours. Inspect the wound, and keep the dressing off until the health care provider arrives. Wait until the health care provider orders the removal of the surgical dressing.

Wait until the health care provider orders the removal of the surgical dressing.

2. Which action should the nurse avoid before irrigating a patient's foot wound? Assess the patient for a history of allergies to tape and irrigating solution. Review the provider's orders for the type of irrigating solution to be used. Assess the patient's pain on a scale of 0 to 10. Warm the irrigant to body temperature in the microwave.

Warm the irrigant to body temperature in the microwave.

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

Wearing clean gloves to remove soiled dressings

2. What would minimize the nurse's risk for contamination during the removal of a nasogastric tube? Wearing treatment gloves Providing the patient with an emesis basin Protecting the patient's chest with an absorbent towel Discarding any soiled tissues in the biohazard receptacle

Wearing treatment gloves

4. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? When 25% of the patient's nutritional needs are met by the tube feedings When bowel sounds return When central line has been in for 10 days When 75% of the patient's nutritional needs are met by the tube feedings

When 75% of the patient's nutritional needs are met by the tube feedings

1. What is the proper method for cleansing the evacuation port of a wound drainage system? Cleanse it with normal saline. Wash it with soap and warm water. Rinse it with sterile water. Wipe it with an alcohol sponge.

Wipe it with an alcohol sponge.

2. What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? Ask the patient to cough. Withdraw the tube to the nasopharynx. Encourage the patient to swallow. Instruct the patient to hyperextend the neck.

Withdraw the tube to the nasopharynx.