Exam #2 Study Guide

A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant?

-A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids. -The care of the client diagnosed with renal calculi may safely be delegated to the nursing assistant. The registered nurse should care for the client who had surgery 12 hours ago because the client requires close assessment. The client with uncontrolled diabetes mellitus also requires careful assessment by the registered nurse. In addition, the registered nurse should care for the client who requires neurological assessment, which isn't within the scope of practice for the nursing assistant.

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply.

-Add baking soda to the water in a tub bath; Keep nails short and clean; Rub the skin when it itches with knuckles instead of nails. -Baking soda baths can decrease pruritus. Keeping nails short and rubbing the area with knuckles can decrease breakdown when scratching. Calamine lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase edema and weaken skin integrity.

What is the primary goal of nursing care during the emergent phase after a burn injury?

-Replace lost fluids. -During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the stage of burn injury to promote wound healing.

The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema?

-Separate opposing skin surfaces with soft cloth. -Placing soft cloth between opposing skin surfaces absorbs moisture and keeps the area dry, thus preventing any further breakdown. The child with nephrotic syndrome and severe edema is usually maintained on bed rest. Therefore, ambulation is not appropriate. Applying lotion or powder to edematous surfaces that touch increases moisture and can lead to maceration, causing further breakdown.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?

-The granulation tissue is at the wound edges. -Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?

-elevated temperature -A shift to the left means that more immature than mature WBCs are at the site of inflammation or infection. Immature WBCs are less effective at phagocytosis and do not produce classic signs of inflammation, such as pus, redness, swelling, or heat. Fever is the only sign; therefore, it is a significant sign of infection in a client with immature or depressed WBCs.

When teaching the diabetic client about foot care, what should the nurse instruct the client to do?

-Avoid going barefoot. -The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn because they will cause blisters that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because of the risk of burns due to insensitivity to temperature.

A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task?

-Raise the bed to approximately waist level. -To minimize stretching and reaching, the nurse should raise the bed to approximately waist level, position the overbed table with supplies at a 90-degree angle to the bed, lower the side rails, and position the client on the near side of the bed. Keeping the side rails up, positioning the overbed table away from the bed, or positioning the client on the far side of the bed increase the nurse's risk of injury.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"-The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." -Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown?

-reduced sensation of pressure. -Pressure ulcers usually occur over bony prominences. An alteration in the protective pressure sensation results from a decline in the number of Meissner's and Pacinian corpuscles. Older adults do have altered balance that may result in falls but not skin breakdown. Impaired hearing and vision do not contribute to pressure ulcers.

A client has had a cast applied to the arm. When discharging the client, the nurse should tell the client to:

-smell the cast for foul odors. -the client should be instructed to smell the cast to note foul odors, a sign of potential infection.Powder should not be used around the cast, because it can get under the cast and become a potential medium for infection.Nothing should be inserted into the cast because a break in skin integrity can lead to an infection.A heating pad is not applied to a fracture; rather, the application of cold may be used to decrease edema and help decrease pain.

A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first?

-Assess for bladder distention. -The imbalance between the client's intake and output indicates that the client may be retaining urine since the removal of his Foley catheter. The nurse's first action is to validate this assumption by assessing for bladder distention. Applying a condom catheter will not relieve urinary retention; condom catheters are meant to be used for incontinence. A urine specimen for a culture is obtained if a urinary infection is suspected, but this is not a priority at this point. Kegel exercises are helpful in controlling urinary dribbling but do not treat retention.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

-Check on the client at regular intervals to ascertain the need to use the bathroom. -Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or UAP should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written prescription from a health care provider (HCP) before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first?

-Cover the abdominal organs with sterile dressings moistened with sterile normal saline. -When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele?

-Cover the defect with moist, sterile saline dressings. -The sac is kept moist by covering it with nonadherent, sterile saline dressings. The dressings will need to be moistened often to prevent them from drying out. The sac also is inspected carefully for leaks, abrasions, and signs of infection.Tincture of benzoin is an adherent and should not be used, because it could potentially cause disruption of the neonate's skin integrity.The neonate should be positioned on the abdomen to avoid tearing the sac.The sac must be kept moist. If left open to the air, it would dry out, possibly causing the sac to tear, which would allow cerebrospinal fluid to leak.

A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do?

-Empty the bladder every 2 to 3 hours. -Pyelonephritis usually begins with colonization and infection of the lower urinary tract via the ascending urethral route, and the client should have an adequate intake of fluids to promote the flushing action of urination. Bubble baths and limiting fluid intake increase the risk of developing a urinary tract infection. Antibiotics should be used on a short-term basis because the risk of antibiotic resistance may lead to breakthrough infections with increasingly virulent pathogens.

What intervention should the nurse include in the plan of care for a child with a fracture in skeletal traction to prevent osteomyelitis?

-Encourage the child to eat nutritious foods. -The best prevention strategy for osteomyelitis, a bacterial infection of the bone, is to maintain skin integrity and promote good nutrition. Encouraging the intake of nutritional foods is essential to ensure bone repair and healing, thereby minimizing the risk of infection.Unless the child already has a bacterial infection, antibiotics are not administered prophylactically when skeletal traction is used.Maintaining reverse isolation is not necessary for this child and could lead to social isolation.Protecting the child from visitors with colds is inappropriate because colds are caused by viruses while osteomyelitis is caused by bacteria invading bone tissue. Additionally, restricting visitors could lead to social isolation.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

-Establish a regular voiding schedule. -Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure?

-I.V. catheter insertion -Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

A nurse is performing a baseline assessment of a client's skin risk assessment. Which finding will most impact the goal of the plan of care?

-Overall potential of developing pressure ulcers -When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers, as well as potential areas for development of pressure ulcers. Family history is not important when assessing skin integrity.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

-Place a pressure-reducing mattress on the client's bed. -A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?

-Remove elastic stockings once per day and observe lower extremities. -Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin. Elevating the client's legs while out of bed and teaching isometric leg exercises will promote venous return. However, after applying the stockings, the nurse's priority should be the client's skin integrity. Ordering a second pair of stockings would not be a priority.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

-Remove the dressing, clean the site, and apply a new dressing. -A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. The nurse should notify the physician if any catheter-related complications are observed. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

-Reposition the client every 2 hours; Perform range-of-motion exercises.; Encourage the client to eat a well-balanced diet. -To prevent pressure ulcer formation, the nurse should turn and reposition the client every 2 hours, perform range-of-motion exercises, avoid using commercial soaps that dry or irritate skin, avoid tucking covers tightly into the foot of the bed, and encourage the client to eat a well-balanced diet.

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. What should the nurse do next?

-Reposition the client off the reddened skin and reassess in a few hours. -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.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

-Shift your weight every 15 minutes. -The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.

When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches the client how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?

-The client keeps the drainage bag below the bladder at all times. -To maintain effective drainage, the client should keep the drainage bag below the bladder; doing so allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because the bag could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?

-The client voids 500 mL of urine. -Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable, and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the client should be able to sit up and go to the bathroom without assistance.

A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her?

-This symptom is normal and results from the fetus exerting pressure on the bladder. -During the first trimester, hormonal changes and uterine pressure on the bladder cause urinary frequency and urgency. During the second trimester, when the uterus rises out of the pelvis, urinary symptoms abate. However, as term approaches, pressure on the bladder by the presenting part of the fetus again causes urinary frequency and urgency. Urinary frequency isn't abnormal unless accompanied by other urinary symptoms, such as burning and pain. Fluids shouldn't be limited during pregnancy. Urinary frequency doesn't subside after the presenting part is engaged. Instead, the presenting part exerts pressure on the bladder.

A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

-Turn him regularly. -The most important intervention for maintaining skin integrity is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure is not relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and pressure ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area, but does not prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. Massage of bony prominences will restore circulation to that area.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do?

-Turn the client every 1 to 2 hours. -The client is at greater risk for skin breakdown in the lower extremities related to the edema and to remaining in one position, which increases capillary pressure. Turning the client every 1 to 2 hours promotes vasodilation and prevents vascular compression. Administering pain medication will not have an effect on skin integrity. Encouraging fluids is not a direct intervention for maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene does influence skin integrity but is secondary in this situation.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do?

-Use an alternating air pressure mattress. -Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is:

-a decrease in the blood flow through the kidneys." -There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.

Which client is at highest risk for developing a urinary tract infection?

-a man with an indwelling urinary catheter -Indwelling catheters are considered to be a major contributor to nosocomial infections. Any client with an indwelling catheter is at high risk for developing a urinary tract infection. A history of previous births does not necessarily predispose a client to urinary tract infections. Clients with a history of renal calculi are not necessarily at risk for developing urinary tract infections unless the renal calculi recur. Clients with diabetes mellitus are at a higher risk for developing urinary tract infections, but this risk can be decreased by maintaining good control over blood glucose levels.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection?

-an 86-year-old with burns from using a heating pad -The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection.The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection.A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns.While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

-avoiding using deodorant soap on the irradiated areas -Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

-breathe deeply. -When inserting a urinary catheter, the nurse can facilitate insertion by asking the client to breathe deeply. Breathing deeply will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, and doing so may contaminate the sterile field.

The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should determine if the client has which symptom?

-difficulty starting the urinary stream -The symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy, and urinary retention. Impotence does not result from BPH. Flank pain is most commonly related to pyelonephritis. Hematuria occurs in urinary tract infections, renal calculi, and bladder cancer, to name some of the most common causes.

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (footdrop) for a client on complete bed rest. The UAP should:

-encourage active range of motion to unaffected extremities. -Active range of motion should be encouraged to help prevent the development of contractures, including plantar flexion. A UAP can help a client perform active range-of-motion exercises to unaffected extremities. A bed cradle relieves the pressure of bedclothes on the feet but cannot prevent plantar flexion.Massaging lotion helps maintain skin integrity.A trochanter roll is placed at the hips to prevent external rotation.

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem?

-friction along the urethra when the catheter is being inserted.. -Liberal lubrication of the catheter before catheterization of a male reduces friction along the urethra and irritation and trauma to urethral tissues. Because the male urethra is tortuous, a liberal amount of lubrication is advised to ease catheter passage. The female urethra is not tortuous, and, although the catheter should be lubricated before insertion, less lubricant is necessary. Lubrication of the catheter will not decrease spasms. The nurse should use sterile technique to prevent introducing organisms. Crusts will not form immediately. Irrigating the catheter as needed will prevent clot and crust formation.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction?

-in a widening circle around the drain, outward from the center -When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from the superior portion of the wound to the inferior when cleaning a vertical incision. Cleaning the wound laterally from the distal area to the center increases the client's risk for infection.

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

-incorporate the client's toileting schedule into the pattern of his wandering. -Incorporating the client's toileting schedule into his wandering assists with elimination and increases the chance of continent episodes. Sedation and restraints will decrease the client's mobility but won't decrease the number of incontinent episodes. Wearing two briefs at a time won't ensure urine absorption and won't address the incontinence issue.

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

-inserting a Foley catheter -According to Maslow, elimination is a first-level, or physiologic, need and therefore takes priority over all other needs. Inserting a Foley catheter helps meet the client's elimination need. Raising the side rails on the bed meets safety needs, which are a second-level need. Arranging a visit from a member of a support group and placing the client in a room with someone the same age meet the need for belonging and acceptance, which are third-level needs. Second- and third-level needs can be met only after the client's first-level needs have been satisfied.

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

-keeps the new urethra from closing -The main purpose of the urethral catheter is to maintain patency of the reconstructed urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The urethral catheter will have no effect on the child's pain level. In fact, because bladder spasms are associated with its use, the child's problems of pain may actually increase. Urine output can be measured through the suprapubic catheter because it provides an alternative route for urinary elimination, thus keeping the bladder empty and pressure-free.

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child's reaction is based on which factor?

-lacking understanding of body integrity -The preschool-age child does not have an accurate concept of skin integrity and can view medical and surgical treatments as hostile invasions that can destroy or damage the body. The child does not understand that exsanguinations will not occur from the injection site. Here, the child is verbalizing a fear consistent with the developmental age. The child would most likely verbalize concerns of not wanting another procedure or exhibit other symptoms associated with pain if those were the underlying issues. If control was the main issue, the child would try to control more than just the bandage removal.

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first:

-mark the area of drainage. -The nurse should mark the bloody drainage and observe it again in 10 minutes to assess if the bleeding is continuing.There is no need to notify the health care provider immediately because some oozing and bloody drainage are expected.A fresh postoperative dressing should not be changed unless the health care provider prescribes it. Although the wound edges will be closed, no epithelialization has occurred yet to protect the deep tissues. Undressing the wound at this point increases the risk of a wound infection.Given the slight amount of drainage, there is no need to reinforce the dressing.

Which is the appropriate nursing intervention for a client with pruritus caused by medications used to treat cancer?

-medicated cool baths -Nursing interventions to decrease the discomfort of pruritus include those that prevent vasodilation, decrease anxiety, and maintain skin integrity and hydration. Medicated baths with salicylic acid or colloidal oatmeal can be soothing as a temporary relief. The use of antihistamines or topical steroids depends on the cause of the pruritus, and these agents should be used with caution. Using silk sheets is not a practical intervention for the hospitalized client with pruritus.

A nurse is caring for an 8-year-old girl with multiple chronic urinary tract infections. The child's parents appear protective, never leaving their daughter's side. While the nurse helps the child's mother provide morning care, the child states, "My uncle doesn't clean me that way." Her mother becomes visibly upset and gives the girl a stern warning not to discuss the matter. She states, "Don't tell anyone about that again." The nurse has a legal responsibility to:

-notify the nursing supervisor and the authorities of the possibility of abuse. -The nurse has a legal responsibility to report suspected abuse of a child or an elderly person. It's inappropriate to offer to clean the child in the same way as the suspected abuser. Leaving the room doesn't fulfill that responsibility. A chart entry about the parent's behavior reflects the nurse's opinion and isn't based on subjective assessment and objective data.

Which aspects of client care would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

-obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted -The most appropriate action to delegate to a UAP is collection of a urine specimen for a culture and sensitivity analysis. Collecting the specimen does not require sterile technique.The nurse can anticipate that the elderly client with an enlarged prostate may be difficult to catheterize. Depending on the scope of practice for a UAP, this action may not be within the UAP's responsibilities.It is not within the UAP's scope of responsibility to change IV fluids.It is the registered nurse's responsibility to assess a client's report of pain or heartburn; assessment responsibilities cannot be delegated.

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

-urinary retention -A full bladder is likely to push the uterus to the right of midline, so the nurse should further assess for symptoms of urinary retention. A full bladder can prevent the uterus from contracting properly (uterine atony), possibly leading to hemorrhage. When the bladder is empty, it normally is nonpalpable and lies about in the midline. Uterine inversion occurs when the pressure from palpation pushes the uterus outside the vagina. Abdominal distention, constipation, and pain are commonly associated with a paralytic ileus, which may occur after a cesarean birth. Perineal hematoma may result from an episiotomy. It has no relation to the fundus being to the right of midline.

A nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?

-Yellow, purulent drainage -Yellow, purulent drainage suggests infection; the nurse must report this finding to the physician immediately and obtain a culture as ordered. Approximated wound edges, sutures being in place, and pink granulation tissue represent normal findings for a wound.

Which nutritional deficiency may delay wound healing?

-lack of vitamin C -Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching?

-"Ecchymoses are large, purple skin bruises." -Large, purplish skin lesions caused by hemorrhage are called ecchymoses. Small, flat, red pinpoint lesions are petechiae. Numerous petechiae result in a reddish, bruised appearance called purpura. An abrasion is a wound caused by scraping.

Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes?

-"Does the child urinate as much as usual?" -Most likely, the nurse suspects that the child is exhibiting signs and symptoms of glomerulonephritis, such as periorbital edema and fever. Other signs and symptoms include loss of appetite, dark-colored urine, pallor, headaches, and abdominal pain. To confirm this suspicion, the nurse would ask about the child's urinary elimination patterns. Typically the child with glomerulonephritis experiences a decrease in urine output. Asking about any recent sore throat would provide additional information to confirm the suspicion of glomerulonephritis, because the most common type is acute poststreptococcal glomerulonephritis, which follows a strep throat by 10 to 14 days. Frequently, the children have only mild cold symptoms and do not realize they have a streptococcal infection. Asking whether the child plays with friends as usual is important and gives the nurse information about how the child feels in general. However, this is a general question that would be appropriate to ask later on in the history. Although asking the mother about the color of the child's urine is important, the nurse needs to determine whether there is any change in the child's urinary output first.

A nurse is caring for a client who is an employee in the hospital. The client has recently received a diagnosis of genital herpes and is being treated for a urinary tract infection (UTI). A co-worker asked the nurse how the employee is doing. What is the nurse's best response?

-"I'll be sure to tell the client you said hello" -Offering to tell the client that the coworkers said helllo is only appropriate response. The disclosure of the herpes and UTI are a breach in confidentiality. Nurses should never encourage employees to read medical records that are not assigned clients.

A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the

-middle stream of urine from the bladder. -The midstream specimen is recommended because it's less likely to be contaminated with microorganisms from the external genitalia than other specimens. It isn't necessary to collect a full volume of urine for a urine culture and sensitivity.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

-using sterile technique during the dressing change -The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process.

The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions?

-"I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container." -When obtaining a urine specimen from an indwelling catheter, a sterile syringe and needle should be used to access the catheter port that allows removal of urine from the closed system. This technique preserves sterility of the system and the urine specimen.Urine cannot be collected from the drainage bag because it would not be a fresh specimen.Disconnecting the tube from the catheter bag could introduce organisms into the urinary system, causing a urinary tract infection.

After teaching the mother of a young girl about measures to help prevent urinary tract infections, which statement by the mother indicates successful teaching?

-"We'll make sure she takes a water bottle with her to after school events." -Taking a water bottle to after school events increases the likelihood the adolescent will drink adequate fluids to promote frequent urination needed to flush bacteria out of the urinary tract. Bubble baths and long soaks in the tub may result in irritation, possibly resulting in painful urination and subsequent inadequate bladder emptying.Emptying the bladder frequently and at the first urge to void prevents urinary stasis and decreases the risk of infection ascending to the kidneys.

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to:

-realign fracture fragments. -Traction promotes realignment of the bone fragments. This will facilitate subsequent internal fixation. Traction immobilizes the fracture site and may increase the client's comfort. Mobilization could result in further damage.The use of traction does not prevent neurologic damage and can, in fact, cause pressure that leads to nerve damage.Traction increases circulation to the affected part but does not control internal bleeding.Traction may create, rather than prevent, a problem with skin integrity.

The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse explain is the expected outcome of these exercises?

-strengthening the perineal muscles -The purpose of Kegel exercises is to strengthen the perineal muscles in preparation for the labor process. These movements strengthen the pubococcygeal muscle, which surrounds the urinary meatus and vagina. No evidence is available to support the idea that these exercises reduce the risk of hemorrhoids, alleviate lower back discomfort, or strengthen the abdominal muscles.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?

-Administer pain medication 30 minutes before therapy to help manage pain. -Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy.

An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

-Apply lanolin or petroleum jelly to intact skin;. Encourage a reduced-calorie, reduced-fat diet; Inspect the involved areas daily for new ulcerations; Use an electric razor to shave. -Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving warfarin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body.

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?

-Continue to monitor and record hourly urine output. -Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply.

-nutrition and hydration needs; capillary refill; continued need for restraints; skin integrity -A restraint is a method of involuntary physical restriction of a client's freedom of movement, physical activity, or normal access to his/her body. The nurse must monitor and provide care to optimize the physical and psychological well-being of the client including, but not limited to, respiratory and circulatory status, skin integrity, and vital signs. With each assessment, the nurse needs to ascertain that restraints are still required for client safety. The least restrictive intervention based on an individualized assessment of the client's medical or behavioral status or condition is needed.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:

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