FUND week 7 ATI

Vitamin A Vitamin C

A nurse is reinforcing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins should the nurse include in the teaching as promoting wound healing.

An increase in neutrophils. Localized edema.

A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection?

A client who has swelling and tenderness around the wound.

A nurse is collecting data from four children who have wounds. The nurse should recognize that which of the following clients has a manifestations of a wound infection?

Use pillow to keep heels off the bed surface. Minimize skin exposure to moisture.

A nurse is contributing to the plan of care for a patient who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the clients risk of skin breakdown?

A deep crater without visible bone, tendon, or muscle

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

Reposition the client at least every 2 hours.

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Have two information sessions

A nurse is planning to reinforce teaching with a client who has a low health literacy level. Which of the following ethos should the nurse use?

Gloves Eyewear Gown Mask

A nurse is preparing to exit the room of a client who has a draining wound that contains methicillin-resistant Staphylococcus aureus (MRSA) and requires contact precautions. Identify the sequence the nurse should follow to remove personal protective equipment (PPE) after caring for this client.

Remove the wound dressing. Wipe cleansing solution directly over the surgical incision. Clean skin along side the incision. Remove every other staple. Remove remaining staple.

A nurse is preparing to perform wound care and remove staples from a clients surgical incision following a hip replacement. Identify the sequence the nurse should follow.

Continue the discussion while avoiding eye contact.

A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?

"As long as I change my gloves between clients, it is not necessary to wash my hands."

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

Place uncapped needles in a puncture-proof container after use.

A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needle stick injuries. Which of the following actions should the nurse recommend?

Establish a trusting relationship with the client.

A nurse is reinforcing teaching with a newly licensed nurse about using the therapeutic techniques of confrontation when caring for a client. Which of the following instructions should the nurse include in the teaching?

Ask the client to demonstrate the skill.

A nurse is reinforcing teaching with an adult client who has a low literacy level about the subcutaneous administration of medication. Which of the following strategies should the nurse use to promote the clients understanding?

Place the dressing in a biohazardous waste container

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

WBC count

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Trimethoprim/sulfamethoxazole

A nurse is assisting with the admission of a client who has an open wound the is infected from community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA). The clients wound has not responded to treatment with surgical drainage. The nurse should anticipate that the client will require which of the following interventions?

Apply a moisture barrier ointment to the skin.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Place the client in supine with the knee flexed.

A nurse is caring for a client who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

Cover the wound with moist sterile gauze.

A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the clients room, he states that following a bout of coughing. "something popped in my belly." The nurse lifts the sheets and sees that the clients gown is bloody. After sending a coworker to get the charge nurse ad call the surgeon, which of the following actions should the nurse take next?

Cover the wound with a sterile saline-soaked towel.

A nurse is caring for a client who tells the nurse he sneezed and felt his incision "give way". The nurse observes abdominal contents protruding from the incision. Which of the following actions should the nurse take?

"My children can make changes to my living will if I an incapacitated."

A nurse is reinforcing teaching about advance directives with a client admitted to the hospital and is scheduled for surgery. Which of the following statements made by the client indicates need for further teaching?

Grilled salmon

A nurse is reinforcing teaching with a client about diets that help with wound healing. Which of the following foods should the nurse indicate contains the best source of protein?

Places sterile supplies within the 2.5 cm (1in) border of the sterile field.

A nurse is setting up sterile filed to perform wound irrigation on clients leg. Which of the following actions should the nurse identify as contaminating the sterile field?

Identify the clients at greater risk for development of pressure ulcer.

A charge nurse in a long term care facility will be implementing a new protocol to meet the Joint Commissions National Safety Goal of preventing health care-associated pressure ulcer. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the primary?

More difficulty seeing due to a greater sensitivity to glare. Decreased cough reflex. Decreased bladder capacity. Dehydration of intervertebral discs.

A nurse in an extended-care facility is reinforcing teaching for with a group of newly licensed nurses about the expected physiological changes if aging. Which of the following information should the nurse include?

Cut below the suture knot.

A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take?

Cover the wound with a moist sterile dressing

A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?

Transparent

A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following dressings should the nurse apply to the wound?

There is full-thickness skin loss with a crater.

Upon inspection of a clients skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statements by the nurse describes a stage 3 pressure ulcer?

Granulation tissue

A nurse is collecting data on a clients wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

The wound has a halo of erythema on the surrounding skin.

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse

Apply pressure directly to the wound.

A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first?

"I have a set of my brothers crutches in my basement that I can also use."

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?

"It is a good idea to use the handrails in the bathroom.?

A nurse is assisting with teaching a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident indicates an understanding of the teaching?

Laceration

A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the clients leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds.

Fully recollapse the reservoir after emptying it.

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Vitamin C

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protien and which of the following nutrients?

Cover the area with saline-soaked sterile dressing.

A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the clients surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Cover the area with a sterile dressing, moistened with saline.

A nurse is caring for a client who is 6 days postoperative from abdominal surgery. The nurse observes that the clients wound is in evisceration. After calling for help, which of the following actions should the nurse take next?

Provide the client with a diet high in protein.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client skin integrity?

Wipe the top of the drainage port with an alcohol swab after emptying. Squeeze the suction bulb while inserting the plug into the drainage port.

A nurse is caring for a client who has a close would drainage system connected to a portable bulb suction device. Which of the following actions should the nurse take to care for the drain?

Granulation tissue on the surface of the wound.

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Cleanse with 0.9% sodium chloride irrigation

A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

Poor nutritional state. Obesity. Wound infection

A nurse is caring for a client who has a surgical wound. Which of the following factors places the client at risk for dehiscence?

Contact

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types if precautions should the nurse place to take while caring for this client?

Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.

A nurse is caring for a client who has a wound infection. Which of the following action should the nurse take when obtaining a wound drainage specimen for culture?

Clean gloves

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus(MRSA) in an abdominal wound. The nurse enters the room to check the clients pulse. Which of the following items should the nurse wear?

Purulent

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the clients wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Edema

A nurse is changing the dressing on a client wound. The nurse should recognize that which of the following findings is an indication of a wound infection