Module 1

Match each term with its definition. Adhesion (A) Passage of escape into the tissues, usually of blood, serum, or lymph (B) Infection of the skin characterized by heat, pain, erythema, and edema (C) Collection of extravasated blood trapped in the tissues or in an organ, resulting from incomplete hemostasis after surgery (D) Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection (E) Protrusion of an internal organ through a wound or surgical incision (F) Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen (G) Separation of a surgical incision or rupture of a wound closure

(F) Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen

14. Several high school teachers completed a CPR class. Which comment by one of the teachers demonstrates knowledge of proper CPR? (Select all that apply.) 1. "The chest compression rate should be at least 100 per minute." 2. "A jaw-thrust maneuver should be used on all patients when I open the airway." 3. "The proper sequence for CPR is circulation, airway, and breathing." 4. "I should look, listen, and feel for breathing for no more than 10 seconds." 5. "The adult chest should be compressed at least 2 inches during compressions."

1. "The chest compression rate should be at least 100 per minute." 3. "The proper sequence for CPR is circulation, airway, and breathing." 5. "The adult chest should be compressed at least 2 inches during compressions."

5. A patient is being discharged to home with an order for oxygen. The order reads, "Continuous O2 at 2 L per N/C." What is the best explanation of this order for the nurse to give the patient? 1. "You will have oxygen on 24 hours a day at home by use of a nasal cannula, with the flow meter set at 2 liters." 2. "You will need to wear your oxygen during the hours you are awake since your body uses more oxygen during the day. Your order is for 2 liters by nasal cannula." 3. "Your doctor has ordered oxygen for you to use at home to keep your blood oxygen levels at a good level." 4. "You will need to wear oxygen at home whenever you are feeling short of breath. Be sure to set your flowmeter at 2 liters and use your nasal cannula."

1. "You will have oxygen on 24 hours a day at home by use of a nasal cannula, with the flow meter set at 2 liters."

3. What is the maximum time suction should be applied during nasotracheal suctioning? 1. 15 seconds 2. 20 seconds 3. 30 seconds 4. 45 seconds

1. 15 seconds

Figure-of-8

1. Anchor bandage at center of joint (see Steps 1 through 3, Circular). 2. Ascend obliquely around upper half of circular turn above joint followed by turn that descends obliquely below joint. 3. Continue in same manner, overlapping half of previous turn until desired immobilization is attained. 4. Be certain to cover the joint with bandage to prevent fluid shift to those tissues and subsequent impaired circulation. 5. Secure end of bandage. Used to cover joints and provide immobilization. Outer surface of fabric is against skin during ascending application of bandage. Each reverse turn places alternate side of bandage toward skin.

spiral reverse bandage

1. Anchor bandage at distal border of area to be covered (use one to three circular turns). 2. Advance bandage on ascending angle of approximately 30 degrees. 3. Halfway through each turn fold bandage toward you and continue around part in downward stroke. 4. Continue advancing bandage as in Steps 2 and 3 until desired proximal point is reached. Secure bandage. Used to cover inverted cone-shaped body parts such as calf or thigh.

Spiral

1. Anchor bandage at distal end of body part with two circular turns (note Steps 1 through 3, Circular). 2. Advance bandage on ascending angle, overlapping each preceding turn by half to two-thirds the width of bandage roll until proximal border of area is covered. 3. Secure end of bandage. Used to cover cylindric body parts, where contour of part does not vary significantly in size (e.g., slender wrist and forearm).

Recurrent

1. Anchor bandage with two circular turns (see Steps 1 through 3, Circular) at proximal ends of body part to be covered. 2. Make reverse turn at center front, and advance fabric over distal end of the body part to center back, forming covering perpendicular to first circular turns. 3. Make reverse turn at back and bring bandage forward, overlapping one-half of perpendicular bandage on one side. Make reverse turn at front and overlap opposite side of center, continuing on to back. Repeat these steps, overlapping each previous strip of bandage until entire area is covered. 4. Anchor bandage with two circular turns. 5. Secure end of bandage. Provides caplike coverage for scalp or amputation stump.

Wound Treatment

1. Closure: 2. Drains and Drainage • 80-120ml 1st 24hrs normal • 300ml is the maximum normal 3. Measurement of Wounds & Drainage • Size, condition of wound bed, condition of skin surrounding wound, pain • Drainage (serous, serosanguinous, sanguineous & purulent) 4. Cleaning wounds 5. Dressings • Circle the drainage 6. Documenting wound care • S/S infection: purulent drainage, foul odor, pain, redness, warmth & fever. • Protein to enhance healing and prevent edema. • Vitamin C (Ascorbic Acid) for the formation of collagen For diabetic patients need to control blood sugar, smoking cause vasoconstriction which can hinder healing

11. What are the traditional purposes of a wet-to-dry dressing? (Select all that apply.) 1. Débridement 2. Cooling 3. Comfort 4. Prevent infection 5. Maintenance of moisture at the wound bed

1. Débridement (the removal of damaged tissue or foreign objects from a wound) 5. Maintenance of moisture at the wound bed

General Anesthes

1. Loss of consciousness • Amnesia regarding the procedure 3. Pain relief 4. Skeletal muscle relaxation 5. Blocking reflexes such as coughing & gagging, as well as endocrine and autonomic responses • Disadvantages include risk for aspiration due to vomiting. respiratory or cardiac arrest, brain damage, stroke & death. Will have a respirator breathing for the patient

Recovery room

1. Maintain airway and gas exchange: R. Spon, and breath sounds, assess skin color; provide suction PRN • ABCs 2. Monitor cardiac function: BP AP, peripheral pulses, skin temp 3. VS every 5-15 minutes as determined by the condition 4. Monitor level of responsiveness 5. Monitor surgical site and drains 6. Administer IV fluids 7. Equipment: telemetry, O2, Foley catheter, NG, PCA, etc. 8. Assess and medicate pain, nausea, and other discomforts (Zofran or Phenergan for nausea) 9. Safety interventions (Bed alarm, side rails, call light, lights, low bed position) 10. Documentation

8. The nurse is reviewing the arterial partial pressure of oxygen (PaO2) level on the patient's arterial blood gas report. Which level is most concerning to the nurse? 1. PaO2 75 mm Hg 2. PaO2 80 mm Hg 3. PaO2 85 mm Hg 4. PaO2 90 mm Hg

1. PaO2 75 mm Hg

1. The LPN/LVN is suctioning a patient through an endotracheal tube. What indicates proper technique? (Select all that apply.) 1. Preoxygenating the patient before suctioning 2. Dipping the suction catheter into sterile saline before suctioning 3. Using a clean catheter with each suctioning attempt 4. Withdrawing the catheter with the thumb continually covering the suction control vent 5. Suctioning the tube for at least 30 seconds with each suctioning attempt

1. Preoxygenating the patient before suctioning 2. Dipping the suction catheter into sterile saline before suctioning

18. When providing care to a patient with a Hemovac drain, what actions are included in the plan of care? 1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations. 2. Clamp the tubing during patient ambulation and activity to prevent excess drainage during these times. 3. Empty the bulb drainage receptacle when it is one-fourth full. 4. Pin the bulb above the insertion site to assist in proper drainage of exudate.

1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations.

15. The nurse is assessing a patient who is displaying early signs of hypoxia. What signs and symptoms will the nurse observe? (Select all that apply.) 1. Restlessness 2. Increased pulse rate 3. Decreased blood pressure 4. Irregular apical pulse 5. Dyspnea

1. Restlessness 2. Increased pulse rate 3. Decreased blood pressure 4. Irregular apical pulse 5. Dyspnea

The basic rules for first aid treatment of wounds

1. Stop the bleeding. 2. Treat shock. 3. Prevent infection.

6. The home health nurse is visiting a patient who is on home oxygen therapy. What action by the patient and family members alerts the nurse that further teaching about home oxygen therapy is necessary? (Select all that apply.) 1. The nurse notes a fire extinguisher in the kitchen. 2. The patient's brother-in-law is in a separate room smoking a cigarette. 3. The patient states that when shaving an electrical razor is used. 4. The patient is using a water-soluble gel to help with lubricating dry mucous membranes. 5. The oxygen tubing is coiled and secured with a rubber band to prevent the patient from tripping over the tubing.

1. The nurse notes a fire extinguisher in the kitchen. 2. The patient's brother-in-law is in a separate room smoking a cigarette. 3. The patient states that when shaving an electrical razor is used.

12. The nurse is preparing to perform tracheostomy care and suctioning. What is the best order of actions when performing these two procedures? Place the steps in the correct order. 1. The nurse performs tracheostomy suctioning. 2. The nurse changes the tracheostomy ties/strap. 3. The nurse changes the dressing around the tracheostomy. 4. The nurse cleans around the tracheostomy with prescribed solution.

1. The nurse performs tracheostomy suctioning. 4. The nurse cleans around the tracheostomy with a prescribed solution. 3. The nurse changes the dressing around the tracheostomy. 2. The nurse changes the tracheostomy ties/strap.

3. The health care provider has ordered the patient's wound be irrigated. What is the primary rationale for this procedure? 1. To remove debris from the wound 2. To decrease scar formation 3. To improve circulation from the wound 4. To decrease irritation from wound drainage

1. To remove debris from the wound

Circular

1. Unroll 3 to 4 inches (7.62 to 10.16 cm) of bandage from back of roll. 2. Place flat bandage surface on anterior surface of portion of body to be covered and hold end in place with thumb of nondominant hand. 3. Continue rolling bandage around same area until two overlapping layers of bandage cover part. Remove excess bandage roll. 4. Secure end of bandage with safety pin or clip if it is attached to end of bandage. If end of bandage has raw edge, fold to 1 inch (1.27 to 2.54 cm) under before securing bandage. Gauze bandage is possible to secure with strip of adhesive tape.

4. If a patient's condition requires a very precise delivery of oxygen concentration, the nurse anticipates that the health care provider will order oxygen to be delivered via which device? 1. Venturi mask 2. Simple face mask 3. Nasal cannula 4. Transtracheal cannula

1. Venturi mask

13. The nurse has just performed oropharyngeal suctioning. Which documentation is the most complete after this procedure? 1. "Suctioned patient using a Yankaur suction catheter. Large amount of mucus suctioned. Patient tolerated procedure well and is breathing better." 2. "Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored." 3. "Oropharyngeal suctioning performed due to patient being unable to expectorate secretions. Used Yankaur suction catheter to perform procedure. Patient breathing better following suctioning." 4. "Patient requiring suctioning. Oropharyngeal suctioning performed. Patient unable to cough up thick mucus. Breathing improved after suctioning. Used a Yankaur suction catheter for procedure."

2. "Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored."

12. A patient comes to a sports medicine clinic after twisting his ankle while playing soccer. The health care provider determines he has a sprain. What discharge instructions will the nurse include in discharge summary for the patient? (Select all that apply.) 1. "Apply ice to the sprained area for 1 hour, then off for 1 hour." 2. "Wrap your ankle with an ACE bandage each morning." 3. "Elevate your leg as much as possible to prevent further swelling." 4. "Exercise your ankle as soon as you get home to prevent stiffness." 5. "You will use warm compresses to increase blood flow to the area after removing the ice."

2. "Wrap your ankle with an ACE bandage each morning." 3. "Elevate your leg as much as possible to prevent further swelling." 5. "You will use warm compresses to increase blood flow to the area after removing the ice."

14. The health care provider has ordered a patient diagnosed with pneumonia to have oxygen via a simple face mask. The nurse is aware that the patient will be receiving a FiO2 of what percentage depending on the flowmeter setting? 1. 24%-44% 2. 35%-55% 3. 24%-55% 4. 60%-90%

2. 35%-55%

9. The nurse is assessing an adult patient who has been brought to the hospital with third-degree burns covering his head, right arm, and right leg. The nurse demonstrates accurate assessment skills by determining what to be the extent of the patient's burns? 1. 27% 2. 36% 3. 45% 4. 54%

2. 36%

13. The student nurse is changing a patient's dressing. What action indicates the need for further education? (Select all that apply.) 1. Enclose the soiled dressing within a latex glove. 2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves.

2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves.

1. A patient is developing shock. Which action should the nurse take? 1. Elevate the victim's head. 2. Elevate the victim's legs and feet. 3. Elevate the victim's upper body. 4. Leave the victim in a flat position.

2. Elevate the victim's legs and feet.

2. The nurse finds a client in a burning car. The client is breathing with fractured arm and lacerations that are bleeding profusely. What action should the nurse take first? 1. Splint the fractured arm. 2. Get the client out of the car. 3. Give mouth-to-mouth resuscitation. 4. Stop the bleeding.

2. Get the client out of the car.

8. The nurse is in the park and witnesses a child getting stung by a wasp. What action should the nurse implement first? 1. Cleanse the site with soap and water. 2. Remove the stinger with a scraping motion. 3. Apply ice to the stung area. 4. Determine whether the child has an allergy to wasps.

2. Remove the stinger with a scraping motion.

19. During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding? 1. The dressing is saturated with bright red sanguineous drainage, and the patient has an increased urinary output. 2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased. 3. The dressing is saturated with serosanguineous drainage, and the patient is diaphoretic with a decrease in pulse and respirations. 4. The dressing is dry and intact, and the patient reports shortness of breath and has an elevated temperature.

2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased.

10. The nurse observes the student nurse suction the patient with a tracheostomy. Which action by the student nurse requires the nurse to intervene? (Select all that apply.) 1. The student preoxygenates the patient before beginning suctioning. 2. The student suctions the patient for 30 seconds during each suctioning attempt. 3. The student uses tap water to clear the catheter tubing between suction attempts. 4. The student applies intermittent suction when withdrawing the suction catheter from the airway. 5. The student places the thumb over the suction control vent when advancing the catheter into the patient's airway.

2. The student suctions the patient for 30 seconds during each suctioning attempt.

13. The patient suffered a fracture of the tibia after crashing his motorcycle. He tells the nurse that his health care provider told him he shattered his tibia in three places and will need surgery. The nurse is aware that the patient has which type of fracture? 1. Greenstick fracture 2. Spiral fracture 3. Comminuted fracture 4. Compound fracture

3. Comminuted fracture

3. A neighbor tells the nurse that her 12-year-old child has been burned with scalding water. The arm is red and starting to blister. In addition to advising her to see a health care provider, what will the nurse tell the neighbor to apply to the burn? 1. Hydrogen peroxide 2. Petroleum jelly 3. Cool compresses 4. Salt water compresses

3. Cool compresses

6. A neighbor tells the nurse that her 5-year-old son has ingested one of her liquid cleaning supplies. The child is in no distress at this time. The mother shows the nurse the bottle; the nurse is unfamiliar with the ingredients. Which action by the nurse is appropriate? 1. Give syrup of ipecac to induce vomiting. 2. Give milk to neutralize any acids. 3. Give water to dilute the poison. 4. Call the poison control center.

3. Give water to dilute the poison.

16. The student nurse is correct when indicating which drain as providing suction-assisted drainage? 1. Jackson-Pratt 2. Hemovac 3. Penrose 4. Wound VAC system 5. T-tube system

3. Penrose

4. The nurse comes across a one-car automobile accident. The driver of the car is walking around with a dazed look on his face. He states that he was wearing his seatbelt but is unsure of what happened exactly. He has no visible injury. In checking his vital signs, the nurse finds his blood pressure is 84/56 mm Hg, his pulse is 110 beats per minute, and his respirations are 32 per minute. Another bystander says that an ambulance is on the way. What is the nurse's initial action? 1. Complete a neurologic assessment. 2. Instruct him to get back in the car and rest. 3. Position him on his back on the ground with legs and feet elevated. 4. Assess for any wounds that may be contributing to his memory loss.

3. Position him on his back on the ground with legs and feet elevated.

4. What is the best indicator that a wound has become infected? 1. Palpation of the wound reveals excess fluid under its edges. 2. Wound cultures are positive. 3. Purulent drainage is coming from the wound area. 4. The wound has a distinct odor.

3. Purulent drainage is coming from the wound area.

10. The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention? 1. Collection of wound drainage 2. Reduction of abdominal swelling 3. Reduction of stress on the abdominal incision 4. Stimulation of peristalsis from direct pressure

3. Reduction of stress on the abdominal incision

7. What is the first step when packing a wound? 1. Assess its size, shape, and depth. 2. Prepare a sterile field. 3. Select gauze packing material. 4. Irrigate the wound.

3. Select gauze packing material.

10. A man suffers heat exhaustion while mowing the grass. The man's wife demonstrates knowledge of proper care of her husband with which action? (Select all that apply.) 1. The wife calls 911 immediately. 2. The wife encourages her husband to sit in a tub of cold water. 3. The wife gives her husband cold water and a sports drink. 4. The wife carefully monitors her husband while he finishes mowing. 5. The wife loosens her husband's clothing.

3. The wife gives her husband cold water and a sports drink. 5. The wife loosens her husband's clothing.

5. The nurse is told in report that one of the patients has been very depressed lately. On checking the unit, the nurse finds the patient in the bathroom with one wrist bleeding profusely. The patient states that he broke a glass and used it to cut his wrist in a suicide attempt. What should the nurse do after sending someone to call for help? 1. Attempt to find out what has been causing her depression. 2. Apply a tourniquet above the injury. 3. Use 4- × 4-inch gauze pads to apply direct pressure. 4. Thoroughly wash the wound.

3. Use 4- × 4-inch gauze pads to apply direct pressure.

7. The nurse encourages the patient to drink an adequate amount of fluids to help with dry mucous membranes and to liquefy secretions. What fluids should the nurse include in this teaching? (Select all that apply.) 1. Coffee 2. Milk 3. Water 4. Juice 5. Tea

3. Water 4. Juice

1. The patient has just returned from the postanesthesia care (PAC) unit. During report, the nurse is told that the patient has a Penrose drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate? 1. "The drain allows for the postoperative instillation of wound irrigation fluid." 2. "The drain is used to reduce infection in the postoperative period." 3. "Penrose drains are used to drain body fluids from the area surrounding the wound by suction." 4. "Gravity is used to drain fluid from the area around the wound with the Penrose drain."

4. "Gravity is used to drain fluid from the area around the wound with the Penrose drain."

2. A patient's physician told the patient that she was suffering from hypoxia. The patient asks the nurse what that means. Which statement by the nurse is most accurate? 1. "Hypoxia means that there is a deficient amount of oxygen in your blood." 2. "It would be best if you asked your physician to explain hypoxia." 3. "There is too much carbon dioxide in your blood." 4. "Hypoxia means that the cells in your body's tissues are not receiving enough oxygen."

4. "Hypoxia means that the cells in your body's tissues are not receiving enough oxygen."

7. The nurse comes upon a victim who is unconscious. Place in order the interventions that the nurse should take. 1. Administer 30 chest compressions. 2. Give 2 mouth-to-mouth breaths. 3. Check the carotid pulse. 4. Activate the EMS. 5. Open the airway.

4. Activate the EMS. 3. Check the carotid pulse. 1. Administer 30 chest compressions. 5. Open the airway. 2. Give 2 mouth-to-mouth breaths.

12. What action should the nurse implement to reduce surgical wound infection? (Select all that apply.) 1. Adhering to the principles of hand hygiene 2. Cleansing the incision from the least contaminated to the most contaminated area 3. Leaving the incision open to the air 4. Changing the dressing using sterile technique 5. Ensuring the patient is consuming an adequate diet

4. Changing the dressing using sterile technique

5. Which nursing entry is the most complete in its description of a wound? 1. Wound appears to be healing well, dressing dry and intact 2. Wound well approximated with minimal drainage 3. Drainage size of quarter; wound pink; 4 × 4 applied 4. Incisional edges approximated without erythema or exudate; two 4 × 4s applied

4. Incisional edges approximated without erythema or exudate; two 4 × 4s applied

15. When the nurse is caring for a person who has developed a nosebleed, which nursing action is appropriate? 1. Apply steady pressure to the bridge of the nose for 5 minutes. 2. Remind the victim to try to breathe through the nose. 3. Avoid using ice over the nose. 4. Keep the victim's head tilted slightly forward.

4. Keep the victim's head tilted slightly forward.

8. What is the correct procedure for the wet-to-dry dressing method? 1. Place dry gauze into the wound and remove it when it is wet. 2. Medicate the patient for pain after you change the dressing. 3. Complete this type of dressing change just once a day. 4. Place moist gauze into the wound and remove it when it is dry.

4. Place moist gauze into the wound and remove it when it is dry.

17. The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri-Strips applied. During suture removal, the nurse notices the incision edges are slightly separating. What is the best action by the nurse? 1. Continue removing the sutures and apply the Steri-Strips. 2. Stop the suture removal and contact the health care provider immediately. 3. Continue removing the sutures and applying the Steri-Strips, then cover the incision with a dry sterile dressing. 4. Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.

4. Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.

6. Which statement is correct in regard to the use of an abdominal binder? 1. It replaces the need for underlying dressings. 2. It should be kept loose for patient comfort. 3. The patient has to be sitting or standing when it is applied. 4. The patient must have adequate ventilatory capacity.

4. The patient must have adequate ventilatory capacity.

2. The nurse finds that the patient's incision has eviscerated. What action should the nurse take? (Select all that apply.) 1. Place the patient in high Fowler's position. 2. Give the patient fluids to prevent shock. 3. Do not allow the patient to get out of bed. 4. Replace dressings with sterile fluffy pads. 5. Apply warm, moist sterile dressings.

5. Apply warm, moist sterile dressings.

Factors That Impair Wound Healing

Age malnutrition obesity impaired oxygenation smoking drugs diabetes mellitus radiation wound stress

30. A young man who is injured is brought to the clinic by his friends. They are all very excited, but they are able to point out that he has a stick poking out of the anterior chest wall. Which symptoms indicate that the patient has a pneumothorax? Select all that apply. (407) 1. Pain worsens with inspiration and expiration efforts. 2. Breathing is labored and difficult. 3. A hissing sound is audible as air flows in and out of his chest. 4. The patient is unconscious and unresponsive to normal stimuli. 5. Pulse is weak, rapid, and thready. 6. His chest does not expand on the side of injury during inspiration.

Answer 1, 2, 3, 5, 6: Respiratory distress, pain, and decreased perfusion are signs/symptoms of a pneumothorax or hemothorax. A patient could be unconscious and responsive if excessive blood is lost or decreased oxygenation of tissues has occurred; however, patients with a hemothorax or pneumothorax are frequently conscious and experiencing pain, anxiety, and severe respiratory distress.

13. In caring for a patient with a tracheostomy, what interventions will the nurse use to reduce the risk for infection? Select all that apply. (346) 1. Evaluate the patient for excess secretions and suction as often as necessary. 2. Provide constant airway humidification. 3. Provide frequent mouth care. 4. Wear a mask when performing routine tracheostomy care. 5. Remove water that condenses in equipment tubing. 6. Change or clean all respiratory therapy equipment every 8 hours.

Answer 1, 2, 3, 5, 6: The nurse would not routinely wear a mask to do tracheostomy care, unless the patient is under airborne or droplet precautions. The other options are correct.

15. A patient has just returned from surgery. What are the initial assessments that the nurse would make related to the surgical site? Select all that apply. (620) 1. Inspect the protective dressing that was placed by the surgical team. 2. Look at the area around the dressing and record observations. 3. Check under the patient to make sure that the exudate is not pooling. 4. Carefully remove the dressing and inspect the suture line for intactness. 5. Expect and note the amount of serous drainage that is coming from the wound

Answer 1, 2, 3: Initially, the nurse inspects the dressing for intactness and for any signs of hemorrhage. The skin surface around the dressing is also noted for baseline comparison. Exudate will drain downwards, so the nurse must look underneath the patient to ensure that there is no drainage present. The initial dressing is generally removed by the surgeon. Sanguineous drainage is expected at first; serous drainage occurs later as wound healing progresses.

16. Which interventions are appropriate for a victim who is in hypovolemic shock at the scene of an accident? Select all that apply. (403) 1. Establish an airway. 2. Control bleeding. 3. Keep the head elevated. 4. Cover with a blanket or coat. 5. Provide oral fluids, such as water. 6. Administer over-the-counter analgesics.

Answer 1, 2, 4: Immediate measures are to establish an airway and control bleeding. Body temperature should be maintained, so covering the person helps minimize heat loss. The head should not be elevated, because this will decrease perfusion to the cerebrum. Also, spinal precautions would be applied if head or neck injuries are suspected. Oral fluids are typically withheld. Intravenous fluids would be started if available. No medication should be given at the scene of the accident.

8. With appropriate instruction and supervision, which tasks related to wound care can be delegated to unlicensed assistive personnel? Select all that apply. (642) 1. Emptying a closed drainage container 2. Removing sutures or staples 3. Applying an abdominal binder 4. Assessing breathing with a breast binder in place 5. Measuring intake and output

Answer 1, 3, 5: Removing sutures or staples requires concurrent assessment of the wound, so this cannot be delegated. Likewise, assessment of breathing and patient comfort cannot be delegated.

5. Which patient has the best chance to fully recover because of the nurse's actions? (395) 1. 4-year-old drowns; nurse starts cardiopulmonary resuscitation (CPR) within 4 minutes of clinical death 2. 32-year-old with brain death has a cardiac arrest; nurse starts CPR within 2 minutes 3. 17-year-old with biologic death has a respiratory arrest; nurse immediately delivers rescue breaths 4. 55-year-old is electrocuted; nurse starts CPR within 10 minutes of clinical death

Answer 1: Clinical death means that the heart beat and breathing have stopped. If cardiopulmonary resuscitation (CPR) is started within 4 minutes, tissue is spared and condition can be reversed. In brain death or bioloic death the damage is permanent. A delay of 10 minutes in initiating CPR is likely to result in brain death.

Which patient is the most likely candidate for an endotracheal tube? (346) 1. The patient is discovered in the bathroom, unresponsive and pulseless. 2. The patient is choking on a foreign body that cannot be dislodged. 3. The patient needs long-term mechanical ventilation for oxygenation. 4. The patient needs a precise, controlled concentration of oxygen.

Answer 1: Endotracheal tubes (ET) are used in emergency situations to establish an airway for patients who are not breathing. Also ET tubes are used for surgical patients who need general anesthesia. An emergency tracheostomy is needed if foreign body cannot be dislodged. Patients who need long-term mechanical ventilation may get tracheostomy. Those needing precise controlled concentrations would be fitted with a venturi mask.

11. The nurse arrives outside of the public library and finds a person lying on the ground. What is the first action to take? (394) 1. Check if the victim is unconscious. 2. Check the carotid or brachial pulse. 3. Move the victim to a flat, hard surface. 4. Direct someone to call 911.

Answer 1: First, the nurse assesses level of consciousness. Based on the assessment, the nurse may decide to question the person, start CPR, call 911, or check for injuries.

22. A postoperative patient who was happy and cheerful earlier now demonstrates restlessness and anxiety. He reports feeling "a little lightheaded." He is mildly diaphoretic and his pulse feels thready. What assessments does the nurse perform to identify a suspected complication? (628, 629) 1. Checks the pulse rate, blood pressure, and assesses for pain 2. Assesses for localized warmth or redness with tenderness 3. Observes the incision site for wound edge approximation 4. Takes the temperature and checks for purulent drainage

Answer 1: For a postoperative patient, the nurse is likely to first suspect hemorrhage, so taking the pulse and blood pressure and checking for pain would be the best actions. The nurse would check for wound approximation. The patient is more likely to report a pop or release sensation if the incision comes apart. Infection is also a possibility. The symptoms in the scenario could accompany septic shock, but the goal is to identify infection signs prior to the onset of septic shock. (Note to the student: The patient's symptoms could also be related to other disorders such as pulmonary emboli or hypoglycemia.)

9. The nurse sees that the patient takes steroids for a respiratory condition. What would be the expected affect of steroids on wound healing? (618) 1. Decreased inflammatory response 2. Prolonged bleeding times 3. Decreased keloid formation 4. Impaired formation of granulation tissue

Answer 1: Patients who take steroids can have a decreased inflammatory response. Steroids are used to decrease inflammation in disorders, such as arthritis.

31. The home health nurse sees the patient lying on the floor. On entering the house, the nurse can smell a strong odor of gas and the house is extremely hot. What should the nurse do first? (410) 1. Step out of the house and call 911. 2. Call Poison Control and describe the situation. 3. Establish responsiveness and start cooling measures. 4. Open the windows and move the patient out of the house.

Answer 1: The nurse cannot immediately determine if the patient has been overcome by gas or heat, or by something else; however, for the nurse's safety, he/she steps out of the house and calls 911. If the nurse is overcome by gas and help has not been summoned first, the nurse and the patient could die. If the nurse can remove the patient from the house, this would be the best thing for the patient; however, if the nurse cannot safely move the patient, the nurse should use critical thinking. (Windows could be broken from the outside. Two strong neighbors could assist the nurse to drag the patient from the house.) Cooling measures and contacting Poison Control can be done once the victim is out of the hot and toxic environment.

28. An older patient comes to the clinic for epistaxis (acute hemorrhage from the nostril, nasal cavity, or nasopharynx). It is readily controlled with steady pressure applied to the bridge of the nose. What additional assessment is most important for this patient? (405) 1. Measuring the blood pressure 2. Understanding of self-care measures 3. First-aid attempts performed by the patient 4. Checking an oral temperature

Answer 1: The nurse should assess all of the options; however, for elderly patients hypertension is a primary risk factor. If hypertension is the underlying cause, the blood pressure is likely to be very high. Because the bleeding was easily controlled, the nurse suspects that the patient did not know how or could not perform the self-care measures to stop the bleeding, so knowledge and skill must be assessed. Infections can also contribute to nosebleeds, so checking the temperature would also be appropriate.

18. The nurse is preparing to remove the patient's staples, but after assessment, the nurse decides that the staples should not be removed. The decision was based on which finding? (630) 1. The wound edges were partially separated. 2. Dried serous drainage was noted around the staples. 3. The patient was anxious about staple re-moval. 4. Early keloid formation was observed.

Answer 1: The nurse would not remove staples or sutures if the wound edges appeared to be separating. Serous drainage is a sign of healing and should be cleaned away. The patient's anxiety can be addressed before the procedure. Staple removal should feel like a tug or a pinch, but should not cause great pain. The site can be reinforced with SteriStrips, so this should decrease worries about the incision coming apart. Keloid formation and scarring could be aggravated by leaving the staples in too long.

27. The patient needs a breast binder. What is the most important consideration for the nurse when implementing this application? (642) 1. Respiratory function must not be restricted. 2. Vomiting and nausea are a contraindication. 3. Binders cannot be used for patients who are obese. 4. Older patients have difficulty tolerating the binder

Answer 1: The primary concern is that respiratory function could be restricted if the binder is too tight. Vomiting and nausea are not contraindications, but the patient may need assistance in positioning the emesis basin. Binders can be used for obese patients, but the appropriate size is needed. Older patients do have more fragile skin, so the skin must be assessed frequently, or the nurse may decide that the binder should not be used because of the fragile skin.

11. The nurse is caring for a patient with a tracheostomy. What signs/symptoms indicate the need for suctioning? Select all that apply. (353) 1. Fine crackles in posterior lobes 2. Gurgling sounds heard during respiration 3. Restlessness or anxiety 4. Emesis in the oral cavity 5. Drooling excessive secretions 6. Patient indicates need for suctioning

Answer 2, 3, 4, 5, 6: Gurgling sounds, restlessness, emesis in mouth, and drooling are objective signs that indicate the need for suctioning. Conscious patients are frequently able to indicate the need for suctioning. Fine crackles may indicate a respiratory disorder, such as pneumonia, but the pathology is at the alveoli level, and suctioning removes secretions in the upper airway.

The nurse is caring for a patient who is on 3 L oxygen per nasal cannula. What tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. (340) 1. Ensuring that the oxygen flow is set at 3 L/ min throughout the shift 2. Helping the patient to clean area around nares and ears 3. Counting the respiratory rate and taking the pulse oximeter reading 4. Listening to breath sounds before and after the patient coughs 5. Assisting the patient to a semi-Fowler's position 6. Observe the nares, external nasal area, and ears for breaks in skin integrity

Answer 2, 3, 5: UAP can assist the patient with hygiene, position changes and take vital signs. The nurse is responsible for ensuring the correct flow rate and assessment.

19. Two nurses are shopping together in a mall and they witness a person collapse and become unresponsive. Based on the assessment, they initiate two-rescuer CPR. Under which circumstances can the two nurses discontinue the CPR? Select all that apply. (394) 1. A relative of the unresponsive person tells them to stop. 2. Mall personnel arrive with the automated external defibrillator. 3. The curious crowd pushes in and bystanders are loud and unruly. 4. Trained medical personnel arrive and take over CPR. 5. The person remains unconscious but spontaneous pulse and breathing occur. 6. A layperson offers to take over the role of doing compressions.

Answer 2, 4, 5: CPR can be stopped to apply the automated external defibrillator (AED), and for trained personnel to take over. If the person is spontaneously breathing and has a pulse, CPR should be discontinued even if the person remains unconscious. Pulse and breathing should be continuously monitored. The nurses should not trade off with a layperson unless they are exhausted and unable to continue with CPR. Trading causes delay. In addition, the nurses are more likely to have experience, recent training, and better compression technique than a lay rescuer. The nurses should not be distracted by the relative or the crowd. CPR requires intense effort and timing. The nurses could stop if the relative or crowd were threatening their personal safety.

21. Which assessment finding confirms cardiac arrest? (396) 1. Absence of radial pulse 2. Absence of carotid pulse 3. Absence of spontaneous respirations 4. Unresponsiveness to normal stimuli

Answer 2: Absence of a carotid pulse is indicative of cardiac arrest. The peripheral pulses are not as strong and blood flow to extremities will decrease to preserve the brain and heart. It is possible for respirations to cease while the heart continues to beat (e.g., choking or drowning); however; cardiac arrest will quickly follow respiratory arrest. There are many reasons for decreased responsiveness (e.g., diabetic coma, stroke, drug overdose, electrolyte imbalance) where the heart will continue to beat.

29. Which patient has the greatest risk for internal bleeding? (406) 1. A 20-month-old child who stumbled and struck his forehead on a coffee table 2. A 70-year-old woman sustained a hip fracture and takes an anticoagulant 3. A 25-year-old man who was punched and kicked in the stomach 4. A 30-year-old woman who was admitted for postpartum hemorrhage

Answer 2: All of these patients are at risk for internal bleeding; however, for patients who are on anticoagulants, fractures of hip or femur can result in 500-1500 mL of blood loss. Small children with bumps to the forehead usually do well and are generally discharged to parents with a careful explanation of what to watch for. Blunt trauma to the abdomen can cause rapid or slow internal bleeding. Serial abdominal assessments are performed on these patients and increasing or unrelieved pain is immediately reported to the RN or provider. Women with postpartum hemorrhage can die if the bleeding is excessive or if there are complications, (e.g., disseminated intravascular coagulation), but generally a dilation and curettage and IV fluid replacement are sufficient treatment.

23. The patient has a T-tube in place following an abdominal cholecystectomy. What is the expected output of bile in the first 24 hours? (635) 1. 30 mL per hour 2. 250-500 mL 3. 10-50 mL 4. 1-2 L

Answer 2: An expected output ranges from 250-500 mL.

24. The nurse is observing a new staff member perform a sterile dry dressing change. The nurse would intervene if the staff member performed which action? (622) 1. Loosens tape and gently pulls towards the incision 2. Uses sterile gloves to remove the old dressing 3. Cleanses wound by starting at incision moving outward 4. Allows antiseptic cleansing solution to air-dry

Answer 2: Clean gloves are adequate to remove old dressings. The other options are correct.

2. To address the signs and symptoms of the inflammatory phase, which action would the nurse perform? (616) 1. Cover the wound with clean gauze and apply direct pressure. 2. Elevate the injured part and apply an ice pack as ordered. 3. Observe for purulent exudate and cleanse the wound. 4. Observe for granulation tissue and keep the wound moist.

Answer 2: During the inflammatory phase, erythema, heat, swelling, pain and tissue dysfunction occur. Elevation and ice packs can reduce pain and swelling if applied during this phase.

10. The nurse notes heavy spurting of bright-red blood from the patient's groin area after he returns from an arteriogram procedure. The nurse dons clean gloves and applies gauze and direct pressure. The gauze is quickly saturated. What should the nurse do first? (404) 1. Increase the patient's IV fluid, take vital signs, monitor bleeding, and notify the provider. 2. Place an additional layer of gauze on top of the saturated dressing and continue to hold pressure. 3. Elevate the hips and apply more pressure over the groin area; ask someone to check a distal pulse. 4. Apply a pressure bandage and monitor distal pulses, sensation, and temperature of the skin.

Answer 2: For active arterial bleeding, place additional gauze on top of the saturated dressing and continue to hold pressure. The nurse could ask another nurse to check pulses or call the provider. Taking vital signs can be delegated to UAP. Elevating the hips is impractical and applying a pressure dressing over the groin area would be difficult. Once the bleeding has stopped, monitoring for rebleeding and for distal perfusion is appropriate action.

23. The nurse is performing CPR on an infant. What is the most common event that could occur? (399) 1. Fracture of the rib 2. Gastric distention 3. Aspiration of emesis 4. Laceration of spleen

Answer 2: For infants, gastric distention is common because an excessive amount of air is delivered during rescue breathing. To prevent this, the amount of air that is held in the nurse's cheeks is given during each rescue breath.

6. Which patient has a condition that could resemble brain death? (396) 1. The patient has a blood alcohol level of 80 mg/dL. 2. The patient has a core temperature below 30° C (86° F). 3. The patient has oliguria secondary to hypovolemic shock. 4. The patient fainted and was unconscious for 5 minutes.

Answer 2: Hypothermia, anesthesia, poisoning, or drug intoxication can resemble brain death. A core temperature below 30° C (86° F) results in lowered metabolic rate and patients may appear dead but should be slowly warmed and cardiopulmonary resuscitation may be needed.

25. The nurse is assessing a trauma patient who was treated for shock in the emergency department. Oliguria (production of abnormally small amounts of urine) is noted and immediately reported to the provider. Which complication is most related to this finding? (402) 1. Right-sided heart failure 2. Kidney failure 3. Paralytic ileus 4. Electrolyte imbalance

Answer 2: Oliguria is urine output less than 500 mL in 24 hours. During shock, blood flow to the kidneys is decreased. This can result in damage to the kidneys. Paralytic ileus is decreased or absent motility of the bowel, which can also occur with shock; however, the appropriate assessment would be bowel sounds, abdominal pain, or failure to pass gas or stool. Shock can also produce electrolyte imbalance, but assessment of laboratory values would be more appropriate than observing amount of urine output. Heart failure is the least likely complication of shock. Right-sided heart failure is more associated with long-term respiratory or circulation problems.

35. Which patient is most likely to need a tetanus toxoid injection? (406) 1. Patient fell off a bike and has abrasions on the knee, last known tetanus shot was several years ago. 2. Patient sustained a puncture wound from stepping on a nail that went through his workboots. 3. Patient was elbowed during a basketball game and has swelling and ecchymoses on the right lateral chest. 4. Patient sustained a deep cut on the hand while washing a drinking glass; there was extensive bleeding.

Answer 2: Patients who sustain puncture wounds should have a tetanus toxoid injection unless they had one within the past 10 years. Patients with closed wounds do not need tetanus shots. The patient who was cut by a drinking glass is also likely to get a tetanus shot, but the wound bleed freely and the drinking glass is a less likely source of tetanus compared to a dirty object such as a nail.

11. After abdominal surgery, a patient is at risk for wound stress related to coughing and moving. What equipment does the nurse need to teach the patient the self-care measure of splinting? (617) 1. An abdominal binder 2. A pillow or rolled blanket 3. A large triangular bandage 4. Several wide elastic bandages.

Answer 2: Splinting is accomplished by holding a pillow, a rolled blanket or palms of hands over the incision area when coughing. This reduces the tension on the suture line.

26. The nurse is assessing the amount of drainage that the patient has from a surgical wound and finds that 650 mL has drained from 9:00 am until now, 11:40 pm. What should the nurse do first? (628, 629) 1. Record the amount and appearance of the drainage and continue to observe. 2. Take the patient's vital signs, assess for other symptoms, and inform the surgeon. 3. Make sure that the patient's linens are clean and dry and empty the drainage receptacle. 4. Apply a pressure dressing and place the patient in a supine position.

Answer 2: The amount of drainage is excessive, so the nurse would take vital signs and assess for other symptoms of hemorrhage or shock and inform the surgeon. Documenting is always necessary and comfort measures are always welcome once the immediate problem is addressed. The nurse should not apply a pressure dressing, but the supine position would be appropriate if the nurse determines that the patient is hypovolemic.

14. The nurse is caring for a patient who has a large abdominal incision. The patient tells the nurse that she is afraid to sit up or even move because of the pain and the strain on the incision site. What instructions should the nurse give to the patient? (617) 1. "Rest in bed until the incision site is less tender and healing has progressed." 2. "Roll to one side, use your elbow as a lever, and push to a sitting position." 3. "Hold a pillow next to your abdomen and roll forward into a sitting position." 4. "Call for assistance whenever needed and someone will help you sit up.

Answer 2: The nurse helps the patient learn to move independently and safely. This is accomplished in steps: rolling, leverage, and pushing. The patient should not be encouraged to just lay in bed. Holding a pillow to the abdomen is appropriate during coughing and deep-breathing. Calling for assistance is okay, but this limits independence.

12. The patient had an uneventful hip surgery several days ago and will soon be transferred to a rehabilitation unit. The patient says to the nurse, "I feel silly complaining about this, but I feel a little short of breath and I feel a little anxious and fuzzy-headed." The patient has no known history of respiratory or cardiac problems. What should the nurse do first? (342) 1. Reassure the patient that she is not being silly, and that anxiety is normal. 2. Take the vital signs, apply a pulse oximeter, and listen to breathe sounds. 3. Ask the patient to describe what she is feeling and what she thinks is going on. 4. Apply oxygen per nasal cannula, notify the charge nurse, and call the provider.

Answer 2: The nurse must assess this patient first, because the symptoms are vague and the patient is not in acute distress. There are many things that could be causing the patient's subjective symptoms, but surgical patients always have some risk to for pulmonary embolism (symptoms can be severe, or the patient can be asymptomatic). The nurse first takes vital signs and pulse oximeter readings. Breath sounds are ausculated if the patient is not in severe distress and then the nurse would ask the patient to describe the symptoms in more detail (talking interferes with breathing, so the nurse would check a pulse oximeter reading, before asking the patient to answer questions). Based on assessment, the nurse might decide to apply oxygen and notify the charge nurse and the provider. It is also possible the patient may just feel anxious and needs to talk about the transfer to rehab and other future plans.

16. A patient had surgery 4 days ago and now reports an increase in pain and has a temperature of 101.6° (38.7° C). The incision site looks red compared to yesterday and a small amount of purulent drainage is seeping around the suture line. Which laboratory result will the nurse check before contacting the surgeon? (619) 1. Hemoglobin and hematocrit 2. White blood cell count 3. Platelet count 4. Blood glucose level

Answer 2: The nurse suspects that an infectious process is occurring and knows that an elevated white blood cell count is likely to validate this suspicion.

21. After a total abdominal hysterectomy, a post-operative patient develops a wound evisceration. What should the nurse do first? (629) 1. Check the patency of the intravenous (IV) site for delivery of fluids. 2. Place the patient in low Fowler's position to reduce strain on the wound. 3. Prepare the patient for surgery and contact the surgeon. 4. Cover the wound with a sterile dressing moistened with saline.

Answer 2: The patient should be placed in a low Fowler's position with the knees slightly flexed The wound should be covered with sterile dressings moistened with saline.. The surgeon should be notified. A patent IV is needed because the patient is likely to need a surgical repair.

18. The nurse finds a person lying at the bottom of a long staircase. The person is conscious but appears dazed and confused. There are no obvious injuries or signs of bleeding. What should the nurse do first? (394) 1. Assist the person to sit up and suggest that he rest on a step. 2. Instruct the person to remain still and ask for permission to assist. 3. Initiate spinal cord precautions and hold head and neck in alignment. 4. Ask the person what happened and if he is having pain or distress.

Answer 2: The person should not be moved, but since he is conscious it would be appropriate for the nurse to identify self and ask for permission to help. Resist the impulse to assist the person into a sitting or standing position. (Person may also be attempting to get up.) Initiating spinal precautions is correct; however, failure to ask permission or explain actions could be interpreted as an attack, especially if the person is confused and the nurse is a stranger to him/her. Asking the person about pain, symptoms, and events is appropriate after he is calm, immobile, and help has been summoned.

17. Which patient is most likely to benefit from the application of a triangular binder? (639) 1. Has a chronic pressure injury on the sacral area 2. Has a possible fracture in the forearm 3. Has venous stasis ulcer on left ankle 4. Has a surgical wound on the lateral chest area

Answer 2: The triangular binder (sling) will provide support for the possible fractured forearm.

17. During a camping trip, a person who is allergic to bee stings is stung by a bee. The nurse immediately scrapes the skin to remove the stinger. Which question should the nurse ask first? (411) 1. "What happens when you get stung by a bee?" 2. "Do you want to go to the hospital?" 3. "Where is your epinephrine pen?" 4. "Do you have any diphenhydramine?"

Answer 3: A person with a known allergy to bee stings is supposed to carry an epinephrine pen and the pen should be immediately available in case the person has an anaphylactic reaction or becomes unconscious or unable to speak. If a pen is not available, taking diphenhydramine and immediately seeking medical assistance would be the next best thing. Discussions about past episodes of allergic reaction should not delay treatment or seeking medical assistance. Allergic reactions can be progressively worse with repeated exposures to allergens.

10. The nurse must be vigilant for signs of hypoxia in an older patient who has dementia and also has risk for decreased oxygenation because of chronic respiratory disease and immobility. What is an early sign that warrants additional assessment of respiratory status? (341) 1. Lips are cyanotic, fingers are cool, and capillary refill is sluggish. 2. Respirations are slow and shallow. 3. Patient seems restless and anxiously picks at linens. 4. Pulse is slower than normal and is thready and weak.

Answer 3: For patients who are unable to verbalize complaints or symptoms, the nurse must be vigilant and investigate subtle changes in behavior, such as anxiety or a change in mental status. Cyanosis and slowing of pulse and respiratory rate are late signs.

7. The nurse is teaching basic CPR to a new group of unlicensed assistive personnel (UAP). When would the nurse intervene? (397) 1. The UAP leans forward over the mannikin and creates pressure to depress the sternum at least 2 inches (5 cm). 2. The UAP compresses at a rate of 100 to 120 compressions per minute without pausing between compressions. 3. The UAP places the heel of one hand over the lower end of the sternum and places heel of the other hand on top. 4. The UAP interlaces fingers to keep them off the chest and keeps hands in contact with the chest.

Answer 3: Heel of the hand should be placed over the center of the sternum between the nipples. This position decreases the likelihood of fracturing the xiphoid process or ribs or lacerating an organ and maximizes the compression action over the heart.

14. The person gives the universal sign for choking. How does the nurse prepare to perform abdominal thrusts? (401) 1. By instructing the person to lean over the back of a chair 2. By placing the fist over the sternum 3. By placing the fist slightly above the navel 4. By putting the heel of the hand over the xiphoid process

Answer 3: Placing the fist just above the navel is the position to create enough force to expel the foreign body, and to avoid fracturing underlying bone structures. Bending over the back of a chair is a method that should be tried if a person is alone and unable to summon assistance.

12. Which lunch tray is best for providing protein, vitamins A and C, and zinc, the nutrients required for wound healing? (617) 1. A peanut butter sandwich with a glass of milk 2. A bowl of bean soup with crackers and iced tea 3. Broiled seafood with spinach salad and tomato juice 4. Stir-fried mixed vegetables with rice and hot tea

Answer 3: Seafood supplies protein and zinc. The salad provides vitamin A and the tomato juice provide vitamin C. The other meals also provide good nutrition, but do not offer all of the required nutrients.

9. The nurse is caring for a patient who may have a cervical spine injury. The patient is lying flat and begins to vomit. What should the nurse do? (416) 1. Immediately use an oral suction catheter to remove vomitus and direct the patient to hold breath during suctioning. 2. Direct the patient to look straight ahead and not move his neck, then sit him up-right using the bed mechanism. 3. Direct several people, acting together as one unit, to help logroll the victim onto his side to allow drainage. 4. Immediately report vomiting to the provider and ask if cervical spine injuries have been ruled out.

Answer 3: Several people acting together should logroll the patient. A nurse or provider should control and maintain the position of the head and neck during the roll.

In performing nursing skills and procedures for patients, which nursing action demonstrates the nurse's understanding and use of Standard Precautions? (339) 1. Always checks the patient's armband and asks the patient to state his or her name 2. Assesses the patient's understanding and teaches accordingly 3. Performs hand hygiene before and after every patient encounter 4. Evaluates the patient's response to and tolerance of the procedure

Answer 3: Standard Precautions are based on the assumption that every patient is a source of infectious organisms, so hand hygiene before and after every patient encounter contributes to safety and infection control. The other options are important aspects of performing any procedure.

37. The nurse is on a hiking trip and one of the children finds an injured bat and picks it up. The bat bites the child before any of the adults can intervene. What should the nurse do first? (411) 1. Monitor for shock and seek medical attention immediately. 2. Capture the bat and observe for injury or signs and symptoms of the disease. 3. Immediately wash the bite area with soap and water for 5 minutes. 4. Assess for and control bleeding and apply a thick gauze bandage.

Answer 3: Studies show that through wound cleansing markedly reduces the incidence of rabies. It would be appropriate to capture the bat if it can be done safely and quickly; then take the child and the bat (for rabies testing) and seek medical assistance.

22. The latest recommendation for CPR is to go "hard and fast" when performing chest compressions. What is the best rationale for maintaining the recommended 100 compressions/ minute? (397) 1. The rescuer will become fatigued if compressions exceed 100/minute. 2. Lacerations of the liver or spleen are more likely to occur if speed is excessive. 3. Releasing external chest compression allows time for blood to flow back into the heart. 4. A smooth motion is required to prevent rocking and rolling that decrease the force.

Answer 3: The goal of CPR is to mimic the pumping action of the heart and if compressions are too rapid and the heart is not allowed to fill with blood, there is nothing to pump out. The rescuer will become fatigued even if the proper rate is maintained; altering the speed of compressions is not the solution. Lacerations or fractures are more associated with proper hand position than speed of compressions. A smooth motion is more related to proper position of arms and hands in relation to the victim's body. Rescuer fatigue could also contribute to smoothness of movements.

20. The patient returned to the unit 3 hours ago after having surgery on the abdomen, and the dressing is now saturated with red, watery drainage. What should the nurse do first? (633) 1. Notify the charge nurse and the surgeon. 2. Take the patient's vital signs and assess for pain. 3. Securely reinforce the dressing with layers of gauze. 4. Remove the dressing and observe the wound site.

Answer 3: The nurse should first reinforce the dressing, because this may help stop or slow the bleeding. Next, the nurse would assess for signs of shock. The charge nurse and the surgeon should be notified about the saturated/reinforced dressing and the vital signs and pain symptoms. The dressing should not be removed at the 3-hour point by anyone except the surgeon.

6. The nurse observes that the dressing over the wound has exudate that has a strong, pungent odor. Which action is the most important? (633) 1. Weigh the soiled dressing. 2. Cleanse the wound with an antiseptic. 3. Perform a wound culture. 4. Circle and date the drainage on dressing.

Answer 3: The nurse would obtain a wound culture and notify the surgeon about possible infection. Weighing the dressing and circling the drainage and dating the dressing are used to track the amount drainage. Cleansing the wound with antiseptic might be ordered by the surgeon, but a wound culture should be obtained first.

26. The nurse hears a scream; a patient has slipped in the bathroom. There is bright-red blood spurting from her forearm. What should the nurse do first? (404) 1. Don sterile gloves and apply firm pressure using a sterile gauze pad. 2. Use layers of sterile dressing material and wrap them snugly with an elastic bandage. 3. Don clean gloves and use a clean towel to apply direct pressure; elevate the arm. 4. Locate the brachial artery and use the

Answer 3: The patient has an arterial bleed, so the nurse would not waste time seeking out sterile supplies. Clean gloves and a clean towel are adequate. Elevation above the level of the heart will also help control the bleeding. Wrapping the area with layers of sterile gauze would be done after initial bleeding is controlled. Pressure to the brachial artery would only be done if direct pressure and elevation were not controlling bleeding.

The nurse walks into the room and notices that the patient is anxious, demonstrates labored breathing, and seems to be struggling to get out of bed. What should the nurse do first? (342) 1. Gently advise the patient to calm down, then and ask him what is wrong. 2. Count the respiratory rate, note rhythm, and auscultate breath sounds. 3. Assist him to sit upright and calmly in-struct him to take slow, deep breaths. 4. Stay with the patient, apply oxygen, and have another nurse call the provider.

Answer 3: The patient is in obvious distress and there are many things that could be causing his behavior, but oxygenation is the priority. The quickest action is to help the patient sit upright; this allows for maximum chest expansion and is the most comfortable position for patients with respiratory distress. Helping him to take slow deep breaths, maximizes use of room air oxygen. If oxygen is immediately available in the room the nurse could apply it. (Note to student: Oxygen does require a provider's order, but in an emergency situation, the nurse must use critical thinking; apply oxygen as needed and get an order as soon as possible.) Taking vital signs should be done as soon as oxygen needs are met. Nurse uses clinical judgment to decide when to ask the patient to answer questions (talking interferes with breathing).

25. A nurse is supervising a nursing student who is doing a wet-to-dry dressing change. What does the nurse do when the student applies a dry dressing over the wet gauze? (624) 1. Directs the student to moisten all of the layers. 2. Hands the student an occlusive dressing. 3. Tells the patient that the student is doing a great job. 4. Suggests removal of all layers and starting over.

Answer 3: The student has performed the correct action. Telling the patient that the student is doing a great job gives the student positive reinforcement, while reassuring the patient that the student's technique is correct. The other options are incorrect.

10. The nurse is applying a dressing over the insertion site of a peripheral intravenous catheter. Which dressing is the best choice? (625) 1. Sterile tape with dry gauze 2. Steri-Strips and transparent dressing 3. Transparent dressing 4. Sterile pad with chevron taping

Answer 3: The transparent dressing is currently the dressing of choice.

20. The provider informs a patient's wife that her husband has suffered brain death and is in an irreversible coma, even though his heart is still beating. Which comment indicates that the wife has understood what the provider said? (395, 396) 1. "His heart is still beating, so there is still a chance he'll recover." 2. "He is in a coma, but do you think that he can hear what I say?" 3. "I must notify the family so that everyone can come and say goodbye." 4. "How long do you think he will have to stay in the intensive care unit?"

Answer 3: The wife is acknowledging that it is time to say goodbye. It is not uncommon for families to need additional time at the bedside when someone dies. The other statements indicate a belief or hope that he can still recover.

3. During the reconstruction phase of healing, what is the most serious complication? (616) 1. Keloid formation 2. Granulation tissue 3. Wound dehiscence 4. Phagocytosis

Answer 3: Wound dehiscence occurs most frequently during the reconstruction phase. Nurse would have the patient remain in bed and receive nothing by mouth (NPO). Tell the patient not to cough; place a warm, moist sterile dressing over the area until the surgeon evaluates the site. Keloid formation is a collagen overgrowth. It is not dangerous, but appearance of the scar tissue may upset the patient. Granulation tissue develops during healing by secondary intention. Phagocytosis a process by which certain cells engulf and dispose of microorganisms and cell debris.

13. Which sign or symptom of a foreign body airway obstruction is of greatest concern? (400) 1. Says, "I think I swallowed something." 2. Is coughing so hard that he can't speak. 3. Makes a wheezing sound between coughs. 4. Demonstrates a high-pitched inspiratory noise.

Answer 4: A high-pitched inspiratory noise suggests that there is an object in the airway that is allowing a small amount of air to go around the object. This is an emergency, because the object could become lodged and allow no air movement. If the person can speak, this means that air is passing over the vocal cords and into the airway. Forceful coughing is a good sign because it is the most effective means for the person to independently rid the airway of a foreign body. If the person is coughing, rescuer would not interfere, even if some wheezing is heard.

24. An infant is observed picking up something from the floor and putting it into his mouth before the mother can stop him. He demonstrates coughing, gagging, stridor, and respiratory distress. What should the nurse do first? (401) 1. Instruct the mother to hold the child and look into the mouth with a flashlight. 2. Place the infant in a supine position and deliver five chest thrusts. 3. Place two fingers just above the navel and deliver five abdominal thrusts. 4. Hold the infant with the head lower than trunk and deliver five back blows.

Answer 4: For infants, use five back blows, turn him over and deliver five chest thrusts. For back blows and chest thrusts, head should be lower than the trunk. See Figure 16-9. If the object is expelled during blows or thrusts and the head is downward, gravity will help. Using a flashlight and looking in the mouth will delay the intervention of clearing the airway. The child is likely to struggle out of fear and respiratory distress and visualizing the back of the mouth will be very difficult.

12. A patient is unresponsive to normal verbal stimuli and not breathing. How does the nurse assess for a carotid pulse? (394) 1. Assess the location of the pulse for a maximum of 5 seconds. 2. Check the strength of the pulse for 5 seconds and then compare it to the opposite side. 3. Assess the pulse rate for 10 seconds and then check for a 3-second capillary refill. 4. Check the rate, rhythm, and strength of the pulse for a maximum of 10 seconds.

Answer 4: Health care professionals, including nurses, should check for a carotid pulse, but spend no longer than 10 seconds.

What does the nurse observe during the first phase of healing if fibrin is functioning correctly? (616) 1. Erythema, heat, edema, and pain occur. 2. There is an overgrowth of whitish collagen. 3. Wound looks irregular, raised, and purplish. 4. Clot begins to form and bleeding subside

Answer 4: Hemostasis is the first phase of wound healing and fibrin in the clot begins to hold the wound together and bleeding subsides. The second phase is inflammatory and erythema, pain, swelling and heat are expected. In the third phase, reconstruction, the wound is purplish, raised and irregular. In the maturation phase a white, red or pink overgrowth of collagen (keloid) may form in some people.

27. Under what circumstances would the nurse use a tourniquet? (404) 1. The nurse is acting in good faith and con-forms to Good Samaritan principles. 2. The provider gives a telephone order to apply a tourniquet. 3. The victim tells the nurse to apply a tourniquet. 4. Pressure and elevation have failed to control life-threatening bleeding.

Answer 4: If direct pressure, elevation, and indirect pressure have failed to control bleeding and the patient's life is in danger, the nurse would use a tourniquet. Use of a tourniquet should not be considered part of general first aid or the Good Samaritan principles. A provider could order the application of a tourniquet over the phone or the victim could request it; however, as with other procedures that are not within the scope of practice, the nurse should decline unless he/she deems that the patient's life is in jeopardy.

19. The nurse is preparing to change the patient's dry sterile dressing. Upon attempting the removal of the old dressing, it adheres to the site. What should the nurse do? (621) 1. Notify the surgeon. 2. Leave the dressing alone. 3. Pull the dressing off quickly. 4. Moisten the dressing with saline.

Answer 4: If the dressing is moistened with saline, this will help loosen the crusty exudate.

32. The nurse comes home and finds that her teenage son and his friends have been challenging each other to chug large shots of whiskey. Which adolescent needs to be taken to the hospital for serious alcohol intoxication? (411) 1. Face appears flushed and seems sleepy. 2. Demonstrates slurred speech and continuously giggles. 3. Is loudly singing and starting to remove clothes. 4. Is incontinent of bowel and bladder and is hallucinating.

Answer 4: Loss of bowel and bladder function, rapid and weak pulse, labored breathing, seizures, nausea, vomiting, diarrhea, loss of memory, lack of coordination, and depressed muscle reflexes are signs of serious intoxication. The other adolescents are demonstrating signs and symptoms of mild intoxication.

8. The nurse initiates CPR on a frail older woman who has a cardiac arrest. During the compressions, the nurse hears and feels the cracking of the ribs. What should the nurse do? (397) 1. Change hand position and then continue compressions. 2. Stop compressions and assess for crepitus or flail chest. 3. Stop compressions, but continue to deliver the rescue breaths. 4. Verify correct hand position and continue compressions.

Answer 4: Nurse verifies hand position; incorrect hand position increases the chance for factures, but even with correct positioning, fracturing the ribs is a possibility, especially in the frail elderly. Resuscitation efforts should continue.

The patient requires suctioning of pulmonary secretions. What is the most accurate problem statement for this patient's condition? (341) 1. Potential for fluid volume excess 2. Inability to maintain breathing pattern 3. Potential for inadequate tissue perfusion 4. Inability to clear airway

Answer 4: Secretions are obstructing the air passages; suctioning will clear the airway.

What is included in the preparation for tracheostomy care in the acute care environment? (342) 1. Using clean technique and supplies for cleaning 2. Preparing cotton balls to clean inside the ostomy 3. Removing and cleaning the outer cannula 4. Placing the patient in a semi-Fowler's position

Answer 4: Semi-Fowler's position allows the patient to breathe easier and allows easy access for nurse. Sterile technique is required. The outer cannula is not removed. Cotton balls should not be inserted into the tracheostomy.

7. What is an important nursing responsibility associated with a Penrose drain? (633) 1. Drainage in bulb should be observed and measured, suction should be reestablished. 2. Ensure that the irrigation pressure does not exceed 4 to 15 psi. 3. Drain should be observed for patency and flushed as needed. 4. Drainage on dressing should be observed, the position of the safety pin is noted

Answer 4: The Penrose drain is an open system made of rubber tubing that goes from inside the wound through a surgical stab wound and the drainage is collected on a dressing. A sterile safety pin is inserted through the drain to prevent it from sliding back into the wound. With a Jackson-Pratt the drainage in the bulb should be observed, measured and discarded and then the bulb is depressed to reestablish suction. Drains are never irrigated or flushed unless surgeon specifys irrigation or flushing.

13. The patient has no contraindications for fluid intake. Over a 24-hour period, he drank 16 ounces of decaffeinated coffee, 10 ounces of juice, 6 ounces of milk, and a half a liter of soda. What instructions does the nurse give the patient about fluid intake to promote wound healing? (617) 1. Instructs the patient to continue drinking the same amount as he drank today 2. Tells the patient that tomorrow he should try to drink twice as much as today 3. Advises the patient that drinking excessive fluid is likely to decrease appetite for food 4. Suggests that he drink 2-3 additional 8-ounce servings of his favorite fluid every day

Answer 4: The goal for the patient (assuming no fluid contraindications) is 2000-2400 mL. He drank a total of 1460 mL, so he if he drinks two or three additional 8-ounce servings, he will be closer to the recommended amount. 16 ounces = 480 mL 10 ounces = 300 mL 6 ounces= 180 mL Half a liter =500 mL Total intake =1460 mL

The nurse is reviewing laboratory results and sees that the PaO2 level for a 75-year-old patient is 80 mm Hg. What should the nurse do first? (344) 1. Notify the provider about the unusually low level. 2. Contact the clinical laboratory to verify the low result. 3. Check the previous laboratory values for comparison. 4. Assess the patient for signs/symptoms of respiratory distress.

Answer 4: The nurse would immediately assess the patient for respiratory distress and intervene as necessary. If the patient is not in immediate distress, the nurse would consider factors that could affect PaO2: such as age or chronic health conditions. Comparing past laboratory data is also useful to note trends. Based on assessment of the patient and contributing factors, the nurse may or may not decide to immediately call the provider.

5. Which dressing requires that the nurse place tape strips on all sides of the dressing? (621) 1. wet-to-dry dressing 2. Dry dressing 3. Transparent dressing 4. Occlusive dressing

Answer 4: The purpose of an occlusive dressing is to prevent air or oxygen from reaching the wound site, so the nurse would use tape to seal the edges of the dressing.

36. The patient has a sutured laceration on the palmar surface of the hand. When will the super-vising nurse intervene? (409) 1. The student nurse positions the hand in the anatomical position before applying the bandage. 2. The student nurse covers the entire wound with the dressing and roller gauze is applied uniformly. 3. The student nurse applies roller gauze with a number of evenly spaced overlapping turns. 4. The student nurse covers the tips of the fingers with the gauze bandage and secures roller gauze with tape.

Answer 4: Tissue distal to the wound, in this case the fingers, should not be covered. This allows the nurse to assess capillary refill, skin temperature and finger joint movement. The other actions are correct.

33. It's the Fourth of July and the nurse is working at a walk-in clinic. Several people who were viewing a parade come in and report abdominal cramps, headache, weakness, nausea, and diaphoresis. All are alert and oriented. Which intervention would the nurse use first? (413) 1. Establish peripheral intravenous sites for everyone. 2. Give everyone several cool compresses. 3. Assist everyone to remove constrictive clothing. 4. Move everyone into a cool environment.

Answer 4: Victims are first moved into a cool environment. Next, the nurse would assist to remove constrictive clothing, offer cool drinks, and give cool compresses. A circulating fan will also help.

Hip surgery restrictions

Cannot bend more than 90 degress, cross legs, cannot sit low, bent foward, roatate foot legs,

Abscess

Cavity that contains pus and is surrounded by inflamed tissue, formed as a result of suppuration in a localized infection

Hematoma

Collection of extravasated blood trapped in the tissues or in an organ that results from incomplete hemostasis after surgery or injury

Diagnostic

Determines the cause of a particular health problem

fraction of inspired oxygen (FiO2)

Nasal cannula 1-6 L/min = 24%-44% O2 Simple face mask 5-8 L/min = 35%-55% O2 Venturi mask 4-10 L/min = 24%-55% O2 Partial rebreather mask 6-12 L/min = 60%-90% O2 Nonrebreather mask 6-15 L/min = 70%-100% O2

A patient asks if an antiseptic or ointment can be applied to her third-degree full-thickness burns. Which advice would the nurse give to the patient? O "Use sprays or creams instead of antiseptics and ointments. O "Only oil-based antiseptics and ointments should be applied O "Antiseptics or ointments may interfere with medical treatment." O "Anything that will cause the child to be more comfortable can be applied."

O "Antiseptics or ointments may interfere with medical treatment." Rationale It is not appropriate to apply antiseptics, ointments, sprays, or creams to the burn because they may potentially interfere with medical treatment and cause complications. Loose sterile dressings can be applied to the burn area.

Which instruction does the nurse give a patient when the patient reports irritation of the nares while receiving 2 L/min of oxygen via nasal cannula? O "Remove oxygen periodically! O "Use petroleum jelly on nares." O "Switch to a simple face mask." O "Apply a water-soluble lubricant."

O "Apply a water-soluble lubricant." Rationale The nurse would instruct the patient to apply water-soluble lubricant to the nares to treat irritation. Petroleum jelly should not be used, as petroleum-based products are combustible. Instructing the patient to remove oxygen could lead to hypoxia. Masks are used to deliver oxygen at rates greater than 4 L/min and would not be appropriate for a patient receiving 2 ymin.

A child has ingested furniture polish. Which instruction would the nurse give the mother? O "Call 911 for an ambulance O "Call the poison control center. O "Give ipecac syrup to induce vomiting. O Take the child to the emergency room.!

O "Call the poison control center. Rationale The mother should call the poison control center immediately to receive instructions regarding to what to do next. Taking the child to the emergency room or calling 911 for an ambulance would not be the first intervention because it could delay treatment. The mother should not give ipecac unless instructed to do so by the poison control center personnel. Inducing vomiting may not be the appropriate action for this type of poisoning

The nurse is providing educational packets to a patient before gallbladder removal surgery. Which question would the nurse ask to determine whether the patient can read and understand the material presented? O "Can you read this packet?" O "Do you understand what you are reading?" O "Can you please read to me the first paragraph of the packet?" O "Can you please tell me, in your own word, what you're reading in this packet?"

O "Can you please tell me, in your own word, what you're reading in this packet?" Rationale The nurse should ask the patient to present, in his or her own words, the information in the packet. If the patient cannot read, he or she is unlikely to admit it. Therefore, asking the patient if he or she can understand or read the packet would be unhelpful. Although the patient may be able to read what he or she sees in the packet, this is not the same as understanding what is in the packet

Which instruction would the nurse provide to a patient who is receiving oxygen via a transtracheal tube for the first time? O "Change the catheter every 3 months." O "Refrain from drinking fluids during use." O "Report small amounts of dear exudate! O lean the area every 4 hours with saline!

O "Change the catheter every 3 months." Rationale The transtracheal oxygen catheter should be changed a minimum of every 3 months because the catheter can become brittle over time. Patients can drink, eat, and talk while the transtracheal catheter is in place. Small amounts of clear exudate are normal; however large amounts of thick, colored exudate should be reported. The area should be cleaned with hydrogen peroxide two times a day.

Which information would the nurse provide to a home care patient when teaching how to use humidified oxygen at 3 L/min? Select all that apply. O "Change the solution every 24 hours." O "Use bottled water in the chamber." O "Use humidification when wearing a face mask. O "Use distilled water in the chamber O "Wear gloves when touching the oxygen equipment."

O "Change the solution every 24 hours." O "Use distilled water in the chamber Rationale Distilled water should be the only type of water used in the humidification chamber. The water should be changed every 24 hours to prevent bacterial growth. Bottled or tap water should not be used. Gloves do not need to be worn. Humidification can be used, no matter which oxygen delivery device is being used.

Which instruction would the nurse give a patient before performing oropharyngeal suctioning with the Yankauer catheter? O "Lie back in the supine position." O "Cough to bring up any secretions." O "We need to check if your nostrils are blocked!" O "We need to turn up your oxygen supply to a higher amount."

O "Cough to bring up any secretions." Rationale Before oropharyngeal suctioning, patients should be encouraged to cough, which moves secretions from the lower airway into the mouth for suctioning. The patient should be sitting in semi-Fowler's or a higher position, rather than in the supine position, to prevent aspiration. The patency of the nostrils should be determined before nasopharyngeal, not oropharyngeal, suctioning. The nurse should not increase oxygen administration because this would not follow the health care provider's orders.

Which statement by the nurse about the effects of ambulation in the postoperative period indicates effective learning? O "Early ambulation helps hasten postoperative recovery." O Ambulation is necessary for patients with severe infection O "Patients should get in and out of bed within a month after surgery." O "Early ambulation causes urinary retention and thrombophlebitis.

O "Early ambulation helps hasten postoperative recovery." Rationale Early ambulation after surgery increases circulation and metabolism and therefore, hastens postoperative recovery in the patient. Ambulation is contraindicated in patients with severe infection as the patient may be weak and needs to conserve energy. Patients should get in and out of bed as soon as possible after the surgery to prevent deep vein thrombosis. Early ambulation improves kidney function and prevents urinary retention. There are low chances of thrombophlebitis because early ambulation increases circulation.

Which instruction would be given to a patient receiving transtracheal oxygen who reports the catheter has come out and he or she is unable to replace it? O "Force the catheter back in place." O "Go to the emergency room immediately! O "Administer oxygen at a higher flow rate." O "Clean the catheter site with hydrogen peroxide."

O "Go to the emergency room immediately! Rationale If the transtracheal catheter is removed and not replaced in a timely manner, the transtracheal opening can close over. If this occurs, the surgical procedure will need to be repeated. Patients should be instructed to go to the emergency room if the catheter comes out. Patients should never be instructed to force the catheter back in place. Patients should consult with the health care provider to determine the required flow rate. Twice daily maintenance of the transtracheal catheter site includes cleaning with hydrogen peroxide.

Which statement about tertiary intention is correct? O "Initially, wounds should be left open. O It occurs when the skin edges are open. O "It begins during the inflammatory phase." O "The wounds are covered by a gauze dressing."

O "Initially, wounds should be left open. Rationale The wound-healing process is categorized into three types based on the severity of the wound. In the tertiary intention healing method, the wounds are left open and are closed only when the infection is controlled. This type of healing occurs when wounds are contaminated by microbes. Unlike primary intention, tertiary intention does not begin during the inflammatory phase of healing. The primary intention method of healing can be seen when the patient has a wound with minor scarring. The secondary intention of healing often is found in patients who have wounds with open skin edges. The health care professional should cover open wounds with gauze to prevent infection.

Which instruction would the nurse give the home care patient who is receiving oxygen at 3 L/min and uses extension tubing that is 50 feet long? O "Keep an eye on the tubing to prevent falls." O "Tie up any excess tubing to prevent injuries." O "Only use portable oxygen tanks while at home." O "Don't use more than 25 feet of tubing at home."

O "Keep an eye on the tubing to prevent falls." Rationale Long extension tubing for oxygen can increase the patient's risk of falling. Excess tubing should not be tied; if tubes become kinked, they may deliver too little oxygen, Portable tanks should be used when leaving the home but are not necessary when the patient is at home. Only using shorter tubing will limit mobility and the patient's independence while at home.

Which information on preventing skin breakdown does the nurse provide the family of an older patient who is wearing oxygen tubing? Select all that apply. O "Loosen the straps." O "Reposition the tubing." O "Add padding over the ears." O "Remove oxygen supply for 15 minutes every hour." O "Apply petroleum jelly to the areas."

O "Loosen the straps." O "Reposition the tubing." O "Add padding over the ears." Rationale The nurse should instruct family members to loosen the straps, reposition the tubing, and add padding over the patient's cars to prevent skin breakdown resulting from use of oxygen tubing. The family should not be instructed to remove the oxygen supply for any period because the patient can become hypoxic Petroleum jelly is combustible and should never be used near the oxygen

Which instructions would be given to a patient who will be using oxygen at home? Select all that apply. O "Maintain oxygen at prescribed settings!" O "Don't use electrical equipment near oxygen." O Place nasal prongs facing upward in the nares." O "Use extension cords if extra mobility is needed." O "Store oxygen cylinders near a heating vent to warm them.

O "Maintain oxygen at prescribed settings!" O "Don't use electrical equipment near oxygen." O Place nasal prongs facing upward in the nares." O "Use extension cords if extra mobility is needed." Rationale The nurse should instruct the patient to maintain oxygen at the prescribed settings, refrain from using electrical equipment near the oxygen, and to place the nasal prongs in the upward position in the nares. Oxygen cylinders should be stored in a cool, dry place; they do not need to be kept warm and should not be stored near a heat source. Extension cords should not be used. If additional mobility is needed, extension tubing can be used.

A patient experiencing postoperative pain refuses to take analgesics and says that the pain is tolerable. Which instruction does the nurse tell this patient? O "Let me know at once if the pain is increasing or intolerable O You can let me know when you are ready to take the next dose O There are no adverse effects or problems if you delay medication O "Pain medication is more effective when taken at the onset of pain."

O "Pain medication is more effective when taken at the onset of pain." Rationale The nurse needs to inform the patient that it is inappropriate to delay analgesics until there is severe pain because the medications are more effective when taken at the onset of pain. It is not appropriate to tell the patient to inform the nurse only after the pain is intolerable. The nurse should instead encourage the patient to take medications as directed for effective pain management. Pain medications are administered as prescribed, and the nurse should not delay the dose according to the patient's readiness. The patient may need increased doses of pain medications if there is delay and the pain becomes intolerable later, which may cause side effects. Therefore, it is not appropriate to tell the patient that there will be no adverse effects

Which instruction would the nurse give to a patient receiving oxygen to help increase air exchange? O "Humidify the oxygen." O "Perform deep-breathing exercises O "Perform regular oral hygiene." O "Lie on left side when sleeping

O "Perform deep-breathing exercises Rationale Patients on oxygen should be encouraged to perform coughing and deep breathing exercises to facilitate air exchange. Humidifying the oxygen prevents nasal dryness. Oral hygiene helps prevent any bad taste in the mouth. The patient should sit in Fowler's position, not lie on the left side, to maximize oxygenation.

Four hours after surgery, a patient rings the call bell. When the nurse arrives, the patient states that the wound is infected. When the nurse assesses the wound, it is red, swollen, and warm to touch. Which statement would be the most appropriate response to the patient? O "You are correct: your wound is infected O "You are having an allergic reaction to your medication O "The wound is not infected; normal healing is occurring O "I will notify the health care provider of the infection.

O "The wound is not infected; normal healing is occurring Rationale During the appropriate inflammatory process, there is an initial increase in the flow of blood elements. This process causes the cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction. The wound is not infected because it has been only 4 hours since the surgery and this is a normal inflammatory response. This is not an allergic reaction but a part of the normal wound-healing process. There is no indication that the health care provider should be notified because this is a normal finding.

The nurse is planning care after a right hip replacement in a patient who smokes cigarettes. Which postoperative instruction would be most important to prevent respiratory complications in a patient who smokes cigarettes? O "Drink 8 to 10 glasses of water per day." O "Shift position in bed slightly every 15 minutes." O "Alternate pointing toes up and down 20 times every hour! O "Use the incentive spirometer 10 times every hour while awake.

O "Use the incentive spirometer 10 times every hour while awake. Rationale Patients who smoke and undergo anesthesia for the surgery are at an increased risk for atelectasis and pneumonia. It is important for these patients to diligently perform breathing exercises, such as using the incentive spirometer. The patient should increase fluid intake to prevent constipation, shift position in bed often to prevent pressure sores, and extend and flex the toes often to prevent deep vein thrombosis.

The nurse is providing teaching to a patient and his wife regarding postoperative care before a right shoulder replacement. Which comment by the nurse is the best way to facilitate understanding in the patient and his wife? O "Do you have any questions?" O "What questions do you have at this time?" O "Are you concerned about the postoperative period?" O Here is a packet with information on postoperative care. It should answer all of your questions."

O "What questions do you have at this time?" Rationale The nurse should ask open-ended questions to determine the patient and his wife's understanding of the teaching. Asking, "Do you have any questions?" does not facilitate a discussion. Although it is important to determine the patient's concerns, asking if he is concerned about the postoperative concerns requires only a "yes" or "no" answer and does not facilitate discussion. Although a packet may be helpful in facilitating the patient's learning, the nurse should not assume that all questions will be answered by the packet information

Which statement made by the licensed practical/vocational nurse (LPN/LVN) requires correction when teaching a patient with chronic obstructive pulmonary disease (COPD) about oxygen use at home? O"You can place padding over the ears to prevent skin breakdown." O "You can increase the liters of oxygen per minute if experiencing dyspnea." O "You should store the oxygen concentrator and tanks in a cool, secure location. O "You should refill the plastic humidifier battle with distilled water every 24 hours

O "You can increase the liters of oxygen per minute if experiencing dyspnea." Rationale The respiratory drive of a patient with COPD is based on increased carbon dioxide levels. Liters of oxygen per minute should not be increased in a patient with COPD because this will cause the respiratory drive to become diminished, and the patient will experience respiratory distress. Padding can be placed over the ears to prevent skin breakdown, oxygen should be stored in a cool, secure location, and the plastic humidifier bottle should be refilled every 24 hours with distilled water

During the immediate postoperative period, a patient with an external sequential compression device (SCD) wants to ambulate and then sit up for an hour or so without the device. Which statement by the nurse accurately addresses the patient's request? O "I think that will be okay if you feel up to it." O "You can, but only for 30 minutes, then we need to reconnect the SCD." O "I'm sorry, but when the SCD is being used, you are not allowed to get out of bed." O "Let's try having you sit on the edge of the bed first; if you do okay, then we can discuss it further.

O "You can, but only for 30 minutes, then we need to reconnect the SCD." Rationale An SCD device should not be disconnected for more than 30 minutes. The amount of time allowed out of bed when an SCD is being used is not based on whether the patient feels up to it. Patients with an SCD are not confined to bed. Regardless of how well the patient tolerates sitting on the side of the bed, the patient will not be allowed to get out of bed with the device disconnected for an hour.

Which statement by the nursing student regarding mouth-to-mouth ventilation to a patient with a normal pulse needs correction? O "You should initiate one breath every 15 seconds." O "You should utilize the head-tilt chin-lift maneuver." O "You should give one full breath lasting for 1 second! O "You should stop providing ventilation if the initial attempt fails.!

O "You should initiate one breath every 15 seconds." Rationale The statement made by the nursing student that needs correction is that there should be one breath every 15 seconds. When the patient has normal pulse, the nurse should provide one breath every 6 to 8 seconds to restore the patient's breathing capability. Giving the patient one breath every 15 seconds is inadequate because it amounts to only 4 breaths/min, which further promotes hypoxia. Tilting the head and chin helps provide effective mouth-to-mouth ventilation. If the initial attempt fails, the nurse should adjust the position of the head and chin and continue to try to provide ventilation to the patient. The nurse should take a deep breath and give two full breaths to the patient lasting 1 second each. This practice helps deliver an adequate amount of oxygen to the patient.

A patient is scheduled for coronary artery bypass graft surgery (CABG) under general anesthesia. Which information does the nurse include when explaining general anesthesia to the patient? Select all that apply. O "it includes anesthetizing your entire body! O "It includes anesthetizing only the affected part of your body O it is administered through the subcutaneous route." O "It is administered through the intravenous (IV) route or inhalation." O "It involves calculating the drug amount based on your condition and the duration of surgery."

O "it includes anesthetizing your entire body! O "It is administered through the intravenous (IV) route or inhalation." O "It involves calculating the drug amount based on your condition and the duration of surgery." Rationale General anesthesia involves anesthetizing the entire body. This is the preferred method of anesthesia in major surgeries, such as CABG. The route of administration is IV or inhalation The amount of drug required is calculated by the anesthetist and depends on the patient's status, weight, duration of surgery, and so on. Local anesthesia anesthetizes only the affected part of the body, and the common route of drug administration is subcutaneous.

In performing chest compressions on a child, the breastbone is compressed to the depth of how many inches? O 1/2 O 1 1/2 O 2. O 2½

O 1 1/2 Rationale A child's chest is compressed with the heel of one hand at a depth of 1 inches at 100 times per minute inch is not a deep enough compression for a child. Two inches is too deep a compression for a child; 2 inches is too deep a compression for a child.

a patient with a tracheostomy has been assessed and needs suctioning. For how many seconds maximum will the nurse perform suction? O 30 O 20 O 15 O 10

O 10 Rationale Suctioning for longer than 10 seconds depletes the oxygen supply. Anything longer than 10 seconds will compromise patient oxygenation

Which size suction catheter would the nurse select to perform suctioning in an adult? O 6-French (Fr) O 8-Fr O 10-Fr O 12-F

O 12-F Rationale The correct size for an adult nasotracheal suctioning catheter is 12-Fr or 14-Fr. The nurse should select either 6-Fr or 8-Fr to suction an infant. A child would require a 10-Fr or 12-Fr suctioning catheter.

A nurse is caring for an adult patient with severe burns covering the face. anterior of the chest, and anterior and posterior of both arms. According to the rule of nines, which percentage of the patient's body is burned? O 50% O 60% O 45 O 40.5%

O 40.5% Rationale According to the rule of nines, the face equals 4.5%, the anterior chest equals 18%, and the anterior and posterior of both arms equal 18% for a total of 40.5%. The extent of burns can be calculated according to the rule of nines.

What amount of pressure would the nurse administer when assisting a closure (VAC) device to a patient's wound? O 5 to 200 mm Hg O 201 to 300 mm Hg O 301 to 400 mm Hg O 401 to 500 mm Hg

O 5 to 200 mm Hg Rationale Administration of intermittent or continuous negative pressure between 5 mm Hg and 200 mm Hg is acceptable according to health care provider prescription or patient comfort. The average is 125. Any value above 200 is inappropriate.v

When rescue breathing for an adult victim, how many breaths would the nurse provide per minute? O 6 to 8 O 8 to 10 O 10 to 12 O 12 to 14

O 8 to 10 Rationale When providing rescue breathing for an adult victim, 8 to 10 breaths/min would be provided; 6 to 8 breaths/min is too few, 10 to 12 and 12 to 14 rescue breaths are not currently recommended

Which technique would the nurse use to alleviate choking in a baby? O Chest thrusts in the prone position O Abdominal thrusts in the supine position O Blind-finger sweep technique O A combination of back blows and chest thrusts

O A combination of back blows and chest thrusts Rationale A chest thrust, if performed alone, is not helpful to remove the aspirated object from the baby's airway (mouth). The nurse should use a combination of back blows and chest thrusts to remove the object stuck in the baby's mouth. Performing chest thrusts with the child in the prone position is not possible. Abdominal thrusts with the child in the supine position can cause severe injury, so this is not a preferred technique in children. If the object is visible, the nurse can use the blind sweep technique. Because the object is not visible in this case, the nurse should not perform this technique.

Which assessment does finding confirm that cardiac arrest has occurred in a drowning victim? O Absence of pulse O Absence of breathing O Loss of consciousness O Lack of response to a painful stimulus

O Absence of pulse Rationale Absence of pulse confirms the occurrence of cardiac arrest. Absence of respirations, loss of consciousness, and lack of response to a painful stimulus do not confirm cardiac arrest.

Which clinical signs would the nurse expect to find in a patient who is in an irreversible coma? Select all that apply. O Absence of heartbeat O Absence of reflex activity O Absence of respiration O Presence of heartbeat O Presence of constricted pupil

O Absence of reflex activity O Absence of respiration O Presence of heartbeat Rationale An irreversible coma is also called brain death. The usual clinical criteria for brain death include the absence of reflex activity, movements, and respirations. The heart continues to beat even if the brain is dead; therefore the absence of a heartbeat does not indicate brain death. The presence of dilated and fixed pupils indicates irreversible coma; therefore the presence of constricted pupils is not an indication of brain death.

Which wetting agent would the wound specialist advise the nurse to avoid due to it delaying the wound-healing process? O Acetic acid O Normal saline O Lactated Ringer's solution O Sodium hypochlorite solution

O Acetic acid Rationale Acetic acid is toxic to fibroblasts, and fibroblasts are necessary for the healing process. Therefore the nurse should not use acetic acid as a wetting agent. Normal saline and lactated Ringer's solutions are used as wetting agents because they do not delay the healing process. Sodium hypochlorite solution is used for wound débridement and is highly recommended for cleaning necrotic wounds because it does not delay the healing process.

After applying direct pressure to a wound spurting bright red blood for 10 minutes, which action should the nurse take next if the dressing is saturated? O Apply a tourniquet above the level of the wound. O Remove the dressing, and replace it with a new one. O Apply indirect pressure to the carotid artery pressure point O Add an additional dressing on top of the current dressing and maintain pressure.

O Add an additional dressing on top of the current dressing and maintain pressure. Rationale Direct pressure is the most effective way to treat bleeding. If the dressing being used to apply direct pressure becomes saturated, the nurse should add an additional layer on top of the existing dressing. The dressing should not be removed by anyone but the health care provider. A tourniquet should only be used if all other methods to stop the bleeding have failed and the victim's life is in danger. Indirect pressure over a pressure point, such as the carotid artery, should only be done if direct pressure and elevation fail to stop the bleeding.

Which action to prevent hypoxia should the nurse perform before suctioning a patient? Select all that apply. O Administer 100% oxygen. O Have the patient take several deep breaths. O Suction the patient only twice. O Have an assistant apply a resuscitator bag. O Rinse the catheter with sterile normal saline.

O Administer 100% oxygen. O Have the patient take several deep breaths. O Have an assistant apply a resuscitator bag. Rationale Suctioning can cause oxygen levels to fall, resulting in hypoxia. Before suctioning, administering 100% oxygen, having the patient take several deep breaths, and/or having an assistant apply a resuscitator bag can help prevent hypoxia. The nurse can suction the patient up to three times. The catheter should be rinsed with sterile normal saline to maintain sterility. but this does not prevent hypoxia.

Which is the priority nursing intervention for a patient with hypoxia who has an oxygen level of 78%, dyspnea, and confusion? O Administer oxygen O Obtain pulse oximetry. O Measure blood pressure. O Initiate telemetry monitoring

O Administer oxygen Rationale After the nurse determines a patient with hypoxia has a low oxygen level and is experiencing dyspnea and confusion, the initial nursing intervention should be to administer oxygen. Obtaining pulse oximetry, measuring blood pressure, and initiating telemetry are not the priority over delivering oxygen

The nurse observes that a burn wound in an elderly diabetic patient is taking a longer time to heal than a similar wound in a 10-year-old child. Which factors are known to cause delayed healing? Select all that apply. O Age O Body mass O Physique O Chronic illness O Affect

O Age O Chronic illness Rationale Age, infection, nutrition, and chronic illness are factors that affect the healing of wounds. Young children and adults have improved metabolism and heal more quickly than elderly patients. Patients with a chronic illness such as diabetes take a longer time to heal due to decreased metabolism. A wound free from infection heals faster; proper nutrition also helps the healing process. But in this case, age and illness are causing a delay in wound healing. Affect, body mass, and physique do not affect wound healing.

Which type of drug is the most commonly abused in the world? O Alcohol O Illegal drugs O Prescriptions medications O Over-the-counter medications

O Alcohol Rationale Alcohol, a central nervous system depressant, is the most commonly abused drug in the world. It is easily available and causes many adverse reactions and even death. Abuse of drugs is a major problem worldwide. Not only illegal drugs but also prescription and over-the-counter medications are abused. These drugs are currently not the most common ones abused, but this abuse is on the rise

The caregiver of a patient with frostbite asks the nurse if giving alcohol to the patient will be beneficial. Which response would the nurse give? O Alcohol may cause the core temperature to drop further." O "Alcohol in a small amount may help raise the temperature." O "Warming the alcohol will increase the temperature more rapidly!! O "Wait until the patient's temperature increases, and then give the alcohol."

O Alcohol may cause the core temperature to drop further." Rationale If the victim of frostbite is conscious, warm fluids may be offered. Alcohol should never be given because of its vasodilatory effect on the blood vessels, it can cause the central core temperature to drop further. Alcohol should not be given in any quantity or at any temperature. If the alcohol is given after the patient's temperature has increased, it can cause the temperature to decrease, which can be detrimental to the patient.

Which statement about storing oxygen tanks is correct? O Tanks should be kept outside the home, such as in an outdoor shed. O All tanks kept at home should be stored upright and chained together. O Store tanks somewhere warm, such as in the home's basement near the furnace. O Extra oxygen tanks can be placed on their sides and stacked up in a pile

O All tanks kept at home should be stored upright and chained together. Rationale Oxygen tanks should be chained together and kept upright. Tanks should be kept away from extremes in temperature and therefore should not be stored outside or near a heat source. Placing tanks on their sides and stacking them in a pile are not advised because it can lead to combustion.

A postoperative patient is instructed to avoid iced and carbonated beverages in diet to reduce gastrointestinal disturbances. However, the nurse observes that nausea and vomiting persists in the patient. Which order does the nurse expect from the health care provider? O Antiemetic medications O Six to eight ounces of fluids per hour O Nothing by mouth for 24 hours O Administration of intravenous fluids

O Antiemetic medications Rationale If nausea and vomiting persists even after limiting iced and carbonated beverages in diet, the patient is prescribed antiemetic medications, such as promethazine (Phenergan), benzquinamide (Emete-con), ondansetron (Zofran), or prochlorperazine (Compazine). The patient is encouraged to take six to eight ounces of fluids per hour when oral fluids are introduced after surgery. The patient needs to be on nothing by mouth (NPO) status at midnight before surgery to decrease the risk of intra- and postoperative vomiting and aspiration. Intravenous fluids are administered after the surgery until the patient is able to tolerate oral fluids. Intravenous fluids will not help prevent nausea and vomiting. Instead, antiemetic medications are given intravenously or rectally to stop nausea and vomiting.

Which sign of hypoxia would the nurse assess for in a patient with chronic lung disease who requires intermittent oxygen? Select all that apply. O Anxiety O Cyanosis O Hypotension O Increased fatigue O Sinus cardiac rhythm

O Anxiety O Cyanosis O Increased fatigue Rationale Signs and symptoms of hypoxia include anxiety, cyanosis, and increased fatigue. The patient with hypoxia will be hypertensive, not hypotensive. Patients with hypoxia can present with cardiac dysrhythmias.

if a patient with an abdominal incision and discomfort begins to cough, which intervention is the most appropriate? O Roll the patient to the left side. O Offer the patient a drink of water. O Sit the patient up in a semi-Fowler's position. O Apply a pillow to the incision with slight pressure.

O Apply a pillow to the incision with slight pressure. Rationale Applying a pillow will help reduce stress on the incision. The semi-Fowler's position helps facilitate breathing after surgery but is not the best intervention to help with a cough after surgery. Rolling to the side is encouraged to help a patient who has had abdominal surgery to rise to the sitting position. A drink of water after a coughing episode would help but not during the discomfort of coughing

A patient arrives at the emergency room (ER) with a penetrating, sucking chest wound. Which action should the nurse take first to ensure patient safety? O Assess the vital signs. O Locate the emergency room health care provider. O Medicate the patient. O Apply an airtight dressing

O Apply an airtight dressing Rationale If there is a sucking chest wound, the nurse should apply an airtight dressing. Any available material is acceptable-gauze, plastic wrap, clothing, or a hand. The vital signs should be taken, the health care provider located, and the patient medicated, but the dressing should be applied first because a pneumothorax can become a tension thorax if air continues to enter the open wound. Sometimes the fourth side will have to be untapped to allow air to escape. This will be assessed further once the airtight dressing is in place.

A patient arrives at the emergency room (ER) with a penetrating, sucking chest wound. Which action should the nurse take first to ensure patient safety? O Assess the vital signs. O Locate the emergency room health care provider. O Medicate the patient. O Apply an airtight dressing.

O Apply an airtight dressing. Rationale If there is a sucking chest wound, the nurse should apply an airtight dressing. Any available material is acceptable-gauze, plastic wrap, clothing, or a hand. The vital signs should be taken, the health care provider located, and the patient medicated, but the dressing should be applied first because a pneumothorax can become a tension thorax if air continues to enter the open wound. Sometimes the fourth side will have to be untaped to allow air to escape. This will be assessed further once the airtight dressing is in place.

A child has accidentally consumed floor cleaning liquid. Which actions should the nurse take? Select all that apply. O Give the specific antidote. O Call the poison control center. O Induce vomiting with ipecac. O Ask for the container of the substance. O Treat manifestations of shock.

O Ask for the container of the substance. O Treat manifestations of shock. O Call the poison control center. Rationale Calling the poison control center enables the nurse to provide better care before the medical care provider arrives. Asking for the container of the substance to check for the contents listed on the container is a useful action because it helps identify the chemical nature of the ingested substance(s). This will help provide the proper treatment based on the chemicals ingested. The victim may be in shock; the necessary steps should be taken to treat the patient. Specific antidote administration should be done only after consulting the primary health care provider. Inducing vomiting with ipecac is not advisable because it may lead to other complications, such as persistent vomiting, lethargy, and diarrhea. Because ipecac is a prescription drug, it should be used only if prescribed by a primary health care provider.

In the operating room, a patient tells a circulating nurse that the cataract in the patient's left eye will be removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, which action should nurse perform first? O Notify the surgeon and anesthesiologist O Ask the patient to state his or her name O Assume that the patient is a little confused because of old age. O Check whether the patient has received preoperative medications

O Ask the patient to state his or her name Rationale Ensuring proper identification of a patient is the responsibility of all members of the surgical team, In a specialty surgical setting, where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses should not make assumptions in the care of their patients. The surgical team should perform a timeout where all the team members participate in the identification of the patient. The surgeon and the anesthesiologist are notified once the nurse has confirmed the patient's name and identity. The nurse should not assume that the patient is confused because of old age or premedication. Preoperative medications can be checked after identifying the patient. The patient should first be identified and then further procedures should be carried out

The nurse is providing care for a patient after a right hip replacement. The nurse knows it is vital to turn the patient every 2 hours while the patient is immobile; however, the patient refuses to turn in bed. Which nursing action is best? O Ask the patient why he refuses to turn in bed. O Ask the charge nurse to help turn the patient in bed. O Administer more pain medication because pain is keeping the patient from turning O Explain to the patient the risks associated with not changing position while immobile.

O Ask the patient why he refuses to turn in bed. Rationale The patient may refuse to turn in bed because he feels weak, is in too much pain, or is afraid to reinjure his hip. The nurse can base her interventions around his response. The nurse can ask the charge nurse to help her turn the patient once the patient has agreed and is prepared to turn. It may be necessary to provide more pain medication, but this is presumptive. Although it may be helpful to explain the risks of immobility to the patient, this may not be the best intervention at this time.

The nurse is obtaining information regarding a patient's medication use before abdominal surgery. Which medication, if listed by the patient, would most concern the nurse? O Aspirin O Hydrochlorothiazide O Multivitamin O Acetaminophen

O Aspirin Rationale Aspirin can increase the risk of hemorrhage during and after surgery. The surgeon should be alerted immediately. Hydrochlorothiazide, multivitamins, and acetaminophen should be of less concern to the nurse.

How does the nurse evaluate the effectiveness of a tracheal suctioning procedure? O Auscultate lung sounds O Assess ventilator settings O Examine sputum color and consistency O Determine need for supplemental

O Auscultate lung sounds Rationale Tracheal suctioning is performed to remove secretions and facilitate air movement within the lungs. Auscultating the patient's lung sounds will help the nurse determine the effectiveness of the suctioning procedure. Ventilator settings would be assessed to determine the accuracy of the health care provider's orders. Examining sputum color and consistency can determine if an infection is present. Oxygen levels are assessed to determine the need for supplemental oxygen.

a nurse has finished suctioning a patient who has had a tracheostomy. The nurse disposes of the catheter and performs hand hygiene. Which action should be performed by the nurse at this time? O Document the procedure. O Auscultate the patient's lungs O Place the call bell within reach O Place side rails in the up position

O Auscultate the patient's lungs Rationale After suctioning the patient and disposing of the catheter, the nurse should auscultate the patient's lungs to evaluate the effectiveness of the procedure. Documenting procedure placing the call bell within reach and placing the side rails in an upright position are all appropriate and should be done once the effectiveness of the procedure has been determined

Which information would be included when explaining safety precautions for home oxygen use to patients? Select all that apply. O Avoid open flames. O Refrain from smoking. O Increase oxygen as needed O Wear fire resistant clothing. O Use petroleum jelly at nares.

O Avoid open flames. O Refrain from smoking. O Wear fire resistant clothing. Rationale Oxygen is highly combustible and requires safety precautions, including avoiding open flames, refraining from smoking, and wearing fire resistant clothing. The patient should maintain the oxygen setting at the prescribed level and avoid petroleum jelly near the oxygen as it can cause combustion

Which type of open wound exposes tendons and muscles? O Incision O Avulsion O Puncture O Laceration

O Avulsion Rationale An avulsion is a torn piece of tissue that results in a section being completely removed or left hanging by a flap. Underlying bones, tendons, or muscles may be exposed. A laceration is a wound that has jagged, irregular edges caused by motor vehicle accidents or injury involving blunt objects or heavy machinery. An incision is a smoothly divided wound made by sharp instruments. A puncture is a piercing wound of the skin caused by knives, nails, wood, glass, or other objects that penetrate the skin

Which measures should the nurse take during the assessment of a wound? Select all that apply. O Be alert for signs of redness, swelling, and pain. O Ensure that the dressing is changed as prescribed by the health care provider. O Ensure that every abrasion, laceration, and incision is noted O Ensure that the location and appearance of the wound is documented every day. O Ensure the patient is free of pain.

O Be alert for signs of redness, swelling, and pain. O Ensure that the dressing is changed as prescribed by the health care provider. O Ensure that every abrasion, laceration, and incision is noted Rationale The nurse assesses all skin areas when inspecting a wound. The nurse ensures that every abrasion, laceration, and incision is noted. This helps in making a proper diagnosis of the wound. The nurse is also alert for signs of inflammation such as redness, swelling, or pain. The nurse documents the location and appearance of the wound every day as changes can occur rapidly. Freedom from pain is not realistic. Nurses complete most dressing changes, not the health care provider.

After Ms. Burke ambulates with the physical therapist, the PN prepares to change the surgical dressing. When obtaining the supplies, the PN reviews the sterile procedure to be followed. At what step in the procedure should the PN don sterile gloves? O Prior to removing the dressing on the client's hip. O Before opening the new sterile dressing package. O Before cleansing the client's hip incision. O After cleansing the client's hip incision.

O Before cleansing the client's hip incision.

Which action should the nurse take first when a patient has a pulse but is not breathing? O Begin rescue breathing. O Start chest compressions. O Provide abdominal thrusts. O Sweep the mouth for obstruction.

O Begin rescue breathing. Rationale Respiratory arrest is possible without cardiac arrest. Rescue breathing is then carried out until the patient responds and/or the pulse is no longer palpable. Chest compressions are not warranted because the patient has a pulse, abdominal thrusts are used for dislodging food, and sweeping the mouth is done if choking is suspected.

The nurse is placing a patient's arm in a sling. Which nursing action would enable venous return and facilitate reduction of edema? O Placing the forearm closer to the chest O Placing the apex of the sling behind the elbow O Bending the arm, ith the elbow slightly elevated O Tying the bandage around the neck, on the uninjured side

O Bending the arm, ith the elbow slightly elevated Rationale Placing the arm in an arm sling helps bend the arm to facilitate venous return, and elevating the elbow would facilitate reduction of edema. Placing the arm close to the chest would establish the proper position for the arm sling. Placing the apex of the sling's triangle behind the elbow of the injured arm facilitates usefulness of the sling. Tying the bandage connecting the neck and the uninjured side would help prevent pressure on the cervical spine.

A nurse is assisting a patient on the phone to perform cardiopulmonary resuscitation (CPR). In which groove would the nurse instruct the caller to place three fingers to palpate the pulse? O Under the chin O Inside of the thigh O Inside of the elbow O Between the throat and the neck

O Between the throat and the neck Rationale To determine pulselessness, the carotid pulse is the most reliable and accessible one to evaluate. The position of the head should be maintained, and the nurse slides three fingers into the groove between the trachea and the muscles on the side of the neck. The nurse should use terms that a layperson can understand. Therefore telling the patient to place the fingers in the groove between the throat and the neck can guide the patient to locate the carotid artery. The carotid artery is located on the side of the neck; therefore it is incorrect to instruct the caller to touch under the chin, the inside of the thigh, or the inside of the elbow

During the preoperative assessment, the nurse learns that the patient takes ginger for intestinal gas. Which preoperative test would the nurse anticipate because of this medication? O Electrocardiography O Blood clotting time O Blood levels of ginger O Orthostatic blood pressure measurement

O Blood clotting time Rationale The nurse should anticipate that blood clotting studies will be performed because ginger can increase clotting time and increase the risk for bleeding. Electrocardiography was likely performed before surgery to determine a baseline and would not be affected by the ginger. Blood levels of ginger would not be tested. Orthostatic blood pressure measurement is not indicated at this time.

Which clinical manifestations of hypoxia are cardiac-related? Select all that apply. O Dyspnea O Bradycardia O Hypertension O Dysrhythmias O Apprehension

O Bradycardia O Hypertension O Dysrhythmias Rationale Cardiac-related signs of hypoxia include bradycardia, hypertension, and dysrhythmias. Dyspnea is difficulty breathing and is respiratory-related. Apprehension is a behavior-related clinical manifestation of hypoxia.

A patient accidentally steps on an iron nail, which pierces deep into the foot. Which action should the nurse take first? O Remove the nail immediately. O Call the primary health care provider. O Give a tetanus booster vaccine. O Educate the patient about symptoms of sepsis.

O Call the primary health care provider. Rationale If the object is lodged firmly in tissue, do not attempt to remove it. Leave it in place, and the health care provider will remove it. Removal has the potential to cause significant bleeding or other types of complications that may necessitate emergency surgical intervention. If an iron nail pierces the foot it causes internal tissue damage and sepsis. The nurse should call the primary health care provider immediately. Removing the nail may cause a further increase in bleeding and may lead to an internal infection. Giving a tetanus booster may be considered a follow-up treatment for such injuries. Because the wound has been caused by a metal object, it may lead to sepsis. The nurse should educate the patient about the symptoms of sepsis after proper treatment has been given to the patient.

Which information would the preceptor stress to the graduate nurse about a vacuum-assisted closure (VAC) device? O The schedule for changing the device varies. O Negative pressure is applied to the wound by the device O Care must be taken to remove all materials from the wound. O The wound vacuum can be used for acute and chronic wounds.

O Care must be taken to remove all materials from the wound. Rationale During dressing changes, care must be taken to remove all sponges and remnants from the wound. Material left on the wound may cause delays in healing and abscess formation. It is important for the graduate nurse to understand that the schedule for changing the device varies, the device applies negative pressure, and the device is used for acute and chronic wounds; however, the importance of removing all material from the wound must be stressed because not doing so can affect the healing process,

Positioning a patient with their head slightly tilted back and then placing one hand on the forehead and sliding two fingers of the other hand into the groove between the trachea and sternomastoid muscle in the neck allows the nurse to assess for which physical finding? O Thyroid gland enlargement O Carotid artery pulse rate O Presence of tonsils O Tenderness of posterior cervical lymph nodes

O Carotid artery pulse rate Rationale The carotid artery is palpable in the anterior triangle, an anatomic space defined by the trachea, sternomastoid muscle and base of the jaw. The apex of the triangle is at the suprasternal notch. The carotid pulse rate is measured by placing one hand on the forehead and sliding two fingers of the other hand into the groove between the trachea and the sternomastoid muscle, within the anterior triangle. Palpation of the thyroid gland, including palpation for gland enlargement, involves taking a position behind the patient, who is sitting upright with their head bent slightly forward. With the nurses' hands loosely encircling the neck of the patient, the fingers are used to push the trachea slightly in both directions and palpating the gland while the patient swallows. Presence of tonsils is assessed via direct visualization of the posterior pharynx, not by external palpation. The posterior cervical lymph nodes are palpable bilaterally, between the sternomastoid and trapezius muscles in the neck (the posterior triangle), not between the trachea and sternomastoid muscle

A patient's lab reports indicate reduced bone marrow function and a decreased white blood cell count. Which type of medication does the nurse suspect the patient was most likely taking? O Antibiotic O Antihistaminic O Chemotherapy O Anti Inflammatory

O Chemotherapy Rationale Chemotherapy medications destroy rapidly dividing cancer cells but also reduce the function of bone marrow and decrease the white blood cell count by inhibiting cell division. Antibiotic medications destroy bacteria but do not affect the function of bone marrow. Antihistamines act by inhibiting the actions of histamine. Antiinflammatory medications reduce inflammation in tissues throughout the body and may suppress protein synthesis, wound contraction, and inflammation. These medications do not, however, affect the function of bone marrow or white blood cell count

A patient needs surgical removal of an inflamed gallbladder. Which screening tests does the nurse anticipate the surgeon will prescribe? Select all that apply. O Chest x-ray O Bone density scan O Blood sugar levels O Electrocardiogram (ECG) O Electroencephalography (EEG)

O Chest x-ray O Blood sugar levels O Electrocardiogram (ECG) Rationale The screening tests focus on the body systems that are likely to be affected by the surgery. A chest x-ray and ECG help determine the patient's heart and lung function. Blood sugar levels help determine postoperative wound healing and chances of infection. EEG is required for patients suffering from epilepsy and other brain-related disorders. A bone density scan is performed in females after menopause and is not required for this type of procedure.

Which food allergies indicate that a patient is susceptible to latex allergy? Select all that apply. O Orange O Chestnuts O Kiwi O Avocados O Pineapple

O Chestnuts O Kiwi O Avocados O Rationale An allergy to kiwi fruit, chestnuts, or avocadoes shows cross-sensitivity to latex. If the patient has an allergy to these foods, then the patient needs to be assessed for latex allergy as well. Allergies to oranges and pineapples do not show cross-sensitivity to latex

A nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. Which assessment would be the priority when inspecting the skin that is distal to the bandage? O Bacteria O Inflammation O Impaired skin integrity O Circulatory impairment

O Circulatory impairment Rationale Assessing for signs of circulatory impairment provides a means for comparing changes in circulation after bandage application. Inflammation is a sign of infection and not the result of bandage application. Bacteria would be in the wound and cause signs of infection. Skin integrity should be checked before the bandage is applied.

Which interventions should the nurse implement while encouraging early ambulation in a postoperative patient? Select all that apply. O Clamp the nasogastric tube, if present, while the patient ambulates. O Encourage the patient to walk the same distance at each ambulation. O Maintain a tight hold while ambulating an unsteady patient receiving intravenous (IV) fluids. O Ask the patient to bend, lower, and press back knees hard against bed. O Ask the patient to sit on the side of bed before ambulating for the first time.

O Clamp the nasogastric tube, if present, while the patient ambulates. O Ask the patient to bend, lower, and press back knees hard against bed. O Ask the patient to sit on the side of bed before ambulating for the first time. Rationale If the patient has a nasogastric tube, it needs to be clamped during ambulation to prevent the stomach contents from draining out. The nurse asks the patient to perform muscle strengthening exercises, such as bending, lowering, and pressing back knees hard against the bed, to facilitate easy ambulation. The nurse asks the patient to sit on the side of the bed before ambulating for the first time to prevent fluctuation of the vital signs. The nurse encourages the patient to walk farther at each ambulation to improve stamina and functioning. To prevent any accidents, it is necessary to obtain help from another colleague while ambulating an unsteady patient receiving IV fluids.

The nurse is assessing a patient with a gangrenous leg. While collecting the patient's medical history, the nurse finds that the patient had developed the gangrene after lower-limb surgery. Which class of surgical wound does the nurse expect the patient has? O Class I O Class II O Class III O Class IV

O Class IV Rationale Surgical wounds are classified based on the level of contamination and infection. If the surgical wounds are not properly cared for, they may cause tissue necrosis. Tissue necrosis results in gangrene, and such wounds are classified as class IV. A clean surgical incision has the least chance of being infected and is categorized as a class (clean) surgical wound. Wounds that are at risk of being contaminated are categorized as class II (dean contaminated) surgical wounds. Wounds that are fresh without any pus formation and nonpurulent inflammation are categorized as class III (contaminated) wounds.

Which nursing action is an example of proper care for a transtracheal oxygen catheter site? O Cleaning the site with hydrogen peroxide O Washing the site with mild soap and water O Increasing oxygen flow before cleaning the site O Changing the transtracheal catheter every 4 months

O Cleaning the site with hydrogen peroxide Rationale The transtracheal catheter exit site should be cleaned with hydrogen peroxide. Soap and water should not be used. The patient should not alter the flow rate of the oxygen. The catheter should be changed every 3 months.

A patient is scheduled for surgery. The patient has been fasting for the whole night. The surgery was postponed for 3 hours, and the patient feels hungry. Which type of food would be most appropriate to give to the patient? O Solid food O Fried food O Fatty food O Clear liquids

O Clear liquids Rationale Patients usually have a fasting period before surgery. However, if the surgery gets postponed, the patient may be allowed clear liquids. Clear liquids can be metabolized within 2 hours and may not interfere with the gastrointestinal function or the anesthesia process. Solid food, fried food, and fatty food should not be given to the patient. Solid food requires 6 hours to metabolize. Fried food and fatty food requires hours to metabolize

Which routine type of sedation might be used for a surgical procedure that does not require complete anesthesia but, rather, a depressed level of consciousness? O Bier block O Local anesthesia O Conscious sedation O Regional anesthesia

O Conscious sedation Rationale Conscious sedation is a routine type of sedation that might be used for a surgical procedure that does not require complete anesthesia but, rather, a depressed level of consciousness. A patient under conscious sedation must independently retain a patent airway and airway reflexes and be able to respond appropriately to physical and verbal stimuli. Bier block, also known as intravenous regional anesthesia, is when an anesthetic agent is injected via an intravenous line into an extremity below the level of a tourniquet after blood has been withdrawn. Local anesthesia involves loss of sensation at the desired site. The anesthetic agent can be injected or applied topically. Regional anesthesia results in loss of sensation in an area of the body. The method of induction influences the portion of sensory pathways that is anesthetized.

In classifying wounds, which classification results from the presence of gastrointestinal (GI) products? O Dirty O Clean O Contaminated O Clean-contaminated

O Contaminated Rationale A contaminated wound results from the presence of Gl products; from acute, nonpurulent inflammation; or when aseptic technique is broken during surgery. A clean-contaminated wound is a surgical incision made into the respiratory, GI, or genitourinary tract after special presurgical preparation. A dirty wound is a wound that is infected before surgery. A clean wound is an uninfected surgical wound.

Which action should the nurse take for an 80-year-old patient with an arterial partial pressure oxygen (Pao 2) level of 82 mm Hg? O Call the rapid response team. O Notify the health care provider. O Increase oxygen administration. O Continue the current plan of care.

O Continue the current plan of care. Rationale Normal arterial oxygen levels decrease with age but continue on the low-end of normal. A normal PaO 2 is between 80 and 100 mm Hg. Many older patients display a Pao 2 level between 80 and 85 mm Hg without significant alterations in health. Therefore the nurse should continue the current plan of care with an 81-year-old patient whose PaO level is 82 mm Hg. The nurse does not need to call a rapid response, notify the health care provider, or Increase the amount of oxygen being administered as the patient's Pao reading represents a normal laboratory value

Which action should the nurse take for a patient with full-thickness burns? O Break the blisters with forceps. O Apply antiseptics on the wound. O Apply a cold compress on the wound. O Cover the wounds with loose sterile dressing

O Cover the wounds with loose sterile dressing Rationale Full-thickness burns may result in large surface area exposed to the external environment, which increases the risk of infection. Therefore the burnt area should be covered with loose sterile dressing, which will absorb any draining fluid and also protect the wound from contamination. Vesicles (blisters) should not be broken intentionally, the burn should not be touched with anything except sterile dressings. It is not appropriate to apply antiseptics, ointments, sprays, or creams to the burn because they potentially may interfere with medical treatment and cause complications.

Which action performed by the nurse during tracheal suctioning can cause mucosal membrane injury? O Performing deep suctioning 20 to 25 seconds O Waiting 1 to 2 minutes between suction attempts O Angling the catheter down past nasopharyngeal area O Covering the hole of the suction catheter during insertion

O Covering the hole of the suction catheter during insertion Rationale The nurse should place the thumb over the hole of the suction catheter to facilitate the suction from the device during catheter removal, not during insertion. The nurse should only perform tracheal suctioning between 10 and 15 seconds. Suctioning any longer can lead to cardiopulmonary compromise. The nurse should also wait 1 to 2 minutes in between suction attempts to allow the patient to rest and regain oxygen supply. The nurse should angle the suction catheter downward once past the nasopharyngeal area.

To prevent the thickening of secretions, the nurse would instruct the patient receiving oxygen to refrain from consuming which food or beverage? O Tea O Juices O Coffee O Dairy products

O Dairy products Rationale Dairy products, including milk and yogurt, can thicken secretions, making breathing more difficult. Tea, coffee, and other caffeinated beverages, as well as juices, should also be avoided because they can cause dehydration. However they do not affect secretion formation

The surgeon asks the nurse to apply an abdominal binder on a patient after surgery. Which function does an abdominal binder serve? Select all that apply. O Decreases tension around the wound O Holds the dressing in place O Helps the patient breathe slowly O Provides comfort to the patient O Helps the patient lose weight

O Decreases tension around the wound O Holds the dressing in place O Provides comfort to the patient Rationale Binders are elasticized fabric bands used to decrease the tension around a wound or a suture line. Abdominal binders are placed on abdominal incisions. They make it easier for the patient to breathe deeply or cough because they hold the dressing in place. Binders support the dressing and provide comfort to the patient. Binders do not help the patient breathe slowly as they do not affect the patient's breathing. The abdominal binder is not designed to help a patient lose weight

Which complications are associated with surgical incisions in a patient? Select all that apply. O Cachexia O Singultus O Dehiscence O Evisceration

O Dehiscence O Evisceration Rationale After surgery, there is a risk for dehiscence or separation of a surgical incision or rupture of a wound closure within 3 to 14 days. It is associated with postoperative complications, such as distention, vomiting, excessive coughing, dehydration, or infection. Another complication related to surgical wounds is wound evisceration or protrusion of an internal organ through a wound or surgical incision. Cachexia refers to ill health, malnutrition, and wasting as a result of chronic disease, which may cause dehiscence in a patient 2 weeks after the surgery. Singultus is an involuntary contraction of the diaphragm followed by rapid closure of the glottis. Paralytic ileus refers to a decrease in or absence of intestinal peristalsis that may occur after abdominal surgery

Five days after a patient's abdominal operation, the nurse observes an increase in the flow of serosanguineous drainage into the wound dressing. Which immediate risk to the patient will the nurse assess? O Dehiscence O Hematoma O Internal hemorrhage O Sloughing

O Dehiscence Rationale Dehiscence is the spontaneous opening of the incision a few days after the operation. Obesity, poor nutrition, excessive coughing, and multiple trauma are some of the risk factors that may cause dehiscence. An increase in the flow of serosanguineous drainage (a mixture of serum and blood) into the dressing indicates impending dehiscence. Hematoma is the pooling of blood under the skin. Internal hemorrhage is indicated by swelling around the wound. Sloughing is the shedding of dead tissue.

The nurse is providing preoperative teaching to a patient regarding dietary needs in the postoperative period. Which action is best on the part of the nurse? O Tell the patient to decrease intake of fats O Determine the patient's current eating habits, O Tell the patient to increase intake of carbohydrates. O Determine the patient's understanding of a healthy diet.

O Determine the patient's current eating habits Rationale The nurse should first determine the patient's current eating habits to help the patient understand how the diet should change in the postoperative period. The nurse can then educate the patient to increase or decrease intake of fats, carbohydrates, and proteins based on the patient's current diet. The patient's understanding of a healthy diet is important but does not apply at this time.

Which task should the nurse perform before inserting a catheter who requires nasotracheal suctioning? O Provide oral care. O Obtain Yankauer suction catheter. O Angle catheter in upward position. O Determine which nostril is most patent.

O Determine which nostril is most patent. Before inserting the nasotracheal suction catheter, the nurse should determine if either nostril is obstructed. Oral care is performed after the procedure. A Yankauer suction catheter is used for oropharyngeal suctioning. The catheter should be angled in the downward position

Which finding indicates that a patient is experiencing chronic hypoxia? O Fatigue O Cyanosis O Dysrhythmias O Digital clubbing

O Digital clubbing Rationale Digital clubbing of the fingers is a sign of chronic hypoxia. Fatigue, cyanosis, and dysrhythmiasare signs of acute hypoxia.

The PN is assisting Ms. Burke to the bedside commode on the second postoperative day. Ms. Burke states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the PN identifies which nursing diagnosis to add to Ms. Burke's plan of care? O Disturbed body image. O Disturbed personal identity. O Anticipatory grieving. O Disturbed personal identity.Situational low self-esteem.

O Disturbed personal identity.

The nurse in the ambulatory surgery center learns that the patient scheduled for surgery at 11 a.m. drank water at 7 a.m. Which action is best on the part of the nurse? O Alert the surgeon. O Cancel the surgery. O Document the finding O Warn the patient about the dangers of aspiration during surgery.

O Document the finding Rationale The patient can have clear liquids until 2 hours before the surgery unless the patient has a condition that causes delayed gastric emptying. Therefore, the appropriate action by the nurse would be to document the finding and continue the assessment. The nurse should report this information as part of the preoperative assessment to the health care provider, but the nurse should finish the assessment first. The surgery does not need to be cancelled at this time. The patient should be educated on the risks of aspiration, but this is not the most correct option.

Which action promotes thinning of respiratory secretions? O Drinking adequate amounts of water O Completing oral hygiene twice a day O Performing coughing and deep breathing O Ambulating and changing positions frequently

O Drinking adequate amounts of water Rationale Patients receiving oxygen should maintain adequate sugar-free and decaffeinated fluid intake to help liquefy secretions. Oral hygiene alleviates bad tastes from secretions but will not thin them. Coughing, deep breathing, ambulation, and changing positions frequently help mobilize secretions, but these actions will not alter their thickness.

Which finding indicates the need to perform suctioning for a patient? Select all that apply. O Drooling O Sneezing O Restlessness O Gurgling respirations O Oxygen saturation 92%

O Drooling O Restlessness O Gurgling respirations Rationale Physical signs that would indicate the need for suctioning include drooling, restlessness, and gurgling respirations. Sneezing can occur during the suctioning procedure. An oxygen Saturation of 92% alone does not indicate need for suctioning because it could result from other causes

Which outcome is expected in a patient using vacuum-assisted closure (VAC)? Select all that apply. O Drop in bacterial count in the wound bed O Reduced healing rate O Increased tissue growth O Opening of the wound O Decreased blood flow

O Drop in bacterial count in the wound bed O Increased tissue growth Rationale VAC is used to treat wounds that take a long time to heal. A suction device is attached to the dressing to remove fluid from the wound and facilitate blood flow. After this therapy, there is a drop in bacterial count in the wound bed. Tissue growth also increases due to the mechanical stretching of cells. The therapy speeds up healing by 40%. This therapy helps close the wound completely.

Which finding indicates a patient is experiencing onset of hypoxia (Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) ? Select all that apply. O Apnea O Dyspnea O Cyanosis O Lethargy O Bradycardia

O Dyspnea O Cyanosis O Lethargy Rationale At the onset of hypoxia, the patient displays dyspnea, cyanosis, and changes in level of consciousness, which can include lethargy. Apnea and bradycardia are later signs of hypoxia.

Which signs and/or symptoms are characteristic of complications in a patient with a transtracheal catheter? Select all that apply. O Pallor O Edema O Erythema O Clear exudate O Oxygen saturation 95%

O Edema O Erythema Rationale Signs of complications in a patient with a transtracheal catheter include edema and erythema. Pallor can indicate anemia but is not a complication of the catheter. Some clear secretions would be normal; however, any excessive or purulent exudate should be always be reported. An oxygen saturation level of 95% is a normal finding and does not need to be reported.

The nurse is caring for a patient before elective surgery. For which preoperative tasks is the nurse responsible? O Explaining the risks of the surgery O Discussing the benefits of the surgery with the patient O Educating the patient about postoperative care needs O Ensuring the consent form is signed O Determining the patient's current level of pain

O Educating the patient about postoperative care needs O Ensuring the consent form is signed O Determining the patient's current level of pain Rationale The role of the nurse in the preoperative period is to assess the patient's health status, educate the patient about postoperative care needs and expectations, and ensure the consent form has been signed, among other tasks. The nurse will also determine the patient's current level of pain. The operating health care provider should explain the risks and benefits of the surgery and have the patient sign the consent form.

When providing initial first aid, which actions should the nurse take to address a full-thickness burn on the right lower extremity? Select all that apply. O Elevate the right lower extremity O Apply an antiseptic ointment to the burn. O Apply loose sterile dressings to the burned area. O Attempt to cool the burn immediately by using cool compresses. O Monitor the victim frequently for edema, which may cause further constriction in the burn area

O Elevate the right lower extremity, O Apply an antiseptic ointment to the burn. O Monitor the victim frequently for edema, which may cause further constriction in the burn area

While caring for a patient with a fractured forelimb and continuous bleeding, the nurse places a clean cloth and applies firm pressure on the site of the bleeding. Then the nurse secures a bandage and adds an additional layer of cloth but does not remove the bandage applied previously. Finally the nurse raises patient's hand to a level above his or her heart. Which nursing action may harm the patient? O Elevation of the arm O Retention of bandage O Addition of a clean cloth O Application of direct pressure

O Elevation of the arm Rationale As the patient has a fracture on arm, elevating the arm above the heart may exacerbate the condition, so it should be avoided. Raising the bleeding part of the body above the level of the heart helps decrease blood flow and increase the victim's ability to clot at the injured site. This technique should be used only if there are no suspected or known fractures or conditions that may be exacerbated with use of this maneuver. It is acceptable to elevate a splinted fracture if no other contraindications are present. The nurse should retain the previous bandage, and only the primary health care provider should remove it while providing further treatment. More cloth can be applied if the bandage gets saturated with blood. This action may not cause any harm to the patient. Applying direct pressure helps decrease the flow of blood.

The nurse is caring for a patient who just underwent right hip replacement. The nurse would be most concerned with preventing which postoperative complication? O Embolus O Pneumonia O Constipation O Muscle atrophy

O Embolus Rationale Although pneumonia, constipation, and muscle atrophy are complications of hip replacement surgery, the most serious and life-threatening complication is an embolus, which could lead to stroke, heart attack, and death

Which common postoperative complications are likely to be found in patients who are obese! Select all that apply. O Embolus O Atelectasis O Pneumonia O Hemorrhage O Electrolyte imbalance

O Embolus O Atelectasis O Pneumonia Rationale Patients who are obese are more susceptible to postoperative complications. Embolus forms from venous stasis in the lower extremities. Atelectasis and pneumonia occur because of immobility, reduced ventilatory function, increased secretions, and problems in lung expansion. Hemorrhage can happen in patients with bleeding disorders. A patient who is obese is not at any higher risk of electrolyte imbalances compared with a patient of normal body weight.

The nurse is caring for a patient with an intestinal obstruction. Suddenly, the patient becomes tachycardic, tachypneic, and hypotensive. On assessment, the nurse notes a boardlike abdomen and suspects an intestinal perforation. The nurse knows to prepare the patient for which type of surgery? O Urgent O Elective O Emergent O Transplant

O Emergent Urgent or emergency surgery - When a patient's condition is life threatening, surgery is considered emergent Rationale Bowel perforation is a medical emergency and must be surgically treated immediately to preserve life. This surgery would not be considered urgent or elective, and transplantation would not occur.

The nurse is caring for a postoperative patient. Which measures should the nurse take to prevent venous stasis and thrombus formation in the patient? Select all that apply. O Provide ample rest. O Administer antibiotics O Encourage early ambulation O Apply graded compression stockings. O Encourage patient to perform leg exercises.

O Encourage early ambulation O Apply graded compression stockings. O Encourage patient to perform leg exercises. Rationale Venous stasis and thrombus formation are serious circulatory complications after surgery. Measures should be taken to promote a healthy blood supply to the extremities. Early ambulation helps improve venous return and prevents stasis of blood. Graded compression stockings also help prevent stasis. Leg exercises are encouraged to promote normal venous return. Ample rest is not required after every surgery. Administration of antibiotics is a general precaution against infections and may not help avoid circulatory complications.

The nurse is caring for a patient 6 hours after arrival on the floor after an appendectomy. The nurse notes the patient has not urinated since before the surgery. Which action should the nurse do first? O Call the surgeon. O Place an indwelling catheter to gravity. O Perform straight or in-and-out catheterization O Encourage fluid intake

O Encourage fluid intake Rationale Anesthesia can lead to urinary retention, so it is important to monitor the patient's urine output. If the patient has not urinated 8 hours after surgery, the nurse should palpate for urinary retention and alert the health care provider. However, this patient only returned from surgery 6 hours ago, so the appropriate action is to encourage oral fluid intake. It may be necessary to catheterize the patient, but this requires a health care provider prescription and is not appropriate at this time.

Which physiologic change related to aging is most likely to lead to overdose in older adults? O Smell O Hearing O Eyesight O Weakness

O Eyesight Rationale The main physiologic change that may contribute to overdose in older adults is eyesight. Poor eyesight potentially leads to ingestion of the wrong medication. Anyone assisting with the care of an older adult should ensure that all medications and other substances are identified clearly by using large lettering. Older adults with hearing loss, chronic weakness, or an impaired sense of smell may still be able to read the labels to take medications appropriately.

Which interval is usual at which nursing assessments, including vital signs, are monitored in the postoperative phase? O Four hours, followed by once a shift in O Thirty minutes times 4; every hour times 4; then every 4 hours O Fifteen minutes times 4: every 30 minutes times 4; every hour times 4; then every 4 hours O Five minutes times 4 every 10 minutes times 4; every 30 minutes times 4; then every hour

O Fifteen minutes times 4: every 30 minutes times 4; every hour times 4; then every 4 hours Rationale The usual interval at which nursing assessments, including vital signs, are monitored in the postoperative phase is every 15 minutes times 4, every 30 minutes times 4; every hour times 4; then every 4 hours. Four hours followed by once a shift is far beneath the standard of care generally accepted on postoperative units. Potential patient complications would be missed. This "times four" gauge is the maximum time that should elapse between assessments. Five minutes times 4 is not the typical interval of assessments routinely performed by nurses. Thirty minutes times 4 leaves too much time between assessments for optimal patient safety and monitoring of potential postoperative complications.

Which action by the licensed practical/vocational nurse (LPN/LVN) needs correction when applying a partial rebreather mask to a patient with low oxygen levels? O Using distilled water when applying humidified oxygen O Removing the mask every 2 to 4 hours to evaluate the skin for breakdown O Allowing a patient to place the partial rebreather mask on their own face O Filling the reservoir bag with oxygen after placing the mask on the patient

O Filling the reservoir bag with oxygen after placing the mask on the patient Rationale The LPN/LVN should cover the reservoir hole in the mask and allow the bag to completely fill before placing the partial rebreather mask on the patient. Distilled water should always be used to decrease the growth of microorganisms. Patients should be allowed to place the mask on their own face because this may alleviate feelings of suffocation and apprehension. The mask should be removed every 2 to 4 hours to assess for skin breakdown.

a nurse arrives on an accident scene and quickly recognizes that an individual is going into shock. In which position would the nurse place the patient? O Prone O Fowler's O Side-lying O Flat, with legs elevated

O Flat, with legs elevated Rationale It is essential to treat shock immediately. Priority interventions include establishing an airway; controlling bleeding, if present; and positioning the patient supine, with the legs elevated slightly above the head. In the prone position, the person is lying face down, in the side-lying position, the legs are not raised, and in Fowler's position, the person raises the head to a level higher than the legs, so this position is not appropriate for shock.

Which equipment would the nurse use to ensure the prescribed rate of oxygen is delivered? O Flow meter O Nasal cannula O Oxygen tubing O Venturi mask

O Flow meter Rationale An oxygen flow meter is used to set the prescribed rate of oxygen administration. The nasal cannula, oxygen tubing, and Venturi mask assist in the delivery of oxygen but do not determine the rate

A child's x-ray report shows a bend and cracks in the bone of the left leg. The nurse would identify this as which type of fracture? O Communicated O Impacted O Compressed O Green stick

O Green stick Rationale A bend or crack in bone represents an incomplete break in bone. An incomplete break in bone is also called a green stick fracture. This type of fracture is more common in children because their bones are more pliable. Shattering of the bone into two or more pieces or fragments is called a communicated fracture. In an impacted fracture, the bone ends may jam together. This type of fracture mostly occurs as a result of trauma. Fracture to the vertebrae caused by pressure can be considered a compressed fracture:

Which interve. tion would the nurse implement in a child with an uncontrollable nosebleed? O Position the child flat with the legs elevated. O Have the patient lean forward, and apply pressure toe nose. O Place the child upright, hyperextend the neck, and pinch the nose. O Turn the child on the side, and place an emesis basin to promote drainage

O Have the patient lean forward, and apply pressure toe nose. Rationale The victim experiencing a nosebleed should be kept quiet in the sitting position and leaning forward. If this is not possible, the patient should be placed supine, with the head and shoulders elevated. The thumb and forefinger should be used to apply pressure for 10 to 15 minutes before releasing and an ice compress should be applied. The child should be made to sit upright, or if lying flat, the patient's shoulders and head should be elevated. The child should not hyperextend the neck but should bring it forward. Finally the child should not be turned on the side.

The nurse has received an order to irrigate a patient's wound using an antiseptic solution. Which action should the nurse take to reduce the risk of contamination? O Place the tip of the syringe against the area needing to being cleaned. O Instill the solution with force to remove any debris quickly from the wound. O Direct the solution from unhealthy tissue toward healthy tissue within the wound. O Have the solution flow from the least contaminated to the most contaminated area

O Have the solution flow from the least contaminated to the most contaminated area Rationale The irrigating solution needs to flow from the least contaminated to the most contaminated area to avoid contamination of clean tissue by exudates. Within the wound, the irrigating solution should be directed from healthy tissue and toward unhealthy tissue to reduce trauma to healthy tissue. The tip of the syringe should be placed approximately 1 inch above the area to be irrigated to avoid contamination. The irrigating solution should be instilled gently into the wound to minimize tissue damage, trauma, irritation, and bleeding.

The nurse assesses a patient who has collapsed in the waiting room and determines that the airway may be blocked. Which technique would the nurse use to open the airway? O Logroll O Head-tilt/chin-lift O Abdominal thrusts O Chest compressions

O Head-tilt/chin-lift Rationale The nurse ensures that the patient's airway is opened by performing the head-tilt/chin-lift maneuver. A logroll is used to align the body during movement. Abdominal thrusts and chest compressions are not used to open the airway during cardiopulmonary resuscitation.

The nurse is attending to an elderly patient scheduled for a hernia operation. The nurse understands that as a result of aging, the patient may have rigid blood vessel walls and a reduction in sympathetic and parasympathetic innervations to the heart. Which risks increase in this patient following surgery? Select all that apply. O Hemorrhage O Increased lung expansion O Increased systolic blood pressure O Increased diastolic blood pressure O Increased ability to eliminate drugs

O Hemorrhage O Increased systolic blood pressure O Increased diastolic blood pressure Rationale As the body ages, the blood vessel walls become rigid, causing a reduction in sympathetic and parasympathetic innervations to the heart. These changes may increase the risk of hemorrhage following surgery. The patient may also develop an increase in systolic and diastolic pressures. In postoperative patients, lung expansion may be reduced because of decreased strength of the respiratory muscles. After surgery, the patient may have decreased ability to eliminate drugs because of reduced renal function.

A nurse is assessing a patient who underwent a surgical procedure. The nurse notices a decrease in blood pressure; rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness. Which complication does the nurse suspect? O Depression O Hemorrhage O Electrolyte imbalance O Obstructive sleep apnea

O Hemorrhage Rationale A drop in blood pressure, rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness are symptoms of hemorrhage. Postoperative hemorrhage may lead to a loss of intravascular volume l toeading to a drop in blood pressure and a weak, thready pulse. Heart rate and respiratory rate increase to compensate for the low intravascular volume to maintain tissue perfusion. Depression is not an immediate postoperative complication unless the patient has a history of depression. Electrolyte imbalances may occur in the immediate postoperative period but would not display these symptoms. The symptoms of obstructive sleep apnea would be drowsiness, apneic periods, and somnolence,

Which of the following elements will help to promote wound healing? O High protein O High carbohydrates O Vitamin C O Vitamin A O Vitamin D

O High protein O Vitamin C O Vitamin A

A student nurse is caring for a patient with a wound that is not healing. Which factors in the patient's health history could negatively affect the healing process? Select all that apply. O History of heart disease O Diabetic for 10 years O Smokes a pack of cigarettes daily O Eats three well-balanced meals per day O Physically active with no history of illnesses

O History of heart disease O Diabetic for 10 years O Smokes a pack of cigarettes daily Rationale Healing is affected by age, nutritional status, and physical well-being and medication therapies Lifestyle factors such as smoking can impede healing Alterations in health, including diabetes, cancer, and heart disease, can slow the body's healing process. The fact that the patient eats three well-balanced meals per day will help with the healing process. When the patient is active with no history of illness, the nurse would anticipate normal healing

Which patient conditions would indicate that the patient is in shock? O Polyuria O Bradycardia O Hypothermia O Low oxygenation

O Hypothermia Rationale A patient who has undergone shock usually has cool and clammy skin, and hypothermia may develop. A patient who is at a risk of vasodilatory shock does not have polyuria. Oliguria develops as a result of decreased circulation of fluids, which in turn, results in decreased urine output. The patient has an increased pulse rate. Therefore the patient may be at risk of tachycardia, or heart rate greater than 100. The patient may not be at risk of bradycardia (reduced heart rate). Vasodilatory shock may not develop in a patient with low oxygenation.

The nurse observes that there is swelling at the intravenous (IV) site in a postoperative patient. The nurse also finds that the site is cool to the touch. Which condition does the nurse suspect? O Dehydration O IV solution infiltration O Fluid overload O Pulmonary edema

O IV solution infiltration Rationale Swelling at the IV site which is also cool to touch indicates that the IV solution has become infiltrated. Infiltration may occur because of movement or inadvertent dislodgment of the needle when the patient ambulates. Dehydration may be seen in the patient if the patient's fluid intake and output has reduced considerably. Fluid overload may be indicated if there is swelling in the legs and arms. Difficulty breathing, anxiety, and pale skin are symptoms of pulmonary edema.

With which initial respiratory pattern would a patient with hypoxia present? O Increased rate and depth of res rations O Decreased rate and depth of respirations O Periods of apnea during normal respirations O No changes in the respiratory rate and pattern

O Increased rate and depth of resprations Rationale A patient with hypoxia will initially display an increase in respiratory rate and pattern. As hypoxia progresses, the respiratory rate and depth will decrease. If the hypoxia is not corrected, the patient will eventually develop periods of apnea. Respiratory rate and pattern in a patient with hypoxia would not present as normal.

The nurse is performing a preoperative assessment on a patient and notes that the patient appears anxious. The nurse understands that preoperative anxiety can have which effect on the patient postoperatively? O Increased recovery time O Decreased pain medication needs O Increased risk for hemorrhage O Decreased anesthesia requirements

O Increased recovery time Rationale Anxiety before surgery can lead to increased length of recovery after surgery, increased pain medication requirements, and increased anesthesia needs. Preoperative anxiety has not been shown to increase risk for hemorrhage.

Which stage of general anesthesia includes the administration of anesthetic agents and endotracheal intubation? O Stage IV O Induction O Emergence O Maintenance

O Induction Rationale Induction is the stage of general anesthesia that includes the administration of anesthetic agents and endotracheal intubation. Stage IV begins with the cessation of respirations and must be avoided, or it will necessitate the initiation of cardiopulmonary resuscitation and may lead to death. During the emergence phase of anesthesia, anesthetics are decreased, and the patient begins to awaken. Because of the short half-life of currently used anesthetic agents, emergence may occur in the operating room. The maintenance phase of anesthesia includes positioning the patient and preparing the skin for incision, and the surgical procedure itself.

Which essential problems should be placed on the nursing care plan of a patient with a wound? Select all that apply. O Infection O Nutrition O Skin integrity O Respiratory distress O Altered mental status

O Infection O Nutrition O Skin integrity Rationale The patient with a wound is at risk for developing an infection and has an alteration in skin integrity; these are immediate concerns. In addition, nutrition is essential in wound healing. Unless the patient develops complications, altered mental status and respiratory distress are not immediately identified as problems.

Which interventions should the nurse implement to prevent thrombus formation in a patient after knee surgery? Select all that apply. O Instruct the patient not to cross the legs when in bed. O Use the knee gatch on the bed for safety and comfort. O Instruct the patient to reduce fluids and juices in diet. O Instruct the patient to perform leg exercises every 2 hours O Encourage the patient to get out of bed as often as possible

O Instruct the patient not to cross the legs when in bed. O Instruct the patient to perform leg exercises every 2 hours O Encourage the patient to get out of bed as often as possible Rationale The patient is at risk for thrombosis after a surgery because of inactivity and injury to the blood vessels resulting from anesthesia. The nurse instructs the patient not to cross the legs when in bed because this action impedes blood flow in the legs. The nurse instructs the patient to perform leg exercises every 2 hours and also encourages the patient to get out of bed as often as possible. The nurse avoids using a knee gatch as it hinders venous return in the patient. Reducing fluids and juices in diet is necessary to prevent edema in a patient with deep vein thrombosis.

A student nurse has been assigned to a patient who has a prescription for tracheal suctioning. Which action by the student indicates that the student needs additional teaching? O Suctions the patient during removal of the catheter O Disposes of the catheter after suctioning is completed O Checks the tracheostomy for edema, exudates, and obstruction O Instructs the patient to hold the breath before the catheter is introduced

O Instructs the patient to hold the breath before the catheter is introduced Rationale Preoxygenation is essential before suctioning to prevent oxygen depletion. Preoxygenation can be accomplished by having the patient take a deep breath, setting the ventilator to deliver 100% oxygen, or using a resuscitator. Having the patient hold the breath before suctioning would be an indicator for further teaching. The catheter should be discarded after suction is completed. Before suctioning, it is essential to assess the tracheostomy for edema, exudates, and obstruction. The student should perform suctioning only during removal of the catheter.

The nurse would use a Venturi mask as an oxygen delivery device when observing which finding in the patient? O Discomfort O Has a mustache O Is a mouth breather O Requires humidified oxygen

O Is a mouth breather Rationale A patient who is a mouth breather will be best served by a Venturi mask, which covers the mouth and nose to deliver better oxygen than a nasal cannula (which only delivers oxygen through the nares). Patient oxygen needs, not comfort, will determine the oxygen delivery system. Having a mustache affects sleep apnea treatment systems, not oxygen delivery. Humidified oxygen can be delivered through any device.

While inspecting a patient's wound, the nurse observes that the skin around the wound has softened and is broken. Which finding does this indicate about the wound? O It was covered with a dry dressing O It was covered with a gauze dressing O It was exposed to air for a long time. O It was covered with an occlusive dressing

O It was covered with an occlusive dressing Rationale The softening and breaking of the skin are indicative of maceration. This usually happens because of excessive moisture around the wound. An occlusive dressing prevents air from reaching the wound and keeps the wound moist, which may cause maceration. Dry or gauze dressings allow the passage of air through pores present on the dressing. These dressings do not make the wound moist and they can prevent maceration.

Which method is most appropriate to open the airway of a patient with a suspected neck injury? O Jaw-thrust/chin-lift O Head-tilt/chin-lift O Flexed position O Modified head-tilt/chin-lift

O Jaw-thrust/chin-lift Rationale If a neck injury is suspected, the jaw-thrust/chin-lift is used. If neck injury is suspected, the head-tilt/chin-lift produces hyperextension of the neck and could cause complications. A flexed position is an inappropriate position to open the airway.

While providing first aid to a patient with a penetrating chest wound, the nurse observes the signs and symptoms of pneumothorax. Which intervention would be best to address this complication? O Dress the wound, taping securely on all four sides. O Leave one side of the dressing untaped for air to escape O Give the patient some water to drink to slow breathing O Slowly remove the object that caused the chest wound.

O Leave one side of the dressing untaped for air to escape Rationale If the signs and symptoms of pneumothorax are observed, then one side of the dressing should be left untaped. Tight taping of the dressing may cause respiratory distress. Intake of any liquids during this time may cause aspiration and should be avoided. Removal of an object may cause an escape of fluids into the plural space and increase the bleeding. The nurse should not remove the object.

While caring for a patient, the nurse finds that the patient's wound dressing has become yellow in color. Which parameter does the nurse assess further to investigate the abnormality? O zinc levels O Vitamin A levels O Platelet count O Leukocyte count

O Leukocyte count Rationale Yellow discharge on a bandage implies purulent discharge, which is caused by infection. During acute infections, the leukocyte count increases; therefore, to confirm the presence of infection, the nurse should check the patient's leukocyte count. Decreased zinc and vitamin A concentrations cause a reduced healing process, but these do not indicate the presence of infection. An increased platelet count is characterized by thrombosis. Therefore, it is not necessary to check zinc concentration, vitamin A concentration, or platelet count to identify the presence of infection.

Which different categories of anesthesia are used in surgical procedures? Select all that apply. O Local anesthesia O Conscious sedation O General anesthesia O Epidural anesthesia O Regional anesthesia

O Local anesthesia O Conscious sedation O General anesthesia O Regional anesthesia Rationale Local anesthesia involves loss of sensation at the desired site and is commonly used for minor surgical procedures, such as a biopsy of a tumor or removal of a growth. Conscious sedation involves giving drugs that depress the central nervous system or provide analgesia to relieve anxiety or provide amnesia during surgical diagnostic procedures. General anesthesia is used for major surgery requiring extensive tissue manipulation, and it produces amnesia, analgesia, muscle paralysis, and sedation. Regional anesthesia causes loss of sensation in an area of the body and is used for some surgical procedures and pain management. Epidural anesthesia is a type of general anesthesia.

A postsurgical mastectomy patient has a bandage on the left breast. To assess whether the patient is hemorrhaging, which measure should the nurse take? O Assess the corners of the gauze dressing for blood. O Remove the bandage to determine if blood exists. O Look under the patient for areas of blood O Use a scale to monitor the bandage for an increase in weight.

O Look under the patient for areas of blood Rationale To prevent undetected hemorrhaging, the nurse must inspect the dressing or incision and the area under the patient. Exudate follows the flow of gravity; therefore depending on the contour of the body, the dressing remains dry even though blood and exudates are flowing under the body. Looking under the patient will reveal blood that has flowed backward under the patient. Assessing the corners of the gauze will not reveal hidden blood. Weighing the bandage is not a correct way to assess hemorrhage.

The nurse is caring for a patient with a deep stab wound. Which foods does the nurse advise the patient to include in the diet to facilitate faster healing? Select all that apply. O Milk and eggs O Baked potatoes O Dark green vegetables O Seafood and red meat O Gelatin dessert

O Milk and eggs O Baked potatoes O Dark green vegetables O Seafood and red meat Rationale A diet rich in proteins; carbohydrates, lipids; vitamins A and C; thiamine, pyridoxine; and minerals such as zinc, iron, and copper are required for wound healing. Milk and eggs provide proteins. Baked potatoes provide vitamin C. Dark green vegetables provide Vitamin A. Seafood and red meat provide zinc. Gelatin dessert lacks the nutrition required for healing

Which oxygen delivery system would be used to apply 2 L/min of oxygen to an ambulatory patient with chronic obstructive pulmonary disease (COPD)? O Venturi mask O Nasal cannula O Simple face mask O Nonrebreathing mask

O Nasal cannula

Which statement regarding culture and ethnic considerations is considered to be a true statement? O Native Americans are often stoic when ill. O Written consent has more meaning than verbal consent among Arab Americans O Chinese Americans are usually very willing to ask for pain medications after surgery. O Direct eye contact is a sign of respect to many Southeast Asians and American Indians.

O Native Americans are often stoic when ill. Rationale Native Americans are often stoic when ill. Complaints of pain to the nurse may be in general terms, and undertreatment of pain is common. Verbal consent has more meaning than written consent among Arab Americans because it is based on trust. Chinese Americans may not ask for pain medications after surgery and may require education about pain relief. Direct eye contact may be avoided and considered disrespectful to many Southeast Asians and American Indians.

How many attempts can the nurse make to perform tracheal suctioning at one time? O Only one O No more than three O As many as needed to complete the suctioning O The nurse is not permitted to perform tracheal suctioning

O No more than three Rationale The nurse can only perform tracheal suctioning three times during the suctioning procedure More than one attempt at suctioning may be needed, but the nurse should not exceed three suctioning procedures at one time. It is within the scope of nursing practice to perform tracheal suctioning.

Which information does the nurse include when documenting a tracheostomy suctioning procedure? Select all that apply. O Peristomal skin condition O Use of sterile normal saline O Number of times suctioned O Color and amount sputum O Lung sounds before and after procedure

O Number of times suctioned O Color and amount sputum O Lung sounds before and after procedure

The nurse is preparing to care for a patient who has undergone cardiothoracic surgery (treats conditions in the heart, lungs, and chest). During the immediate postoperative period, the nurse would assess which area of the skin for pressure-related breakdown? O Patella O Ventral foot O Occipital skull O Anterior pelvis

O Occipital skull Rationale The patient undergoing cardiothoracic surgery is on his or her back on a hard surface for an extended period. Therefore, the patient should be assessed for skin breakdown on the occiput, olecranon, calcaneus, sacrum, coccyx, and other dependent areas. This patient would not be at risk for breakdown on the patella, ventral foot, or anterior pelvis.

Which signs would the nurse expect to find to support a medical diagnosis of early stage of shock? Select all that apply. O Oliguria O Warm skin O Tachypnea O Hypotension O Altered level of consciousness O Bradycardia

O Oliguria- the production of abnormally small amounts of urine. O Tachypnea O Hypotension O Altered level of consciousness Rationale During shock the skin is cool and clammy, the patient loses consciousness, and the patient may experience an increase in heart rate (tachycardia) and pulse rate (tachypnea). Urinary output decreases (oliguria), and blood pressure goes down (hypotension). There is increase, not decrease, in heart rate, and the skin is not warm, but cool and clammy. Bradycardia may occur but usually in the late stages of shock.

The nurse is caring for a patient who will have surgery in 3 hours, and the patient's morning medications are due now. Although most medications will be held before surgery because the patient has a prescription for nothing by mouth (NPO), the nurse anticipates administering which medication(s)? Select all that apply. O Oral multivitamin O Oral phenobarbital O Intravenous morphine O Oral digoxin (Lanoxin) O Subcutaneous enoxaparin (Lovenox)

O Oral phenobarbital O Intravenous morphine O Oral digoxin (Lanoxin) Rationale The nurse would plan to administer oral anti seizure and cardiac medications with a small sip of water the morning of the surgery. Intravenous morphine would be given to manage pain because this is not an oral medication. Oral multivitamins would be held before the surgery. Although the enoxaparin (Lovenox) is a subcutaneous medication, it would most likely be held the day of the surgery because of an increased risk of bleeding during the operation.

The nurse is caring for a diabetic patient who has injuries due to an accident. The nurse finds that the patient has delayed wound healing. What food does the nurse suggest to the patient to promote faster wound healing? O Apples O Peaches O Oranges O Watermelon

O Oranges Rationale Vitamins and nutrients play a major role in the process of wound healing, and vitamin C is particularly helpful. Vitamin C maintains tissue integrity and enhances the process of wound healing. Therefore, the nurse should suggest the patient eat fruits that contain vitamin C, such as oranges. Fruits such as apples, peaches, and watermelon do not contain large amounts of vitamin C, so they may be less helpful in promoting wound healing.

The nurse is performing an initial assessment of a patient who just returned from surgery. The nurse notes bright red on the surgical dressing. Which nursing action is best? O Change the dressing and use extra gauze. O Reinforce the dressing with more gauze and tape. O Outline the bloodstain in permanent marker, and reassess frequently O Call the health care provider and prepare the patient to return to surgery.

O Outline the bloodstain in permanent marker, and reassess frequently Rationale Occasionally, the patient will return from surgery with bloody drainage on the surgical dressing The nurse should outline the drainage in permanent marker and reassess frequently If the spot increases, the nurse should contact the health care provider. In general, the first dressing change is performed at a predetermined time by the surgeon; it is inappropriate for the nurse to change the dressing at this time, and it is not necessary to reinforce the dressing as yet. It is not necessary to call the health care provider and prepare the patient to return to surgery at this time.

Which factor would cause a keloid (firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to the color of the person's skin or red to dark brown in color )on the patient's skin at the site of injury? O Shortening of muscle tissue O Overgrowth of collagen O Impaired blood flow O Reduction in skin capillaries

O Overgrowth of collagen Rationale A keloid is a permanent raised, enlarged scar. It occurs due to an overgrowth of collagen Collagen is the fibrous structural protein found in connective tissue. A keloid develops in the final stage of healing, when the scar matures to produce the strongest scar tissue possible. Shortening of muscle tissue can occur when there is a wound around a joint. Impaired blood flow and reduction in skin capillaries are caused by peripheral vascular disease.

Which data would the nurse include when documenting a nasotracheal suctioning procedure? Select all that apply. O Capillary refill O Oxygen saturation O Bilateral breath sounds O Color and amount of sputum O Health care provider notification

O Oxygen saturation O Bilateral breath sounds O Color and amount of sputum Rationale The patient's oxygen saturation level, bilateral breath sounds, and the color, consistency, amount, and odor of sputum suctioned should be documented after the suctioning procedure. It is not necessary to assess capillary refill. The health care provider does not need to be notified.

Which signs are characteristic of hypoxia (Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) ? Select all that apply. O Pallor O Anxiety O Confusion O Restlessness O Decreased blood pressure

O Pallor O Anxiety O Confusion O Restlessness Rationale Signs of hypoxia include pallor, anxiety, confusion, and restlessness caused by lack of oxygen. The initial response to hypoxia is an increase, not a decrease, in blood pressure.

Which delivery system would the nurse use for a patient with an oxygen saturation level of 69% on room air prescribed 100% oxygen to be delivered at 15 L/min? O Venturi mask O Nasal cannula O Nonrebreather mask O Partial non rebreather mask

O Partial non rebreather mask Rationale A nonrebreather mask is designed to administer 70% to 100% oxygen at 6 to 15 L/min. A Venturi mask delivers 4 to 10 L/min at 24% to 55% oxygen. Nasal cannula can only accommodate oxygen flow rates between 1 and 6 L/min at 24% to 44% oxygen. A partial rebreather mask provides 6 to 12 L/min at 60% to 90% oxygen.

While the nurse is starting a heparin lock on a patient with a diagnosis of a drug overdose, the patient begins to have a seizure. Which concern is the nurse's priority? O Patient safety O The medical history O Determining allergies O Securing the intravenous access

O Patient safety Rationale Victims must be protected from self-injury during a seizure or hallucinations by removing potential harmful objects from the patient's vicinity. The patient's safety is essential. Obtaining the medical history, determining allergies, and securing an intravenous access are essential but preventing injury is the priority.

Which information is essential to be documented in the chart after a dressing change? Select all that apply. O Patient's response O Patient's medication O Status of the wound O Level of consciousness O Location of the wound O Type of dressing applied

O Patient's response O Status of the wound O Location of the wound O Type of dressing applied Rationale After a dressing change, document the location of the wound, status of the wound, and description of the exudate or drainage. In addition, document the dressing applied, any teaching provided, and any response to therapy. The patient's level of consciousness and medication may be documented, but these are usually not addressed during wound care.

Which action during suctioning would increase a patient's risk of cardiopulmonary compromise? O Performing suctioning for 20 to 25 seconds O Having the patient rest for 1 to 2 minutes between suction attempts O Using a water-soluble lubricant on the catheter O Angling the catheter downward after initial upward insertion

O Performing suctioning for 20 to 25 seconds Rationale Suctioning should only be performed for 10 to 15 seconds with each pass to prevent cardiopulmonary compromise. The nurse should allow 1 to 2 minutes rest in between suctioning attempts. The catheter should be lubricated with water-soluble lubricant to facilitate passage. The catheter should initially be angled up and then downward to follow the normal anatomy

A young teen with an incision calls the nurse. The patient states to the nurse, "I feel like something gave way in my wound." The nurse assesses the patient and suspects a possible wound dehiscence. Which action should the nurse take first? O Medicate the patient for pain. O Notify the health care provider. O Instruct the patient to lie in Sims position O Place a warm, moist sterile dressing over the area.

O Place a warm, moist sterile dressing over the area. Rationale When wound layers separate, resulting in dehiscence, some patients report feeling that something has given way or broken. If the wound is not covered and dehiscence occurs, the patient should be made to remain in bed and not cough. A warm moist sterile dressing should be placed over the wound. The patient is to remain on nothing by mouth (NPO) status in case surgery is needed to fix the problem. Once the gauze has been placed and the patient's condition is stable, the nurse notifies the health care provider. The patient may be medicated, but it is not a priority, pain is not stated and level is not given. Placing the patient in the Sims position is not appropriate.

The nurse is preparing to care for a patient who has just returned from major abdominal surgery. Which intervention by the nurse in the immediate postoperative period will best prevent cardiovascular complications? O Encourage the patient to restrict movement of legs. O Assist the patient to turn, cough, and deep breathe. O Encourage the patient to get out of bed as soon as possible. patient's legs. O Place sequential compression devices (SCDS) on the legs

O Place sequential compression devices (SCDS) on the legs Rationale In the immediate postoperative period, the nurse should place the SCDs on the patient's legs to promote venous blood return while the patient is immobile. The nurse should facilitate the movement of the patient's arms and legs, not restrict it. Turning, coughing, and deep breathing are important interventions for the respiratory system. Although the patient should ambulate as soon as possible, this is not the best action in the immediate postoperative period.

Which action is essential for the nurse to implement before applying a bandage to an injured leg once the bleeding is controlled? O Elevate the leg. O Massage the calf. O Apply heat to the wounded area. O Place the leg in a functional position.

O Place the leg in a functional position. Rationale The nurse should control the bleeding before applying the bandage. The nurse should always bandage the part in the aligned position. The leg may be elevated after the bandage has been applied, massaging the calf may dislodge a clot, and heat is not indicated at this point.

An emergency tracheostomy was performed on a patient. Which primary intervention would the nurse carry out in the immediate postoperative period? O Offering a soothing back rub O Providing discharge teaching O Arranging for spiritual guidance O Placing a communication board at the bedside

O Placing a communication board at the bedside Rationale The primary nursing responsibilities for maintaining a tracheostomy tube are to keep the airway clear, keep the inner cannula clean, prevent impairment of surrounding tissues, and provide the patient with a means of communication. Because the procedure was done on an emergency basis, the nurse must provide a communication board or pencil and paper for the patient, who will be unable to speak after having had a tracheostomy. It is essential to provide discharge teaching, but it should not be done immediately after surgery. A soothing back rub will help the patient, and spiritual guidance may be needed, but these are not as important as establishing communication with the patient in an effort to address needs in the immediate postoperative period.

Which nursing actions are part of managing an airway obstruction for an unconscious patient? Select all that apply. O Some correct answers were not selected O Placing the patient in the supine position O Initiating cardiopulmonary resuscitation (CPR) O Performing a blind finger sweep of the oral cavity O Opening the airway and attempt to ventilate O Performing abdominal thrusts on the patient

O Placing the patient in the supine position O Opening the airway and attempt to ventilate O Performing abdominal thrusts on the patient Rationale It is necessary have the patient in the supine position when managing airway obstruction to facilitate ventilation. Abdominal thrusts are performed on an unconscious patient (who cannot cough spontaneously) to facilitate removal of an obstructing object in the airway. The nurse would also open the airway and attempt to ventilate, a maneuver known as rescue breathing. CPR becomes necessary only if spontaneous breathing is not restored and the patient no longer has a pulse. Blind finger sweeps are no longer recommended; only attempt to remove an object from the victim's mouth if the object is visible.

Following surgery, Ms. Burke is admitted to the Post Anesthesia Care Unit (PACU). The operative report indicates that Ms. Burke had a left hip replacement under general anesthesia. Initially, Ms. Burke is not responding to verbal stimuli. Her vital signs are T 97.6° F, P 88, R 14, and BP 130/70. What action should the PN implement first? O Position the client on her side. O Observe the surgical dressing. O Place the call bell within reach. O Remove the oral airway.

O Position the client on her side.

A patient returns from abdominal surgery at 1300 with a heart rate of 78, respiratory rate of 14, and blood pressure of 128/86. At 1400, the patient complains of light-headedness; the heart rate is 132, respiratory rate is 22, and blood pressure is 84/58. Which action should the nurse perform first? O Encourage deep breathing O Administer naloxone (Narcan) O Prepare the patient to return to surgery O Document the vitals.

O Prepare the patient to return to surgery Rationale The patient is demonstrating symptoms of hemorrhage and should be prepared to return to surgery. Although the vital signs should be documented, this is not the nurse's first action Encouraging deep breathing is not the best action at this time. Naloxone is used to reverse the respiratory depression effects of opioid medications and is not appropriate based on this patient's condition

The health care provider instructs the nurse to administer preoperative medication before transferring a patient to the surgical suite. Which interventions should the nurse implement after administering the medication? Select all that apply. O Provide a quiet environment. O Encourage the patient to void. O Place the bed in a low position O Raise the side rails of patient's bed. O Monitor the patient every 15 to 30 minutes.

O Provide a quiet environment. O Place the bed in a low position O Raise the side rails of patient's bed. O Monitor the patient every 15 to 30 minutes. Rationale The patient may experience mild discomfort after receiving the preoperative medication Therefore, the nurse supports the patient by providing a quiet environment. The patient may experience drowsiness or vertigo, so the nurse places the bed in a low position to prevent falls. The side rails of the bed are also raised to provide safety from falls. The nurse monitors the patient every 15 to 30 minutes to ensure that there are no complications. The nurse encourages the patient to void before administering the medications because the patient needs to be in bed after the medications are given.

What can be used to determine the presence of hypoxia in a patient experiencing dyspnea? Select all that apply. O Sputum color O Pulse oximetry O Peripheral pulses O Level of consciousness O Respiratory rate and pattern

O Pulse oximetry O Level of consciousness O Respiratory rate and pattern Rationale Obtaining pulse oximetry readings, determining the level of consciousness, as well as respiratory rate and pattern can determine if a patient has hypoxia. Sputum color indicates possible infection. The peripheral pulses are assessed to determine circulation.

Which interventions should the nurse implement while providing care for a postoperative patient who is unconscious? Select all that apply. O Raise the side rails of the bed. O Place a pillow under the head. O Keep the call light within reach. O Raise the bed to a 45-degree angle. O Assess blood pressure and heart rate.

O Raise the side rails of the bed. O Keep the call light within reach. O Raise the bed to a 45-degree angle. O Assess blood pressure and heart rate. Rationale The level of consciousness in a postsurgical patient is altered. Therefore, the nurse raises the side rails of the bed to prevent falls. The nurse also keeps a call light within the patient's reach to help the patient inform the nurses about any complications immediately. The nurse raises the bed to a 45-degree angle to reduce the chances of aspirating vomitus. The nurse assesses blood pressure and heart rate frequently as postoperative complications can occur suddenly. The nurse does not place a pillow under the patient's head until the patient has regained complete consciousness because doing so may cause the tongue to obstruct the airway.

The nurse observes that a postsurgical patient is experiencing symptoms of atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung). Which intervention does the nurse implement before reporting to the health care provider? O Raises the head of the bed O Rolls the patient to one side O Administers pain medications O Provides simple carbohydrates

O Raises the head of the bed Rationale Dyspnea is a symptom of atelectasis that can be relieved by raising the head of the patient's bed. The nurse rolls the patient to one side only if there is a risk for aspiration of vomitus and not to relieve dyspnea Pain medications are not a priority in this case. Instead, oxygen therapy needs to be initiated. Simple carbohydrates are helpful in treating hypoglycemia but will not help to relieve the symptoms of atelectasis.

Five days after surgery, a patient calls the nurse and states that the wound is bleeding. After assessing the wound of the patient, the nurse notes that there is no drainage on the bandage at that time. Which other sign may indicate that the patient's wound is bleeding? O Even respirations O Rapid thready pulse O Increased urinary output O Increased blood pressure

O Rapid thready pulse Rationale If hemorrhage results internally, the dressing may sometimes remain dry while the abdominal cavity collects blood. The nurse should be attuned to less obvious signs of internal bleeding including restlessness, rapid thready pulse, decreased blood pressure, decreased urinary output, and cool and clammy skin. Even respirations are normal. The urinary output decreases and the blood pressure decreases when a patient is hemorrhaging

The nurse is caring for a patient who has undergone abdominal surgery. Following the daily assessment, the nurse finds that the patient has an internal hemorrhage. On the basis of which finding did the nurse make such a conclusion? Select all that apply. O Rapid, thready pulse O Skin hot to the touch O Abdominal distension O Low blood pressure O High urinary output

O Rapid, thready pulse O Abdominal distension O Low blood pressure Rationale A patient who has undergone abdominal surgery may have an internal hemorrhage due to trauma, Internal hemorrhage is characterized by a rapid, thready pulse; abdominal distension; and low blood pressure. This is caused by increased abdominal pressure and vasodilatation. The patient may have cool and clammy skin because of reduced blood pressure. Internal hemorrhage causes reduced blood volume, which causes reduced urinary output. Therefore, increase in skin temperature and urinary output do not indicate internal hemorrhage.

Which action does the vacuum-assisted closure (VAC) device provide for a wound? O Reduces edema and increases circulation O Increases bacterial count after several days O Decreases blood flow and encourages healing O Facilitates positive pressure and wound closure

O Reduces edema and increases circulation Rationale The wound VAC applies negative pressure to wounds. Healing of the wound is facilitated during this process by an increase in blood flow, improved or increased fluid drainage, and enhanced wound closure as the pressure draws the edges of the wounds together. The use of negative pressure removes fluid from the area, decreases edema, and, as a result of decreased edema, increases blood flow. The blood flow is increased and not reduced. Bacterial count is reduced; it does not increase bacterial count. The wound VAC uses negative pressure and not positive pressure to heal.

a newly postoperative patient is transferred to the postanesthesia care unit (PACU). When the nurse reassesses the bandage, bleeding is evident. Which action should the nurse perform next? O Reinforce the bandage. O Increase the intravenous fluid. O Gall the surgeon for additional instructions. O Remove the original bandage and replace with gauze.

O Reinforce the bandage. Rationale Initial surgical dressings may require reinforcement if soiled. Increasing the intravenous fluid is not a nursing function and requires a prescription. The surgeon may eventually be called if bleeding does not stop after reinforcement. The original surgical bandage is not removed but is reinforced with a pressure dressing.

For removing staples from a surgical incision, which intervention is most appropriate? O Remove all the staples. If the edges pull apart, apply Steri-Strips. O Remove every other staple; then wait several days to remove the rest. O Remove the middle staples first, then proceed to the outer edges and apply the dressing O Remove every other staple first and replace with Steri-Strips while ensuring that the incision remains closed.

O Remove every other staple first and replace with Steri-Strips while ensuring that the incision remains closed. Rationale Routinely, every other staple is removed first and replaced with Steri-Strips, unless the orders are different. You would want to monitor that the incision remains closed during the procedure. Unless contraindicated by orders, all the staples are removed at the same time. Starting in the middle of the incision would not reduce the stress on the edges of the incision. Removing all the staples at once will put more stress on the incision, causing an increased risk for the edges to pull apart.

A hunter has been bitten by a snake and is brought to the emergency room. Which measures should the nurse implement? Select all that apply. O Remove restrictive clothing O Assess the patient for shock. O Suction the toxins from the site. O Exercise the limb with the snake bite O Place affected area above the level of the heart.

O Remove restrictive clothing O Assess the patient for shock. Rationale Emergency care for bites from reptiles, such as snakes, includes restricting movement of the affected limb and keeping it below the level of the heart, as well as removing restrictive clothing and jewelry. The patient must be monitored for shock. The toxins are not generally suctioned in the emergency room. This intervention may have been attempted by the patient. This is not a nursing intervention. Exercise should not be done, and the extremity should be kept below the level of the heart.

Which indications are possible with poisoning? Select all that apply. O Respiratory distress O Nausea and vomiting O Hyperthermia O Seizures O Hypothyroidism

O Respiratory distress O Nausea and vomiting O Seizures Rationale Acute signs and symptoms of poisonings are sometimes delayed for hours. The following are possible indications of poisonings: respiratory distress, pulmonary edema; bronchospasm; severe nausea, vomiting, or diarrhea; seizures, twitching, or paralysis; decreased level of consciousness or unconsciousness; restlessness, delirium, agitation, or panic; color changes; pale, flushed, or cyanotic skin; signs of burns or edema around the mouth or other areas of the body; pain, tenderness, or cramps on swallowing characteristic odor on the breath; unusual urine color (red, green, bright yellow, black, bronze); slow, labored breathing or wheezing: abnormal constriction or dilation of pupils; abnormal eye movements, such as nystagmus (constant, involuntary, cyclic movement of the eyeball); skin irritation, erythema, or edema; and shock or cardiac arrest. Hyperthermia is not a sign and symptom of poisoning. Hypothyroidism occurs when the thyroid gland is underactive, and this does not pertain to poisoning

When orders are written to remove sutures in 22 days, which type of sutures does the nurse suspect the patient has been given? O Blanket O Separate O Retention O Continuous

O Retention Rationale Retention sutures are used to close abdominal incisions that are made during abdominal surgery. These sutures can be left in place for 22 days or more. Blanket sutures, separate sutures, and continuous sutures are generally removed in 7 to 10 days to ensure optimal healing

The nurse is performing a preoperative assessment on a patient before elective knee replacement surgery. The patient reports an allergy to latex. Which action should the nurse perform first? O Document the finding O Contact the surgeon. O Cancel the surgery. O Seek more information.

O Seek more information. Rationale The nurse should obtain more information regarding the allergy, including date of onset, details surrounding the event, and the type and extent of the reaction. The nurse should document the finding and contact the surgeon, but the nurse must first seek more information. It is not appropriate to cancel the surgery at this time.

Which action when performing an oropharyngeal suctioning of a 12-year-old patient requires correction? O Using 100 mm Hg wall suction O Moving the Yankauer catheter around mouth O Selecting a 14-French (Fr) suction catheter O Placing the thumb over the end of the connector

O Selecting a 14-French (Fr) suction catheter Rationale The nurse should select a 10- to 12-Fr suction catheter for a child because trauma to the oral mucosa can occur if too large a catheter or too much suction is used. The appropriate suction pressure for a child is 100 to 120 mm Hg. The Yankauer catheter should be moved around the mouth and a thumb placed over the end of the connector to gather secretions.

A patient has come to the postanesthesia care unit (PACU) after hip replacement surgery. What nursing concern would the nurse anticipate to be the highest priority? O Nutrition O Hydration O Skin integrity O Tissue perfusion

O Skin integrity Rationale The existence of hip replacement means there is a wound, which clearly indicates impaired skin integrity; interventions need to be developed to promote wound healing. More information is needed about tissue perfusion, nutrition, and hydration status before those can be identified as higher priorities. Tissue perfusion needs interventions directed toward supporting wound repair if there are circulatory problems. Nutrition is a concern in addition to skin integrity if the patient is having problems with nutrition intake and needs intervention directed toward supporting wound repair. Hydration is a concern in addition to skin integrity if there are problems with fluid balance and needs intervention directed toward supporting wound repair.

Which effect does a bacterial infection with exudate and drainage have on a wound? O Quickens the healing process O Slows the healing process O Causes intense pain in the patient O Leads to hypovolemic shock

O Slows the healing process Rationale A bacterial infection of the skin causes fluid to drain from the wound. This slows the healing process. It will not quicken the healing process or cause intense pain in the patient. It will also not lead to hypovolemic shock as there is no internal hemorrhage.

Which findings does the nurse expect in a diabetic surgical patient who is taking longer than usual to heal O Increased oxygen to tissues O Small blood vessels that impair tissue circulation O Increased ability of the body to fight infection O Decreased temperature due to healing mechanisms

O Small blood vessels that impair tissue circulation Rationale Wounds in diabetic patients take a longer time to heal. This occurs due to small blood vessel disease that impairs tissue perfusion and hemoglobin fails to release oxygen to tissues. This decreases the oxygen to the tissues. An elevated temperature would suggest an infection and is not due to healing. Diabetes decreases the ability of the body to fight infection.

Which wetting agent solution would the nurse use while dressing a patient's wounds when a deodorizing effect is required? O Acetic acid O Povidone-iodine O Lactated Ringer's O Sodium hypochlorite

O Sodium hypochlorite Rationale Sodium hypochlorite solution has a deodorizing effect and is used for cleaning wounds that have necrotic debris because it enhances the process of wound débridement. Acetic acid is effective in preventing infection caused by Pseudomonas aeruginosa, but it does not have a deodorizing effect. Povidone-iodine solution is an antimicrobial solution used for cleaning intact skin but is not used to clean necrotic debris because it may cause irritation. Ringer's solution aids in mechanical debridement but does not have a deodorizing effect.

Which induction method does the anesthesiologist use while administering regional anesthesia to a patient scheduled for lower abdominal surgery? O Nerve block O Spinal anesthesia O Conscious sedation O Epidural anesthesia

O Spinal anesthesia Rationale Spinal anesthesia is used for lower abdominal surgery because the anesthetic effects extend from the tip of the xiphoid process down to the feet. Nerve block is used for orthopedic surgery involving extremities because the anesthesia needs to block the nerve supply to the operative site. Conscious sedation is another form of anesthesia that is given to relieve anxiety or provide amnesia during surgical diagnostic procedures. Epidural anesthesia blocks sensation in the vaginal and perineal areas and, thus, is often used for obstetric procedures.

Which nursing intervention is best when caring for a patient with a possible dislocated shoulder? O Reduce the joint. O Elevate the joint. O Splint the joint O Apply hot packs.

O Splint the joint Rationale Dislocation usually happens after a fall or a blow. In case of shoulder dislocation, the joint should be splinted to prevent any movements of the joint. Movements of the dislocated joint can be painful and may worsen the dislocation. The dislocated joint should not be reduced because it can cause soft tissue injury. The joint should not be elevated because it can tear the fragile soft tissues. Cold packs rather than hot packs should be applied to reduce the edema.

Three days postoperative, the nurse is ordered to remove a patient's sutures but notices a thick liquid oozing from the suture site. Which action should the nurse take next? O Reapply the removed sutures. O Use.a wetting agent and dress the wound. O Stop the process and leave the remaining sutures intact. O Continue the process and apply Steri-Strips all over.

O Stop the process and leave the remaining sutures intact. Rationale If the nurse observes a thick liquid oozing from the suture site while removing sutures, the nurse should immediately stop the process. Oozing could indicate that the wound is not completely healed. The nurse should not suture back the removed stitches or simply dress the wound. Instead, the nurse should let the wound remain open for a period of time, which helps to prevent further injury, and avoid wetting the wound. The nurse should not completely remove the sutures because doing so may cause infection due to incomplete healing. The nurse may be advised to dress the wound, but the next action the nurse should take is to notice the complication and stop.

Which positioning of a patient during suctioning can lead to aspiration of secretions? O Supine O Fowler's O Side-lying O Semi-Fowler's

O Supine Rationale A patient who is supine during suctioning is at risk for aspiration. The nurse should place the patient in a position that facilitates removal of secretions and promotes lung expansion, that is, Fowler's or semi-Fowler's position. The side-lying position should be used if the patient is unresponsive

Which inference could the nurse make from a post appendectomy incision site that has bright red gauze? O Sutures have ruptured. O Normal wound healing is occurring O Sutures have become infected. O Serum is oozing from the sutures.

O Sutures have ruptured. Rationale The presence of bright red gauze during an assessment indicates that the patient has bleeding, which may be due to the rupture of sutures. The presence of blood is not indicative of normal wound healing. The gauze could be pale red if serum oozed from the sutures. Infected sutures are characterized by the presence of pus, and the gauze would appear yellow in color.

Which equipment is used to humidify the oxygen being delivered to a patient with a tracheostomy? O T-tube O Obturator O Inner cannula O Pilot balloon valve

O T-tube Rationale The T-tube is a "T"-shaped piece of equipment that allows for administration of humidified oxygen to a patient with a tracheostomy. An obturator is used to insert a tracheostomy tube. The inner cannula is a part of the tracheostomy tube. A pilot balloon valve keeps the tracheostomy cuff inflated.

The nurse is caring for a patient 12 hours after abdominal surgery. How can the nurse best facilitate controlled coughing in the postoperative patient? O Instruct the patient to control and prevent coughs by drinking water O Teach the patient to splint the incision with a pillow to help prevent pain. O Hold pain medication to ensure the patient is awake enough to participate O Instruct the patient to take shallow breaths to prevent pain while coughing.

O Teach the patient to splint the incision with a pillow to help prevent pain. Rationale The nurse should teach the patient to splint the incision to prevent pain and protect the incision while coughing. The patient should not prevent coughs. The nurse should ensure that the patient's pain is well controlled. A patient with uncontrolled pain is less likely to perform the necessary postoperative exercise to prevent complications. The patient should take several deep breaths before coughing.

The nurse on the preoperative floor is asked to act as witness for the signing of the surgery consent form. The nurse knows that by providing the signature, the nurse is verifying which information? O The consent was voluntary. O The patient was competent at the signing of the consent form. O Proper education was provided before the consent form was signed O The patient understood the procedure before signing the consent form.

O The consent was voluntary. Rationale The witness verifies only that the consent was voluntary and the identity of the person signing the form. It is the surgeon's responsibility to determine the patient's competency, education, and understanding before having the patient sign the form

A graduate nurse receives a patient with frostbite to the big toe. Which action requires immediate correction by the preceptor? O The nurse is rubbing the toe. O The toe is wrapped inside warm towels. O The toe is placed in a whirlpool bathtub. O Several blankets are applied to warm the area.

O The nurse is rubbing the toe. Rationale The nurse should refrain from rubbing the part because friction can bruise and damage underlying tissue. Wrapping the frostbitten part in the warm towels, placing it in a whirlpool of water, and applying several blankets are appropriate interventions for the nurse to implement

The nurse decides to provide external cardiac compression on a patient who is short of breath and has a normal pulse. Which event would occur as a result of this intervention? O The patient may be injured. O The patient's respiratory rate would be restored. O The patient's blood pressure would become normal O The patient would become unconscious as a result of cerebral injury

O The patient may be injured. Rationale External cardiac compression should be given to the patient who has pulselessness. The intervention helps increase the rate of blood circulation to the heart, lungs, brain, and rest of the body. Because it may cause potential injury, this method should be avoided in the patient who has a normal pulse. Respiratory rate will become normal by providing artificial respiration to the patient. External cardiac compression helps maintain normal pulse rate and blood pressure in the patient who has pulselessness. It is not performed in patients who have a normal pulse. This intervention does not cause injury to the brain. Therefore unconsciousness resulting from cerebral injury does not occur in this patient.

Which statement regarding preoperative medication is true? O After surgery, all preoperative medications are automatically resumed for the patient. O The patient who has received an opioid analgesic usually requires a larger amount of anesthetic once in surgery. O The preoperative phase is the optimal time to introduce the concept of patient-controlled analgesia (PCA) to the patient. O After receiving preoperative medication, the patient is generally encouraged to ambulate on the nursing unit to encourage deep breathing.

O The preoperative phase is the optimal time to introduce the concept of patient-controlled analgesia (PCA) to the patient. Rationale An introduction to PCA preoperatively is advantageous because the patient is better able to comprehend the concept and operation of the equipment. Surgery cancels all medications prescribed before surgery except for conditions of longstanding duration, such as phenytoin (Dilantin) for seizure control. The surgeon will prescribe medication again, as necessary, after surgery. The nurse institutes safety procedures, such as keeping the bed in low position and the side rails up and monitoring the patient every 15 minutes until the patient leaves for surgery. The patient who has received an opioid analgesic usually requires a smaller amount of anesthetic once in surgery. After receiving preoperative medication, the patient must remain in bed.

The medical team has arrived to take the patient to surgery. Which observation, if made by the nurse, would prompt the nurse to "stop the line" and prevent the patient from being taken to surgery? O The patient's jewelry has been removed. O The patient's dentures have not been removed. O The surgery "timeout" has not been performed. O The site for the surgery has not been marked

O The site for the surgery has not been marked Rationale The nurse should call a halt to the process and report that the site of the surgery has not been marked to prevent wrong-site surgery. The patient's jewelry should be removed before surgery. Depending on the surgery, the dentures may be allowed to remain in the patient's mouth. The surgery timeout usually occurs in the operating room immediately before the surgery.

A critical care nurse is preparing to suction a patient who has a tracheostomy. Which nursing action may result in damage to the mucosa? O The catheter is inserted until resistance is met O The patient is allowed to rest between each suction effort. O The cannula is rinsed with a solution before the patient is suctioned. O The thumb is placed over the suction control while the catheter is being advanced.

O The thumb is placed over the suction control while the catheter is being advanced. Rationale During tracheostomy suctioning, the thumb should be removed from the suction control before the catheter is advanced because the thumb would prevent suctioning while the catheter is introduced, and this has the potential to damage the mucosa. Inserting the catheter until resistance is met, allowing the patient to rest between efforts, and rinsing the cannula with a normal saline solution before the first suction are appropriate actions.

Which statement regarding informed consent is true? O Informed consent occurs when the nurse discusses the surgical procedure, risks, and alternatives with the patient. O If the patient's life is in danger and the family members cannot be located, the surgeon may not legally perform surgery O The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was voluntary consent. O The best time to have the patient sign the consent form is after the patient has received the preoperative medication because the patient will be more relaxed.

O The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was a voluntary consent. Rationale The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was a voluntary consent. Informed consent occurs when the surgeon discusses the surgical procedure, risks, and alternatives with the patient. If the patient's life is in danger and the family members cannot be located, the surgeon may legally perform surgery. The witness (often a nurse) is not verifying that the patient understands the procedure. Consent should not be obtained if the patient is disoriented, unconscious, mentally incompetent, or, in some agencies, under the influence of sedatives.

The nurse is assessing gastrointestinal function in a postoperative patient. Which assessment finding would indicate that there is normal peristalsis? O Bowel sounds are absent in the patient. O The patient is able to turn every 2 hours. O The patient experiences flatus after consuming food. O There are 5 to 30 gurgles in the abdomen per minute.

O There are 5 to 30 gurgles in the abdomen per minute. Rationale If the nurse hears 5 to 30 gurgles in the abdomen per minute, it indicates that the patient has normal peristalsis and the patient can consume foods and fluids, An absence of bowel sounds may indicate a decrease in or absence of intestinal peristalsis, which needs to be reported immediately. Ability to turn every 2 hours will not indicate that the patient has normal gastrointestinal function, but the turning exercise aids gastrointestinal functioning. Experiencing flatus after consuming food indicates the presence of intestinal gas, which is relieved by limiting iced beverages and offering warm liquids,

Three weeks after surgery, an African-American patient comes to the clinic for follow-up. The nurse notices an overgrowth of scar tissue at the site. Which conclusion would be an accurate nursing evaluation of the finding? O This may be normal for this patient. O The wound has dehisced and is now repairing itself. O There is a need to call the health care provider for additional prescriptions is O The patient must be taught to monitor for signs that indicate the infection

O This may be normal for this patient. Rationale Occasionally a keloid, which is an overgrowth of collagenous scar tissue at the site of the wound, forms during the maturation phase. The tissue is elevated, round, and firm. African Americans, dark-complexioned whites, and young women have the highest incidence of keloid formation. This is a normal finding for an African-American patient. There is no need to call the health care provider as this is a normal finding in this situation. Dehiscence would be evident by the wound opening and drainage being present. The extra tissue does not indicate that there is an infection or it is spreading

Three weeks after surgery, an African-American patient comes to the clinic for follow-up. The nurse notices an overgrowth of scar tissue at the site. Which conclusion would be an accurate nursing evaluation of the finding? O This may be normal for this patient. O The wound has dehisced and is now repairing itself. O There is a need to call the health care provider for additional prescriptions. O The patient must be taught to monitor for signs that indicate the infection is spreading

O This may be normal for this patient. Rationale Occasionally a keloid, which is an overgrowth of collagenous scar tissue at the site of the wound, forms during the maturation phase. The tissue is elevated, round, and firm. African Americans, dark-complexioned whites, and young women have the highest incidence of keloid formation. This is a normal finding for an African-American patient. There is no need to call the health care provider as this is a normal finding in this situation. Dehiscence would be evident by the wound opening and drainage being present. The extra tissue does not indicate that there is an infection or it is spreading

While administering oxygen to a patient with respiratory distress, the nurse places a nasal prong into each of the patient's nostrils in the direction that the prongs are curved. Why does the nurse use ensure the prongs are positioned this way? O To prevent drying of the nasal mucosa O To allow maximum expansion of the lungs O To ensure adequate supply of oxygen O To direct the flow of oxygen into the upper respiratory tract

O To direct the flow of oxygen into the upper respiratory tract Rationale Placing a nasal prong into each nostril in the direction that the prongs are curved facilitates direct entry of oxygen into the upper respiratory tract. This ensures improvement in oxygen saturation levels in the patient. Administering oxygen through the nose can cause dryness of the nasal mucosa. This can be prevented by humidification. Administering oxygen through nasal prongs does not facilitate maximum expansion of the lungs. Maximum lung expansion can be achieved by performing deep breathing exercises. The patency of the nasal cannula and the flowmeter ensures adequate supply of oxygen. Prongs are a part of the nasal cannula which enables direct flow of oxygen into the upper respiratory tract.

Why would the nurse dress a wound after cleaning it with warm water? Select all that apply. O To protect the wound O To absorb drainage O To maintain temperature O To reduce discomfort O To eliminate risk of infection

O To protect the wound O To absorb drainage O To reduce discomfort Rationale Dressings are placed on wounds and used as protective coverings. They apply pressure on the wound to control bleeding and absorb any drainage from the wound Dressings stabilize or support surrounding tissue to reduce the discomfort caused by the wound. Dressings do not affect the temperature of the body. Proper wound care helps reduce the likelihood of infection but does not eliminate infection risk.

Which dressing is the nurse likely to place on the reddened skin on an elderly patient? O Transparent dressing O Wet-to-dry dressing O Foam dressing O Binders

O Transparent dressing Rationale A transparent dressing is placed over the reddened area in the elderly patient to prevent skin breakdown. Wet-to-dry dressings are used on infected ulcers to help slough of necrotic tissue through mechanical débridement. Foam dressings are used for stage || ulcers to avoid bacterial contamination. Binders are used to hold dressings in place.

Why does transtracheal oxygen not require a humidification water chamber? O The oxygen is already humidified when delivered. O The method only administers oxygen during inhalation. O Transtracheal oxygen delivery bypasses the nasopharynx. O Oxygen via the transtracheal route is delivered in smaller volumes, so humidification is not needed

O Transtracheal oxygen delivery bypasses the nasopharynx. Rationale Humidification is required during oxygen delivery via nasal or oral routes because of the tendency of the nasopharynx to become dried out during oxygen delivery. Transtracheal oxygen bypasses the nasopharynx and therefore does not require humidification. Transtracheal oxygen is not humidified when delivered. Oxygen delivered via this route is administered throughout the respiratory cycle, not just during inhalation. A patient receiving transtracheal oxygen will require smaller volumes because of the continuous flow, but this does not influence the need for humidification.

A patient had a closed fracture of the arm. Which type of bandage would the nurse apply? O Compress O Gauze O Triangular O Butterfly

O Triangular Rationale The triangular bandage, as the name indicates, is a triangular piece of doth that is useful in the case of bone injuries (fractures). In this case, the nurse can use a triangular bandage to immobilize the fractured bone and to prevent further injury to the arm. A compress bandage is useful to treat bleeding, as with open compound fractures. In this case, this bandage cannot be used because the arm has a closed fracture. In this case, a gauze bandage cannot be used because it is used as a part of wound dressing or while applying pressure. The arm fracture requires that the limb be kept in position until medical assistance arrives. Hence pressure cannot be applied. A butterfly bandage is used to keep the wound closed in the case of deep cuts that require stitches: closed fractures do not involve external wounds, and therefore a butterfly bandage is not used for closed fractures.

Which intervention should the nurse perform for a patient with chronic lung disease presenting with impaired oxygenation caused by inability to clear the airway? Select all that apply. O Allow frequent rest periods. O Use of incentive spirometer O Administer cough expectorants. O Provide paper for communication

O Use of incentive spirometer O Administer cough expectorants. Rationale The nurse would encourage coughing and use of the incentive spirometer and administer cough expectorants to a patient with impaired oxygenation who is not effectively able to clear the airway. Allowing for frequent rest periods is an intervention for a patient with activity intolerance: A patient with compromised verbal communication as a result of a tracheostomy or ventilator use would require an alternative form of communication, such as writing.

Which approach is the most appropriate way to cleanse the wound and surrounding area for a sterile dry dressing change? O Use a sterile swab to soak up any drainage; then apply a clean dressing. O Using an aseptic swab, start on the side of the wound closest to you and apply one stroke per swab. O Using an aseptic swab, start from the incision outward, applying one stroke per swab; then allow to air-dry. O Using an aseptic swab, start at the top of the incision, using the same swab until dirty: then get a clean swab.

O Using an aseptic swab, start from the incision outward, applying one stroke per swab; then allow to air-dry. Rationale Using an aseptic swab and starting from the incision outward helps to remove bacteria from the wound area and prevents contaminating a previously cleaned area. The wound needs to be cleaned with aseptic solution to prevent contamination before application of a dressing. In cleaning the wound, a new swab needs to be used for each stroke to prevent wound contamination. When cleaning a wound, you need to start on the side farthest from you to prevent contaminating an area already cleaned. The wound needs to be cleaned before a clean dressing can be applied. The same swab is not used until it is dirty, only one stroke per swab.

A patient sustains a first-degree burn after being splashed with hot water. Which treatment would be effective for the nurse to provide? Select all that apply. O Soaking the burned area with ice water O Using cold compress to reduce pain O Giving oral rehydration therapy O Applying a sterile dressing on the burn O Using a specific antiseptic solution

O Using cold compress to reduce pain O Applying a sterile dressing on the burn Rationale When hot water is spilled on the skin, it causes first-degree burns. Using a cold compress can reduce the pain caused by the burn. A sterile dressing should be applied to the burn to prevent infection. Soaking the burned area with ice water is to be avoided because it may cause further damage to the tissue by causing frostbite. Oral rehydration therapy is advisable in the case of second and third-degree burns because these burns may result in fluid loss. As first-degree burns result in erythema and pain, but not blisters, application of an antiseptic solution is not necessary

Which action will decrease tissue trauma to the skin surrounding a wound? O Removing the bandage slowly O Using the thumb to retract skin away from the tape O Applying petroleum jelly on the skin around the wound O Soaking the skin with alcohol before removing the bandage

O Using the thumb to retract skin away from the tape Rationale Using the thumb to retract the skin from the tape minimizes skin trauma and decreases patient discomfort. Removing the bandage slowly may not prevent trauma to the skin. Unless prescribed, petroleum jelly is usually not applied to the skin. Alcohol may be irritating to the skin:

Which statement about the effect of the transtracheal method on oxygen flow rate is true? O Usually this method does not affect the oxygen flow rate in any patients. O Usually this method requires less oxygen flow compared with other systems in some patients. O Usually this method requires more oxygen flow compared with other systems in all patients. O Usually the same amount of oxygen flow is achieved as with other systems.

O Usually this method requires less oxygen flow compared with other systems in some patients.

What would the nurse evaluate after completing nasopharyngeal suctioning to determine effectiveness of the procedure? Select all that apply. O Vital signs O Oral cavity O Level of fatigue O Patency of nares O Level of consciousness

O Vital signs O Level of fatigue O Level of consciousness The patient's vital signs, breathing pattern, levels of fatigue and consciousness, and color should be assessed after suctioning to determine the effectiveness of the procedure. The nurse should provide mouth care after suctioning but does not need to assess the oral cavity. The patency of the nares should be determined before the procedure.

The nurse is caring for a patient with asthma who has undergone surgery. Upon assessing the patient's medical history, the nurse finds that the patient is already using a steroid inhaler for maintenance therapy of asthma. The nurse also finds that the health care provider has prescribed vitamin A supplements. For which reason did the health care provider most likely prescribe vitamin A supplements? O Asthma causes vitamin A deficiency O Vitamin A counteracts steroid activity. O Asthma impairs the patient's visual acuity. O Vitamin A eases discomfort when breathing

O Vitamin A counteracts steroid activity. Rationale Patients with asthma use steroids, which hinder the process of wound healing by reducing the inflammatory response. Therefore, to counteract the activity of steroids, vitamin A supplements are prescribed to patients when they undergo surgery. Asthma is not associated with impaired absorption of vitamin A and does not cause vitamin A deficiency. Vitamin A does not affect the function of the upper respiratory tract, so it does not ease discomfort when breathing. Asthma does not cause visual acuity because it does not hinder ocular function.

When should cardiopulmonary resuscitation (CPR) be discontinued? Select all that apply. O When the patient vomits O When licensed medical personnel arrive O When the rescuer cannot continue O When the patient's ribs are broken O When an automated external defibrillator (AED) is available

O When licensed medical personnel arrive O When the rescuer cannot continue O When an automated external defibrillator (AED) is available Rationale Once started, CPR should not be stopped unless the patient becomes responsive licensed medical personnel arrive on the scene, an AED is available, or the rescuer is unable to continue. Broken bones and vomiting may occur doing CPR.

Under which conditions would a nurse avoid giving cardiopulmonary resuscitation (CPR)? Select all that apply. O When the nurse is scared O When the nurse is confused O When the patient is able to breathe O When the nurse is exhausted O In an unsafe place

O When the patient is able to breathe O When the nurse is exhausted O In an unsafe place Rationale Once the nurse starts performing CPR, it is necessary to continue it till the patient is able to breathe. If the nurse is exhausted while performing CPR, then it is necessary to stop because the nurse may suffer from shortness of breath. An unsafe place increases the risk of infection and injury, so CPR should be immediately stopped, and the patient should be evacuated from there. CPR should be resumed after the patient is moved to a safe place. CPR should be stopped after the patient recovers and breathes properly without any assistance. The nurse instructor should motivate students to not be scared or confused while giving CPR because it is an important lifesaving measure.

When assessing a patient's surgical dressing, the nurse finds separation of the wound edges and pale red, watery discharge on the gauze, and the nurse requests an NPO order (receive nothing by mouth). Which condition could be the possible reason for requesting NPO? O Cellulitis O An abscess O Extravasation O Wound dehiscence

O Wound dehiscence Rationale Dehiscence is caused by a rupture of sutures and is characterized by separation of the wound edges as well as pale red discharge on surgical dressings. In this case, to prevent further damage, the patient is instructed to have bed rest, and nothing is given by mouth. Cellulitis is an infection of the skin and is characterized by heat, pain, and erythema. An abscess is a localized infection characterized by the formation of pus and the presence of inflammation around the wound. Excavation is characterized by the passage of fluids into the blood from subcutaneous tissue.

Which action should the nurse take when performing nasotracheal suctioning a patient with a respiratory infection? O Apply a water-soluble lubricant on the catheter. O Use antimicrobial ointment during suctioning O Flush the secretions from the catheter with sterile saline. O Wrap the catheter around the gloved hand, and then remove the glove.

O Wrap the catheter around the gloved hand, and then remove the glove. Rationale After performing the suctioning procedure, the nurse should wrap the suction catheter around the gloved hand and then remove the glove, leaving the catheter contained inside the glove, to prevent transmission of microorganisms. A water-soluble lubricant is used during insertion to facilitate passage of the catheter. Antimicrobial ointment may occlude the catheter and should not be used. Secretions are flushed from the catheter with normal saline to maintain patency if the patient requires additional suctioning

Which precautions does the nurse take to ensure appropriate wound healing of a thigh laceration? Select all that apply. O checks that the surrounding skin is clean and dry O Ensures therapeutic body position is maintained O Ensures dressings and drains are positioned correctly O Provides appropriate nutrition for faster healing O Decreases fluids to decrease the amount of drainage

O checks that the surrounding skin is clean and dry O Ensures therapeutic body position is maintained O Ensures dressings and drains are positioned correctly O Provides appropriate nutrition for faster healing Rationale The nurse takes adequate precautions to ensure appropriate wound healing in the patient. The nurse ensures that the surrounding skin and tissue are clean and dry to avoid bacterial infection. The nurse ensures that the patient is lying in the correct position so that the wound is not disturbed and there is no undue pressure on the wound. The nurse ensures that dressings, compression stockings, and drains are placed correctly to avoid contamination. The nurse also ensures that the patient receives adequate nutrition that helps with faster healing. Fluids should not be decreased; patients should be offered fluid at least every hour.

Which patient statement regarding how to address frequent epistaxis would the nurse correct? O "Ice compresses applied on my nose may help control the bleeding.' O should tilt my head slightly backward to help stop the flow of the blood." O "I should apply steady pressure to the bridge of my nose for 10 to 15 minutes." O "I need to breathe through my mouth when I have a nosebleed, so I can spit out any blood."

O should tilt my head slightly backward to help stop the flow of the blood." Rationale To manage epistaxis, the patient should tilt the head slightly forward. Ice compresses, steady pressure to the bridge of the nose, and breathing through the mouth to expectorate any blood are all appropriate approaches to manage epistaxis.

Types of Wound Drainage Serosanguineous

Pale, red, watery: mixture of serous and sanguineous

Extravasation

Passage or escape into the tissues; usually of blood, serum, or lymph

Exploratory

Provides further data/diagnosis

Postoperative Problems and complications

Respiratory: Airway obstruction, hypoxemia, hypoxia, hypoventilation, atelectasis, pulmonary embolism, PNA What are S/S of PNA? • Cardiovascular: Tachycardia and other arrhythmias, low-high BP decreased cardiac output, DVT, hemorrhage, shock, thrombophlebitis • Gastrointestinal: N/V, paralytic ileus, constipation • Urinary: retention, UTI • Hypothermia or fever •Pain and discomfort Medicate as needed, Tolerance • Wound infection Antibiotics before and after, Nosocomial • Dehiscence, Evisceration

Ms. Burke is transferred to a stretcher and taken to the operating room (OR). The PN assists Ms. Burke off the stretcher and onto the OR table. After general anesthesia is induced, the PN helps position Ms. Burke for surgery. Which nursing diagnosis has the highest priority at this time? O Ineffective protection. O Ineffective tissue perfusion. O Risk for perioperative positioning injury. O Risk for imbalanced body temperature.

Risk for perioperative positioning injury.

deep vein thrombosis (DVT)

Swelling in the affected leg. Rarely, there's swelling in both legs. Pain in your leg. The pain often starts in your calf and can feel like cramping or soreness. Red or discolored skin on the leg. A feeling of warmth in the affected leg. ways to prevent: ambulate, leg stockings, aspirin ways to identify: Ultrasound

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a woman who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. a. How does the Good Samaritan law affect the nurse in the situation?

a. Good Samaritan laws stipulate legal protection for those who give first aid in emergency situations if they follow a reasonable and prudent course of action. Once the nurse initiates any action, there is a moral and legal obligation to continue until qualified help arrives.

39. The nurse is hiking with a group of friends on a cool, windy autumn day. They come across a man who is sitting in the middle of the trail. He is alert, but his speech is slurred. His clothes are wet and muddy and he is not wearing any shoes. Others in the group look around to see if they can find any additional clues about what happened to the man. The nurse starts to assess the man and notes that he is shivering and decides to assess him for additional signs of hypothermia. a. What factors in the scenario helped the nurse to identify that hypothermia might be occurring?

a. The weather is cool and windy. The man's clothes are wet. He is shivering, confused, and his speech is slurred. The absence of shoes suggests that he has discarded them in his confusion, and that loss of the shoes is contributing to heat loss.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. (625, 627, 628) a. What is the purpose of wound irrigation?

a. Wound irrigation is used to clean the wound and remove debris and eschar.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. b. What equipment is needed for irrigation at the patient's bedside?

b. Equipment needed: 35-mL syringe, 19-gauge catheter, sterile solution, basin and/or linen protectors and a clean towel.

39. The nurse is hiking with a group of friends on a cool, windy autumn day. They come across a man who is sitting in the middle of the trail. He is alert, but his speech is slurred. His clothes are wet and muddy and he is not wearing any shoes. Others in the group look around to see if they can find any additional clues about what happened to the man. The nurse starts to assess the man and notes that he is shivering and decides to assess him for additional signs of hypothermia. b. What are the signs and symptoms of hypothermia?

b. Hypothermia is demonstrated by uncontrollable shivering; low body temperature; slow, slurred speech; disorientation; and uncoordinated or decreased muscle movement. The skin may appear mottled and edematous, with general numbness. Pulse is weak and irregular, with depressed respiratory rate. The victim becomes more lethargic, with decreasing level of consciousness, until reflexes are also lost.

28. The nurse is caring for a 72-year-old patient who is being treated for a chronic ulcer on the right lower leg. The patient lives alone. He is diabetic and reports poor vision. The nurse notes that the patient has trouble with fine motor control. He reports that he does his own meal preparation, although he admits that he doesn't make the effort to prepare fresh produce. He is 15 pounds underweight and he has "cut down on his smoking." b. Discuss how the nurse applies knowledge about older adults to help this patient achieve wound healing.

b. The nurse would assess his ability to perform self-care, to reach the wound, and to manipulate the wound dressings. He has trouble with his vision, so the nurse would adapt the teaching (e.g., using color-coding of dressing materials). The nurse will increase time allowed for the skills and repetition of teaching and give small amounts of information at a time. This patient will have a decrease in sensory receptors and a decrease in pain sensation; therefore, he will need to have someone to help him visually inspect the wound on a routine basis. The nurse should ask the patient about his resources and arrange for home health if necessary. This patient needs assistance to increase fluid intake and nutrition. Social services could be contacted about having meals delivered to his house.

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a woman who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. b. What actions should the nurse take first to help this victim?

b. Use simple language and remain calm. Direct a bystander to call 911. Ask the woman for permission to help her and tell her to remain in a supine position. Identify the source of bleeding and apply direct pressure (use the cleanest material available). Once bleeding is controlled continue observations of skin color, temperature, pupil reaction, and neuromuscular status.

There are five general types of open wounds

brasions punctures incisions lacerations avulsions

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a wom-an who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. c. What assessments would lead the nurse to believe the victim is in shock?

c. A victim in shock may have a change in the level of consciousness, skin temperature and color changes, decreased blood pressure, increased pulse rate and respirations, diminished urinary output, muscle weakness or tremors, pupil dilation, nausea, and vomiting.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. c. How is the syringe positioned for the irrigation? ________

c. Syringe is held 1 inch above the wound for irrigation.

39. The nurse is hiking with a group of friends on a cool, windy autumn day. They come across a man who is sitting in the middle of the trail. He is alert, but his speech is slurred. His clothes are wet and muddy and he is not wearing any shoes. Others in the group look around to see if they can find any additional clues about what happened to the man. The nurse starts to assess the man and notes that he is shivering and decides to assess him for additional signs of hypothermia. c. For the conscious victim with hypothermia, what interventions can be provided at the scene?

c. Victim should be moved to a warm environment if possible and wet clothes should be removed and the victim should be covered with warm blankets. For a conscious victim, warm nonalcoholic fluids should be provided. The victim needs medical help as soon as possible.

Bleeding from a wound may occur through one or more of the following three sources

capillaries, veins, and arteries most common sites of arterial bleeding • Brachial (in the medial aspect of the upper arm) • Carotid (on either side of the neck) • Femoral (in the upper thigh and groin) • Radial (in the medial aspect of the lower arm)

Atelectasis

collapsed lung; incomplete expansion of alveoli sound you will hear on collapsed lung: diminished lung sound or abscence of sound.

paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

-otomy

cutting into

38. The nurse comes upon the scene of a motor vehicle accident. Several people are standing around a woman who is lying on the ground in a supine position. She is crying and trying to sit up. The right sleeve of her blouse is torn and blood is pooling on the asphalt underneath her arm. d. What interventions are appropriate for a victim in shock at the scene of an accident?

d. Appropriate interventions for this victim in shock include: control bleeding, maintain airway, maintain supine body position, and avoid hyperextension of the neck to protect against potential neck or spine injuries. Cover the patient. Do not allow anyone to administer food or fluids. Give emotional support.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. d. What is the direction of cleansing?

d. Direction of cleansing is from least to most contaminated.

29. The student nurse is preparing to implement wound irrigation for a patient. The nursing instructor asks the student to answer the following questions before starting the procedure. e. What findings should be immediately reported to the provider?

e. Report evidence of fresh bleeding, sharp increase in pain, retention of irrigant, or signs of shock.

Deep Partial-Thickness Burns

first layer of skin (epidermis), as well as some of the underlying tissue (dermis); scarring from vesicles and infection is possible. Common causes of second-degree burns are severe sunburn, scalding liquids, direct flame, and chemical substances. Healing may take 5 to 21 days.

Intraoperative

period of time during surgery

Palliative

relieving or soothing the symptoms of a disease or disorder without effecting a cure

The following are possible indications of poisonings

respiratory distress; pulmonary edema; bronchospasm; severe nausea, vomiting, or diarrhea; seizures, twitching, or paralysis; decreased level of consciousness or unconsciousness; restlessness, delirium, agitation, or panic; color changes; pale, flushed, or cyanotic skin; signs of burns or edema around the mouth or other areas of the body; pain, tenderness, or cramps on swallowing; characteristic odor on the breath; unusual urine color (red, green, bright yellow, black, bronze); slow, labored breathing or wheezing; abnormal constriction or dilation of pupils; abnormal eye movements, such as nystagmus (constant, involuntary, cyclic movement of the eyeball); skin irritation, erythema, or edema; and shock or cardiac arrest.

elective surgery

surgery that is recommended but can be omitted or delayed without catastrophe

anastomosis

surgical joining of two ducts, vessels, or bowel segments to allow flow from one to another

-ectomy

surgical removal

-plasty

surgical repair

-orrhaphy

suturing or repair

ablation

the removal of a body part or the destruction of its function

Signs and Symptoms of Hypoxia

• Apprehension, anxiety, restlessness • Behavioral changes • Cardiac dysrhythmias • Cyanosis • Decreased ability to concentrate • Decreased level of consciousness • Digital clubbing (with chronic hypoxia) • Dyspnea • Elevated blood pressure • Increased fatigue • Increased pulse rate: As hypoxia advances, bradycardia results, which in turn results in decreased oxygen saturation • Increased rate and depth of respiration: As hypoxia progresses, respirations become shallow and slower, and apnea develops • Pallor • Vertigo

Medical conditions that increase the risk of surgery

• Bleeding disorders (ex: thrombocytopenia) • DM • Coverage? • Chronic pain • Heart disease (Ex: MI, dysrhythmia, CHF PVD) • Obstructive sleep apnea • URI • Liver disease • Fever • Chronic respiratory disease (Ex: emphysema, bronchitis, asthma) • Immunologic D/O (Ex: leukemia, AIDS, bone marrow depression, chemotherapy) • Abuse of street drugs • Tolerance

Complication of Wound Healing Stat Nursing Response

• Call for help • Stay w/ patient • Low-fowler w/ knee bent • Notify physician immediately • Request sterile normal saline dressing & keep the dressing moist • Monitor VS • Prepare for surgery

Discharge from surgery

• Care for the incision • Cover w/ plastic if showering • Follow-up visits • Sutures removed 7-10 days • Medications • Nutrition & drink 6-8 glasses of liquid a day • Activity level • Avoid lifting 6 weeks on major surgeries • Return to work 6-8weeks • Signs/symptoms of complications • When to call the 911

Cardiovascular System

• Check pulse & rhythm • Monitor circulatory: skin color, peripheral pulses, capillary refill & absence of edema, numbness or tingling • Monitor for bleeding • Monitor dysrhythmias • Monitor for signs of thrombophlebitis • Encourage the use of anti embolism stockings or SCD.

several types of common fractures

• Closed fracture: The skin overlying the injury is intact. • Open or compound fractures: An open wound exists over the fracture site. Often the affected bone is visible as it protrudes through the skin. • Comminuted fracture: The bone is shattered into two or more fragments or pieces. • Spiral fracture: Results from a twisting force. • Impacted fracture: Results from trauma that causes the bone ends to jam together. • Greenstick fracture: An incomplete break, occurring most commonly in children because their bones are more pliable. • Compressed fracture: To the vertebrae as the result of pressure. • Depression fracture: Results from blunt trauma to a flat bone, causing an indentation in the bone. • Displaced fracture: Fracture in which the ends of the bones are not in alignment with each other. • Oblique fracture: Break runs diagonally across the bone, at approximately a 45-degree angle to the shaft of the bone.

Jackson-Pratt & Hemovac

• Compress to maintain suction • Empty when 1/2 full

T-Tube Drain

• Drain by gravity until edema subsides • Empty when full • Protect skin from bile drainage • Stool is brown when patent

Musculoskeletal System

• Early ambulation Physical therapy, Premedicate- CNS depressant • Restrictions • Low-Fowler for chest expansion • Turning Q2 hours • Neurovascular assessment Numbness and tingling, strength, cap refill, skin color, temperature

Abductor/Splint/Pillow

• Foam pillow placed between the legs of patients • Hip replacement • Keeps hips abducted • Remove during skin care & physical therapy

Role of the Nurse in Perioperative Nursing

• Identification bracelet • Allergies • NPO status @ least 8 hours: Due to risk of aspiration, no cough reflex • Review checklist • Informed consents • Operative procedure Anesthesia • Blood transfusions? • Laboratory test/radiological tests • EKG • Pregnancy screening • Cardiology clearance. H & P • Remove the client's jewelry, makeup, dentures, hairpins, nail polish, glasses, and prostheses as appropriate. - Document • Vitals signs • Preoperative medications given • Antibiotics • Last voided

Anesthesia

• Local Anesthesia (Ex: tooth removal) • Regional Anesthesia (Ex: cesarian delivery) • Conscious (Moderate) • Sedation (Ex: colonoscopy) • General Anesthesia (Ex: appendectomy, amputation)

Conscious Sedation

• Medication has reduced the patient's sensation • Allows the patient to be relaxed and in twilight sleep • Able to maintain his or her own airway • Able to respond purposefully • Advantages: patient comfort, less risk & ability to wake the patient Used for colonoscopy

Respiratory System

• Monitor VS • Rate 10-30, depth & quality of respirations • Auscultate lungs: atelectasis? • Monitor airway patency • Monitor secretions: the ability to cough? TCDB • Observe chest for symmetry & the use of accessory muscles • Monitor oxygen administration • Encourage TCDB & IS • No shallow breathing can increase the risk for pneumonia

Foley catheter

• Remove when it's not medically necessary • S/S: urgency, frequency, hesitancy, burning sensation, bladder spasms, back pain & nocturia Intervention • >fluid intake 1.5-2L unless contraindicated • Cleanse 1st 6 inches with soap & water shift • Assess for urinary retention once the catheter is removed/unable to urinate • After should void w/in 6-8 hours, contact if pt has not voided • Bladder scan (PVR)

CPR, it should not be discontinued except for the following reasons

• The victim recovers. • An automated external defibrillator (AED) is available and CPR is discontinued before the equipment is applied. • The scene becomes unsafe and evacuation of the victim is necessary. • The rescuer is exhausted and is not able to continue CPR. • Trained medical personnel arrive on the scene and take over CPR. • A licensed health care provider arrives on the scene, has the authority to pronounce the victim dead, and orders CPR to be discontinued.

Incentive Spirometer (helps prevent atelectisis and pnuemonia)

• Upright position • Mouth around the mouthpiece • Inhale slowly • Hold breath for 5 seconds then exhale through pursed lips • Repeat 10x/Q hour • Cough deeply after Turn Cough & Deep Breath • Upright position • Breath deep 3x by inhaling through the nostrils and exhaling slowly through pursed lips • 3rd breath hold 3 seconds, then cough deeply 3xx Splint abdomen • Perform Q1-2 hours -check meter to ensure the patients are performing exercise correctly.

Post-Op Assessment Priorities

•Vital signs •Assess for bleeding •Assess for pain, nausea, and discomforts •Bowel sounds •Gag reflex •Safety interventions •IV fluids •Drainage & Dressing •Foley or assess for bladder distention •Documentation •Physician's orders

Common catheter sizes:

(1) Infant: 6-Fr to 8-Fr (2) Children: 10-Fr to 12-Fr (3) Adults: 12-Fr to 14-Fr

Nasopharyngeal suctioning Approximate length of insertion

(a) Adults: 16 cm (b) Older children: 8 to 12 cm (c) Infants and young children: 4 to 8 cm

Identify the three most common wound complications.

1. Infection 2. Bleeding 3. Dehiscense

15. Which patient is more at risk for wound dehiscence? 1. The patient who smokes 2. The patient who is obese 3. The patient with a history of peripheral vascular disease 4. The patient who is immunocompromised

2. The patient who is obese

Cellulitis

Infection of the skin characterized by heat, pain, erythema, and edema

Nasotracheal suctioning:

Length of insertion: (a) Adults: 20 to 24 cm (b) Older children: 14 to 20 cm (c) Young children and infants: 8 to 14 cm

Which selections indicate an understanding of foods that are rich in vitamin C? Select all that apply. O Orange juice O Lean meat O Kale salad O Summer squash O Bananas

O Orange juice O Kale salad O Summer squash

clinical criteria for brain death

absence of reflex activity, movements, and respiration. The pupils are dilated and fixed.

advantitious

accidental

Evisceration

Protrusion of an internal organ through a wound or surgical incision

Types of Wound Drainage Purulent

Thick, yellow, green, tan, or brown

ostomy

create an opening

lysis

loosening, destruction

11. The health care provider has ordered oxygen at 100% via a nonrebreathing mask. The nurse evaluates that the mask is working properly when making which observation? 1. The reservoir bag collapses 50% when the patient inhales. 2. The reservoir bag collapses completely when the patient inhales. 3. The reservoir bag remains nearly full when the patient inhales. 4. The reservoir bag inflates when the patient inhales.

3. The reservoir bag remains nearly full when the patient inhales.

Match each phase of wound healing with its correct description. Inflammatory (A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination.

Match each term with its definition. Extravasation (A) Passage of escape into the tissues, usually of blood, serum, or lymph (B) Infection of the skin characterized by heat, pain, erythema, and edema (C) Collection of extravasated blood trapped in the tissues or in an organ, resulting from incomplete hemostasis after surgery (D) Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection (E) Protrusion of an internal organ through a wound or surgical incision (F) Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen (G) Separation of a surgical incision or rupture of a wound closure

(A) Passage of escape into the tissues, usually of blood, serum, or lymph

Match each phase of wound healing with its correct description. Maturation (A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(B) Fibroblasts exit the wound and the wound continues to gain strength.

Match each phase of wound healing with its correct description. Reconstruction (A) New cells are produced to fill the wound. This process closes the wound and aids in the prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(C) Collagen is formed and the wound begins to develop a scar.

Match each phase of wound healing with its correct description. Hemostasis (A) New cells are produced to fill the wound. This process closes the wound and aids in prevention of wound contamination. (B) Fibroblasts exit the wound and the wound continues to gain strength. (C) Collagen is formed and the wound begins to develop a scar. (D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

(D) This phase begins at the time of the surgery. Blood products adhere to the site of the wound and begin to reduce blood loss.

Preoperative Teaching

-Provides a smoother, shorter recovery period -Decreases anxiety, increases compliance -TCDB exercises -Diaphragmatic breathing exercises -Incentive spirometry: helps to prevent atelectasis and pneumonia -Leg/feet exercises -SCDs, TED hose (Compression socks): will prevent DVT can also use blood thinners -Pain management -Nause relief measure

closed wound signs and symptons

1) edema usually appears within 24 to 48 hours; (2) discoloration is likely to result from the formation of a hematoma (swelling containing blood): initially the discoloration is blackish blue and then turns to green or yellow within a few days; (3) deformity of the limbs is caused by fractures and dislocations; (4) shock often follows from the force of the trauma; (5) pain and tenderness at the site are possible; and (6) signs of internal bleeding are sometimes present.

11. The nurse is educating a group of hikers about how to treat frostbite. Which statement by one of the hikers indicates the need for further teaching? 1. "I should place the frozen body part in hot water, around 110° to 114°F (43.3° to 45.6°C)." 2. "I can wrap a frozen body part in a warm moist towel." 3. "I should avoid vigorously rubbing the frozen body part." 4. "After the frozen part is warmed, I should wrap it in clean material and elevate it."

1. "I should place the frozen body part in hot water, around 110° to 114°F (43.3° to 45.6°C)." 2. "I can wrap a frozen body part in a warm moist towel." 3. "I should avoid vigorously rubbing the frozen body part." 4. "After the frozen part is warmed, I should wrap it in clean material and elevate it."

Dressing changes

1st are always changed by the doctor Reinforce dressing (if bleeding does not continue) Circle the area

9. Which phrase best describes serous drainage? 1. Fresh bleeding 2. Thick and yellow 3. Clear, watery plasma 4. Beige to brown and foul smelling

3. Clear, watery plasma

The ABC's of breathing

A- Airway: is the airway patent? • Untreated airway obstruction can rapidly lead to cardiac arrest. •B- Breathing: is the breathing sufficient? • Symmetry & effort • C- Circulation: is the circulation sufficient? Capillary refill time and peripheral pulses • Color changes, sweating, and a < LOC are signs of decreased perfusion. • Heart auscultation should be performed • Electrocardiography & BP S - Safety • Bed alarm, bed rails, call light • Nausea/vomiting

34. A person sustains full-thickness burns to both forearms while lighting an outdoor grill. The nurse would intervene if a bystander attempts to perform which action? (417) 1. Removes smoldering clothing 2. Removes victim's wedding ring 3. Applies an antiseptic cream to the burns 4. Places forearms in cold water

Answer 3: No creams, ointments, sprays, or other topical applications should be put on the skin. The skin will have to be assessed and cleaned at the hospital and topical applications can create complications. The other actions are correct.

15. For an unconscious adult victim with a foreign body airway obstruction, what should the nurse do? (401) 1. Apply a series of three quick chest thrusts. 2. Repeat 10 abdominal thrusts and attempt to ventilate. 3. Perform finger sweeps between abdominal thrusts. 4. Visually look for object each time before providing a breath.

Answer 4: The nurse would visually inspect the mouth for an object, open the airway, and attempt to ventilate. If ventilation is not possible, deliver five abdominal thrusts; then look in the mouth for foreign object and repeat sequence until object is dislodged and breathing resumes, or if no spontaneous breathing, initiate CPR.

Adhesion

Band of scar tissue that binds two anatomic surfaces normally separated; most commonly found in the abdomen

Types of Wound Drainage: Sanguineous

Bright red: indicates active bleeding

Types of Wound Drainage Serous

Clear, watery plasma

When performing nasotracheal suctioning in a young child, to which depth (in centimeters) would the nurse insert the catheter to prevent injury? O 7 cm O 9 cm O 12 cm O 16 cm

O 7 cm Rationale The approximate length of insertion for a nasotracheal catheter when suctioning infants and young children ranges from 4 to 8 cm. Suctioning of older children ranges from 8 to 12 cm. For adults, the length of insertion is approximately 16 cm.

Full-Thickness Burns

Full-thickness burns (also classified as third-degree burns) involve destruction of the skin and underlying tissue, including fat, muscle, and bone. The area usually is charred, and healing is difficult.

Risk for contamination in a clean surgical wound

Less than 5%

The signs and symptoms of shock

Level of consciousness Skin: Cool and clammy Blood pressure Pulse Respirations: Increases Urinary output: Decrease Neuromuscular system Gastrointestinal system

In which position would the nurse place a patient who has been admitted with major trauma-related blood loss and is becoming restless and anxious, has a rapid heart rate, is vomiting, and has cool and clammy skin? O side lying O Trendelenburg's O Supine with legs slighter higher than the head O Sitting with head and shoulders elevated and legs stretched out

O side lying Rationale The patient is displaying signs of hypovolemic shock, because the patient is vomiting, he or she should be placed on the side to allow the airway to dear and encourage drainage Trendelenburg's position is no longer used for the treatment of shock. If the patient is not unconscious or vomiting, he or she should be positioned supine, with the legs slightly higher than the head. If the patient is having trouble breathing he or she should be made to sit, with the head and shoulders elevated and legs stretched out

Dehiscence

Separation of a surgical incision or rupture of a wound closure

Shallow Partial-Thickness Burns

The most common first-degree burns are simple sunburns or burns from contact with hot objects. Healing usually is spontaneous or occurs within 2 to 5 days and is uncomplicated. Signs and symptoms include erythema and pain.

tetanus toxoid

The patient should receive the tetanus vaccine every 10 years to maintain immunity.

Which condition in the postoperative patient will indicate that the fluid status is normal? The patient's urinary output is 30 mL/hr. The patient does not have foul-smelling urine. There is normal bowel movement in the patient The patient is able to consume large amounts of fluids.

The patient's urinary output is 30 mL/hr. Rationale A urinary output of 30 mL/hr indicates that the patient's fluid balance is normal. The absence of foul-smelling urine may indicate that the patient does not have infection. The fluid status may or may not be normal in such a patient. A normal bowel movement may indicate that there is normal kidney function in the patient but may not help indicate the fluid status. Inability to consume large amount of fluids indicates a problem in a gastrointestinal function.

The PN then reviews Ms. Burke's preoperative lab test results, which were obtained earlier in the week. Which serum lab value requires follow-up action by the PN? Sodium of 135 mEq/L WBC of 14,000/mm3 Creatinine of 0.8 mg/dL Hemoglobin of 14 g/dL.

WBC of 14,000/mm3 The normal white blood cell (WBC) count is 5,000 to 10,000/mm3. An increase may indicate the onset of an infection, which may be a contraindication to surgery. The PN should notify the charge RN of this abnormal lab value

Cachexia

a condition of physical wasting away due to the loss of weight and muscle mass that occurs in patients with diseases such as advanced cancer or AIDS

28. The nurse is caring for a 72-year-old patient who is being treated for a chronic ulcer on the right lower leg. The patient lives alone. He is diabetic and reports poor vision. The nurse notes that the patient has trouble with fine motor control. He reports that he does his own meal preparation, although he admits that he doesn't make the effort to prepare fresh produce. He is 15 pounds underweight and he has "cut down on his smoking." a. Identify factors that may impair wound healing for this patient.

a. Factors that impair wound healing include age, malnutrition, smoking, drugs, and diabetes mellitus. Patient's ability to care for himself is also not optimal.

Bleeding is almost always possible to control by the three-step measure

direct pressure, elevation, and indirect pressure

Severe blunt trauma can result in________________?

flail chest (two or more ribs fractured in two or more places, resulting in instability in part of the chest wall) with associated hemothorax, pneumothorax, and pulmonary contusion