Milk
Which individual is likely to have the highest risk of developing tuberculosis osteomyelitis? A 55-year-old female who is in renal failure secondary to poorly controlled type 1 diabetes. A 79-year-old man who is immunocompromised following a bone marrow transplant. A 30-year-old man who has undergone open reduction and internal fixation of his fractured tibia. A 68-year-old woman who had a laminectomy 4 days prior for treatment of her chronic back pain.
A 79-year-old man who is immunocompromised following a bone marrow transplant.
The nurse would assess a client admitted with cellulitis for which of the following localized signs? A. pain B. fever C. chills D. malaise
A. pain Pain, redness, heat, and swelling are all localized signs of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection
Which nursing intervention is appropriate for monitoring the client for the development of Volkmann's contracture? Assess capillary refill in the toes. Assess for paresthesia in the toes. Assess the radial pulse. Assess mobility of the shoulder.
Assess the radial pulse.
A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable
Black classification
In the immediate postoperative period, vital signs are taken at least every 15 minutes. 30 minutes. 45 minutes. 60 minutes.
Correct response: 15 minutes. Explanation: Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.
Which of the following is a disadvantage of surgical debridement? Scarring Bleeding Loss of function Contractures
Correct response: Bleeding Explanation: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.
The nurse is caring for a client that has undergone a colon resection. While turning the client, wound dehiscence with evisceration occurs. What is the nurse's first response? Call the health care provider. Place saline-soaked sterile dressings on the wound. Take a blood pressure and pulse. Return the client to their back.
Correct response: Place saline-soaked sterile dressings on the wound. Explanation: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the health care provider and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
The nurse is documenting the assessment of a wound on a client's foot. Which assessment would be included as subjective data? temperature is 100.4 degrees F (38 degrees C) area around the wound is pink and swollen drainage from the wound is yellow area around the wound is tender to touch
Correct response: area around the wound is tender to touch Explanation: Subjective data is data reported by the client. The other options represent objective data that is observed by the nurse.
When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? at the top of the wound in the middle of the wound at the base of the wound over the total wound
Correct response: at the base of the wound Explanation: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.
A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to: prevent the spread of the infection. debride the wound. keep the wound moist. reduce pain.
Correct response: keep the wound moist. Explanation: Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole ondansetron nizatidine
Correct response: ondansetron Explanation: Ondansetron (Zofran) is used to treat nausea and vomiting.
What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A hemoglobin of 13.6
Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.
A client is diagnosed with a bone tumor after a pathologic fracture. What is the most likely cause of the tumor? Metastatic bone disease Osteochondroma Primary osteosarcoma Osteoma
Metastatic bone disease
Which is a classic sign of hypovolemic shock? Dilute urine Pallor High blood pressure Bradypnea
Pallor Correct response: Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.
Elderly clients who fall are most at risk for which injuries? Wrist fractures Humerus fractures Pelvic fractures Cervical spine fractures
Pelvic fractures
Which type of healing occurs when the edges are not approximated and the wound fills with granulation tissue? First intention Second intention Third intention Cellular necrosis
Second intention
What assessment findings of the leg are consistent with a fracture of the femoral neck? Shortened, adducted, and externally rotated Shortened, abducted, and internally rotated Adducted and internally rotated Abducted and externally rotated
Shortened, adducted, and externally rotated
A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? Strain Contusion Sprain Fracture
Sprain
What are typical assessment findings the nurse expects to observe in a client with a simple fracture of the leg? Select all that apply. Swelling Loss of function Pain Cyanosis Absence of feeling
Swelling Loss of function Pain
A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client? They contain exudate and provide a moist wound environment. They protect the wound from mechanical trauma and promote healing. They debride the wound and promote healing by secondary intention. They prevent the entrance of microorganisms and minimize wound discomfort.
They debride the wound and promote healing by secondary intention.
Which may occur if a client experiences compartment syndrome in an upper extremity? Whiplash injury Volkmann's contracture Callus Subluxation
Volkmann's contracture
A pathologic stress fracture occurs in bones subjected to which type of stress? Sudden direct force Weakening by disease Repeated excessive use Massive muscle contraction
Weakening by disease
Nursing students are reviewing information about primary and secondary lesions. The students demonstrate understanding of the information when they identify which of the following as a primary lesion? Ulcer Fissure Wheal Keloid
Wheal
The nurse is assessing a postoperative client's surgical incision site. The nurse anticipates which finding? Wound edge approximated Moderate amount of scar formation Granulation tissue formation Abnormal cell functionality
Wound edge approximated
Client with a fractured clavicle is told that the bone will heal well if immobilized for the next 6 to 8 weeks, but there will be a large "bump" where the break occurred. This bump will be caused by: localized infection. formation of scar tissue. accumulation of dead white cells. formation of a bony callus.
formation of a bony callus.
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? primary intention secondary intention tertiary intention quadratic intention
tertiary intention
The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? Ondansetron Warfarin Prednisone Propofol
Correct response: Ondansetron Explanation: Ondansetron is an antiemetic and one of the most commonly prescribed medications for nausea and vomiting. Warfarin is an anticoagulant. Prednisone is a corticosteroid. Propofol is an anesthetic agent.
You are a PACU nurse caring for an older adult client who is recovering from surgery. The client tells you they are in pain. You know older adults react to medications differently than younger clients. What does this client's age put them at increased risk for? Acute agitation Overdose of pain medication Anxiety Longer recovery time
Correct response: Overdose of pain medication Explanation: The mechanisms of medication clearance in older adults may be prolonged, leading to risk of overdose. Therefore, older adults usually receive smaller doses of preoperative, intraoperative, and postoperative medications, especially those that affect the central nervous, cardiovascular, and renal systems. The older adult client's reaction to medication does not put them at risk for agitation, anxiety, or a longer recovery time.
A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk? Infection Malunion Complex regional pain syndrome Depression
Infection
The client has a cast applied for a fractured tibia. Which physiologic response to the fracture places this client at risk for compartment syndrome? Inflammation causes increase in volume but cast limits compartment size Joint immobility due to the cast placement Muscle atrophy from lack of ability to exercise Extremity elevation on pillows makes it hard for blood to circulate
Inflammation causes increase in volume but cast limits compartment size
A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: primary intention. secondary intention. tertiary intention. dehiscence.
primary intention. Explanation: Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing.
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: stasis. coagulation. hyperemia. hypotension.
stasis.
A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? Maintain bed rest with the head of the bed at 20 degrees. Withhold opioid pain medication to prevent ileus. Maintain NPO (nothing by mouth) status for surgical repair. Sit the client upright in a padded chair for meals.
Maintain bed rest with the head of the bed at 20 degrees.
An 8-year-old child requires wet dressings four times a day as treatment for a skin disorder. What would be most important for the nurse to do? Premedicate the child before changing the dressing. Elevate the area after performing the dressing change. Ensure that the temperature of the solution is 120°F (48.9°C). Use a fragrance-free, dye-free soap to clean the wound.
Premedicate the child before changing the dressing.
Hyperbaric treatment for wound healing is used for wounds that have problems in healing due to hypoxia or infection. It works by raising the partial pressure of oxygen in plasma. How does hyperbaric oxygen treatment enhance wound healing? Destruction of anaerobic bacteria Increased action of eosinophils Promotion of angiogenesis Decrease in fibroblast activity
Promotion of angiogenesis
Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? Autograft Allograft Homograft Heterograft
Autograft
A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? Infection Pulmonary embolism Avascular necrosis Hypovolemic shock
Avascular necrosis
Which type of fracture involves healing of more than two pieces of bone? Comminuted fracture Transverse fracture Oblique fracture Midshaft fracture
Comminuted fracture
Which of the following type of fracture is associated with osteoporosis? Compression Stress Oblique Simple
Compression
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? "It assists in preventing infection." "It will cut down on the number of dressing changes needed." "The drain will remove necrotic tissue." "Most surgeons use wound drains now."
Correct response: "It assists in preventing infection." Explanation: A wound drain assists in preventing infection by removing the medium in which bacteria could grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the client's question appropriately.
The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first? Notify the physician. Assess for bleeding. Increase rate of IV fluids. Review the client's preoperative vital signs.
Correct response: Assess for bleeding. Explanation: The client is tachycardic with low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the client, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? Document the findings and reassess in 24 hours. Assess for signs and symptoms of fluid volume deficit. Assess for edema. Discontinue the nasogastric tube suctioning.
Correct response: Assess for signs and symptoms of fluid volume deficit. Explanation: The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Acute pain Ineffective airway clearance Decreased cardiac output Urinary retention
Correct response: Decreased cardiac output Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? Hernia Dehiscence Erythema Evisceration
Correct response: Evisceration Explanation: Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Second intention Third intention Fourth intention
Correct response: First intention Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
What is the highest priority nursing intervention for a client in the immediate postoperative phase? Maintaining a patent airway Monitoring vital signs at least every 15 minutes Assessing urinary output every hour Assessing for hemorrhage
Correct response: Maintaining a patent airway Explanation: All interventions listed are correct. The highest priority intervention, however, is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.
What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Swelling of the entire leg owing to edema
Correct response: Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? The client is displaying early signs of shock. The client is showing signs of a medication reaction. The client is displaying late signs of shock. The client is showing signs of an anesthesia reaction.
Correct response: The client is displaying early signs of shock. Explanation: The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by first intention. second intention. third intention. fourth intention.
Correct response: first intention. Explanation: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.
The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: Condylar area. Femoral neck. Shaft of the femur. Trochanteric region.
Femoral neck.
Which type of fracture involves a break through only part of the cross-section of the bone? Incomplete Comminuted Open Oblique
Incomplete
While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? Dry sterile dressing Sterile petroleum gauze Moist sterile saline gauze Povidone-iodine-soaked gauze
Moist sterile saline gauze
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Primary-intention healing First-intention healing Second-intention healing Third-intention healing
Second-intention healing Correct response: Second-intention healing Explanation: When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.
A client has a motor vehicle accident and is diagnosed with a right hip dislocation. For which intervention should the nurse anticipate needing to prepare this client? The client can be discharged and can make an appointment in a few days to see the primary health care provider. The client will need emergency intervention to reduce the fracture and prevent complications. The client will be allowed to walk on the extremity for a few days before any treatment will be done. The fracture will be reduced in 12 hours, at which time the client can apply weight to the extremity.
The client will need emergency intervention to reduce the fracture and prevent complications.
Following an injury, scar formation builds on the granulation tissue framework. Proliferation of fibroblasts occurs with the assistance of which growth factors that have been released from endothelial and inflammatory cells at the site of injury? Select all that apply. Keratinocyte growth factor (KGF) Fibroblast growth factor (FGF) Vascular endothelial cells growth factor (VEGF) Transforming growth factor-beta (TGF-beta)
Transforming growth factor-beta (TGF-beta) Fibroblast growth factor (FGF)
There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? avascular necrosis fat embolism pulmonary embolism shock
avascular necrosis
hich is not one of the general nursing measures employed when caring for the client with a fracture? cranial nerve assessment administering analgesics providing comfort measures assisting with ADLs
cranial nerve assessment
A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? immobilization surgical repair external rotation enhancing complications
immobilization
A fracture is considered pathologic when it results in a fragment of bone being pulled away by a ligament or tendon and its attachment. occurs through an area of diseased bone. involves damage to the skin or mucous membranes. presents as one side of the bone being broken and the other side being bent.
occurs through an area of diseased bone.
During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse? "Perhaps the garment should be resized." "The garment acts as a skin layer and prevents infection." "A snug fit is needed to minimize scarring and overgrowth of skin." "The garment can be removed for an hour each day."
"A snug fit is needed to minimize scarring and overgrowth of skin."
What would the nurse include in the teaching plan for a client who asks "What is a subluxation?" "It happens when a ligament pulls off a section of bone." "It happens with a bone fracture, causing a piece of bone to go under the other." "It involves the displacement of the bone out of a joint." "The bone is partially out of the joint when it is subluxated."
"It happens when a ligament pulls off a section of bone."
The client asks, "What is reduction?" How will the nurse respond? "It refers to realigning the bone." "It means the fracture will be casted." "It is what happens when the fracture is immobilized." "It means the fracture is healed."
"It refers to realigning the bone."
Corticosteroids have which effect on wound healing? Reduce blood supply Mask the presence of infection Cause hemorrhage May cause protein-calorie depletion
Correct response: Mask the presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.
Which client would be considered high risk for falling and fracturing the hip? A 54-year-old man with obesity and short stature A 36-year-old woman whose diet consists of excessive sugar intake A 77-year-old man with hearing impairment and corrective eye lenses An 81-year-old woman taking medication for osteoporosis
An 81-year-old woman taking medication for osteoporosis
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? escharotomy debridement allograft silvadene application
Correct response: escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation
A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? Compound Greenstick Oblique Spiral
Compound
A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn? moist with blisters, which may be pink, red, pale ivory, or light yellow-brown pinkish or red with no blistering from brown or black to cherry red or pearly white; bullae may be present dry and leathery
Correct response: moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: Partial-thickness (second-degree) burns are moderate to deep burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Superficial (first-degree) burns may be pinkish or red with no blistering. Full-thickness (third-degree) burns vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.
What factor may adversely affect bone healing? Immobilization Weight bearing Delayed union Tight alignment
Delayed union
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation Maceration Necrosis Evisceration
Desiccation Correct response: Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue
Explanation: In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.
A bone graft may be used for which of the following reasons? Select all that apply. Joint stabilization Defect filling Stimulation of bone healing Improvement of motion
Joint stabilization Defect filling Stimulation of bone healing
A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Keeping a pillow between the client's legs at all times Turning the client from side to side every 2 hours Maintaining the client in semi-Fowler's position
Keeping a pillow between the client's legs at all times
A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? Moisten with sterile water only. Moisten with saline. Use topical antimicrobials with Acticoat burn dressing. Keep Acticoat saturated.
Moisten with sterile water only.
The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? Surgical debridement Nonselective debridement Enzymatic debridement Selective debridement
Nonselective debridement Correct response: Nonselective debridement Explanation: Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? Dangle at the bedside. Report early calf pain. Take off the pneumatic compression devices for sleeping. Rely on the IV fluids for hydration.
Report early calf pain. Correct response: Report early calf pain. Explanation: The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration.
The nurse is caring for a client with an infected wound that is left to heal by secondary intention. Which observation does the nurse expect to make during assessment of the wound area? Sutures or staples are present in the wound. The wound is healing slowly with epithelial and scar tissues present. The scar tissue present is larger than the original wound. A large mass of scar tissue has developed at the original wound site.
The wound is healing slowly with epithelial and scar tissues present.
A patient falls while skiing and sustains a supracondylar fracture. What does the nurse know is the most serious complication of a supracondylar fracture of the humerus? Hemarthrosis Paresthesia Malunion Volkmann's ischemic contracture
Volkmann's ischemic contracture
A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply. "Use pressure-reduction devices." "Increase carbohydrates in the diet." "Reposition every 1 to 2 hours." "Teach the family how to care for the wound." "Clean the area around the ulcer with mild soap." "Avoid the use of support-surface therapy."
"Teach the family how to care for the wound." "Clean the area around the ulcer with mild soap." "Use pressure-reduction devices." "Reposition every 1 to 2 hours."
What would the nurse include in the teaching plan for a client who asks "What is a subluxation?" "It happens when a ligament pulls off a section of bone." "It happens with a bone fracture, causing a piece of bone to go under the other." "It involves the displacement of the bone out of a joint." "The bone is partially out of the joint when it is subluxated."
"The bone is partially out of the joint when it is subluxated."
Which client presenting to the emergency department would most likely be diagnosed with a pathologic stress fracture? A teenager who fell of a ladder and hit the concrete driveway, landing on his hip A postmenopausal female who was diagnosed with breast cancer with metastasis to bone A competitive volleyball player diving to retrieve a volley and landing on his hip A weightlifter who, while bench-pressing 200 kg (440 lb), lost balance and fell to the side, landing on his hip
A postmenopausal female who was diagnosed with breast cancer with metastasis to bone
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assisting with incentive spirometry every 6 hours Ambulating the client as soon as possible Positioning the client in a supine position Assessing breath sounds at least every 2 hours
Correct response: Ambulating the client as soon as possible Explanation: The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.
The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do? Wash the lesions vigorously. Rupture the bullous lesions. Administer analgesic pain medication. Apply cold compresses
Correct response: Administer analgesic pain medication. Explanation: The patient with painful and extensive lesions should be premedicated with analgesic agents before skin care is initiated.
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? The nurse works outward from the wound in lines parallel to it. The nurse uses friction when cleaning the wound to loosen dead cells. The nurse swabs the wound with povidone-iodine to fight infection in the wound. The nurse swabs the wound from the bottom to the top.
Correct response: The nurse works outward from the wound in lines parallel to it. Explanation: A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.
The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n): Ulceration Abscess Fungus Pustule
Correct response: Ulceration Explanation: Ulceration refers to a site of inflammation where an epithelial surface (e.g., skin or gastrointestinal epithelium) has become necrotic and eroded, often with associated subepithelial inflammation. Ulceration may occur as the result of traumatic injury to the epithelial surface (e.g., peptic ulcer) or because of vascular compromise (e.g., foot ulcers associated with diabetes).The other options do not present these manifestations
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: auscultate bowel sounds. palpate the abdomen. change the client's position. insert a rectal tube
Correct response: auscultate bowel sounds. Explanation: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? at the top of the wound in the middle of the wound at the base of the wound over the total wound
at the base of the wound
The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include? Apply a hydrocolloidal dressing. Place the extremity in a dependent position. Cleanse the area with hydrogen peroxide, and wrap with clean gauze. Restrict protein intake, and encourage fluids.
Apply a hydrocolloidal dressing. Correct response: Apply a hydrocolloidal dressing. Explanation: Full-thickness skin loss occurs in a stage 3 pressure injury. With this type of injury, subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Treatment of this type of injury includes the use of a hydrocolloidal dressing because it forms an occlusive barrier over the area while maintaining a moist environment; this prevents infection, friction, and shear. The extremity should be elevated to reduce pain and improve blood flow. The area should not be cleansed with hydrogen peroxide as this will harm granulation tissue and prevent healing. The injury should be wrapped with sterile gauze to prevent infection. Protein intake should be encouraged to promote wound healing. Fluids should be encouraged to maintain adequate hydration for skin integrity.
During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client rinses around the clean incision site, using gauze squares moistened with normal saline. The client rinses around the clean incision site, using gauze squares moistened with tap water. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.
Correct response: The client rinses around the clean incision site, using gauze squares moistened with normal saline. Explanation: To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of non-raveling material instead of cotton-filled gauze squares.
The client had a full cast applied for a left humerus fracture in the emergency department 3 hours ago and now complains of increased pain at the site. The client cannot feel the pressure applied to the nail beds when the nurse tests capillary refill pressure, which is found to be 4.5 seconds. What action should the nurse take? Elevate the client's left arm on three pillows and reassess in 15 minutes. Complete a neurovascular assessment and notify the physician of the findings. Call for assistance and prepare to split the client's cast immediately. Administer analgesia and perform range-of-motion exercises with the left hand.
Call for assistance and prepare to split the client's cast immediately.
A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? "The drainage contains enzymes that are necessary for wound healing." "Antibiotics cause the cells of the tissues to produce purulent drainage." "If a wound heals on the surface but infection remains, it will open and drain." "The drainage is an indication that the sutures were not tight enough."
Correct response: "If a wound heals on the surface but infection remains, it will open and drain." Explanation: Purulent drainage indicates an infection in situ. A wound may heal over the top, but when infection remains, the wound may reopen at the base and drain the discharge. A wound will continually reopen and drain purulent discharge until the infection is eradicated. It is not related to antibiotics or the ineffectiveness of the sutures.
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.
Correct response: Clean the wound from the top to the bottom and from the center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.
A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? Continue with frequent client assessments. Remove the oral airway. Notify the physician of impaired neurological status. Obtain vital signs, including pulse oximetry, every 5 minutes.
Correct response: Continue with frequent client assessments. Explanation: An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes.
A client fell off his motorcycle, receiving several large abrasion-related surface wounds. What physiologic phenomenon will the client first experience? Healing by primary intention Healing by secondary intention Remodelling Maturation
Correct response: Healing by secondary intention Explanation: Due to the mechanism of injury, deep and wide wounds requiring healing by secondary intention will occur. Secondary intention results in the formation of larger amounts of scar tissue. A sutured surgical incision is an example of healing by primary intention. Remodelling or maturational phase is the third and final phase of healing.
The wound care nurse is teaching a group of nurses about wound healing and, specifically, delays in wound healing. Which situations that interfere with wound healing, and could cause a delay in healing, should the nurse include in the discussion? Select all that apply. Hyperglycemia Infections Malnutrition Superficial wound Children with wounds
Correct response: Hyperglycemia Infections Malnutrition Explanation: Clients with diabetes and hyperglycemia do not respond well to traditional methods of wound treatment because of their high blood glucose levels. Evidence shows delayed wound healing and complications such as prolonged infections in people with diabetes delay wound healing. Gaping wounds tend to heal more slowly because it is often impossible to effect wound closure with this type of wound. Successful wound healing depends in part on adequate stores of proteins, carbohydrates, fats, vitamins (C), and minerals. Children's wounds tend to heal well.
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Listening to music An On-Q pump Watching television An epidural infusion Changing position
Correct response: Listening to music Watching television Changing position Explanation: Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.
The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse? Irrigate the catheter with sterile normal saline. Document the findings. Reassess the output at 11 am. Notify the primary care provider immediately.
Correct response: Notify the primary care provider immediately. Explanation: If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.
A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal: Within the first 12 hours. About 24 hours postoperatively. On the second or third day. 4 days after surgery.
Correct response: On the second or third day. Explanation: The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.
On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Covering the well-approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving it open to the air
Correct response: Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Explanation: Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.
The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first? Position the client off of the ulcer. Massage the ulcerated area vigorously. Place antibiotic cream over the ulcerated area. Notify the health care provider and await orders.
Correct response: Position the client off of the ulcer. Explanation: The first thing a nurse does after a bath would be to position the client off of the ulcer. The ulcer would not be vigorously massaged as this may increase the risk of skin breakdown. Antibiotic cream is not applied as there are signs of skin breakdown but not infection. The nurse would obtain ulcer measurements once the ulcer is discovered and notify the health care provider for further orders.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Elevating the head of the bed Reinforcing the dressing or applying pressure if bleeding is frank Monitoring vital signs every 15 minutes Encouraging the client to breathe deeply
Correct response: Reinforcing the dressing or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? Stage I Stage II Stage III Stage IV
Correct response: Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.
When caring for a client with a wound that is healing by primary intention, the nurse recognizes which characterization best describes this type of wound? Burn injury Surgical incision Abscess Fibrin clot (scab)
Correct response: Surgical incision Explanation: A sutured surgical incision is an example of healing by primary intention. Larger wounds (e.g., burns and large surface wounds) or wounds purposely left open due to infection heal by secondary intention.
A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin
Correct response: Tearing of a structure from its normal position Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider? The client has an absence of bowel sounds. The client's lungs reveal rales in the bases. The client states a moderate amount of pain at the incisional site. A moderate amount of serous drainage is noted on the operative dressing.
Correct response: The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client.
A client has been diagnosed with an abscess. Upon assessment of the client, the nurse would expect to find: a localized pocket of infection composed of devitalized tissue, microorganisms, and the host's phagocytic white blood cells. several raised, reddened nodules containing sanguineous fluid. white patchy areas on the anterior surface. a circular pigmented area with a bull's-eye
Correct response: a localized pocket of infection composed of devitalized tissue, microorganisms, and the host's phagocytic white blood cells. Explanation: An abscess is a localized pocket of infection composed of devitalized tissue, microorganisms, and the host's phagocytic white blood cells—in essence, a stalemate in the infectious process. In this case, the dissemination of the pathogen has been contained by the host, but white cell function within the toxic environment of the abscess is hampered, and the elimination of microorganisms is inhibited. The other options do not describe an abscess.
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? contusion incision avulsion puncture
Correct response: contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? exerting equal, but not excessive, tension with each turn of the bandage wrapping distally to proximally elevating and supporting the stump keeping the bandage free of gaps between turn
Correct response: elevating and supporting the stump Explanation: The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? Notify a health care provider. Apply a warm washcloth. Place an ice pack. Put on a witch hazel pad.
Explanation: The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.
A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed? Apply the saturated fine-mesh gauze dressings over the wound. Apply an occlusive dressing over the saturated fine-mesh gauze dressings. Cover the saturated fine-mesh gauze dressings with an elastic bandage. Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.
Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. Explanation: The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue is usually more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because these products can prevent air circulation and hinder drying of the fine-mesh gauze.
