nur 104 prep u questions 2

a client has: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. what condition would the nurse suspect for this client

hypoxia

when assessing a wound that a client sustained as a result of surgery , she notes well approximated edges and no signs of infection. how will she document this assessment finding

incision

which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen

it determines whether the client is getting enough oxygen

the nurse is teaching a client who is preparing for a left mastectomy due to breast cancer, which teaching about jackson pratt drain will the nurse include

it provides a way to remove drainage and blood from the surgical wound

the nurse is suctioning a clients tracheostomy when the trach becomes dislodged and the nurse is unable to replace it easily. what is the nurses most appropriate response

maintain the clients oxygenation and alert the health care provider immediately

a client with chronic obstructive pulmonary disease (copd) requires low flow oxygen. how will the oxygen be administered

nasal cannula

a nurse is caring for a client with laceration wounds on the knee, she notes that the client is in remodeling phase of wound repair, what describes this phase

period during which the wound undergoes changes and maturation

the nurse is caring for a client with respiratory acidosis, which arterial blood gas data does the nurse anticipate finding

ph less than 7.35, HCO3 high, PaCO2 high

a clients primary care provider has informed the nurse that the client will require thoracentesis. the nurse should suspect that the client has developed which disorder of lung function

pleural effusion

a nurse is caring for a client with atelectasis. when interviewing the client, the nurse would anticipate a history of

pneumonia

when a nurse observes that an older clients skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

poor tissue perfusion

while auscultating a clients chest, the nurse finds crackles in the lower lung base, what condition is this

presence of fluid in the lungs

which activity should the nurse implement to decrease shearing force on a clients stage 11 pressure injury

preventing the client from sliding in bed

the nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. which intervention will she recommend

pursed lip breathing

a client vomits as a nurse is inserting his oropharyngeal airway. what would be the most appropriate intervention

remove the airway, turn the client to the side, and provide mouth suction

a client had a appendectomy for ruptured appendix, and has a open drain left in the wound. health care provider prescribes removal of 2 in of drain every day. which action will the nurse take

reposition the safety pin or clip on the drain

the nurse schedules a pulmonary function test to measure the amount of air left in a clients lungs at maximal expiration. what test does the nurse order

residual volume

collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection, when collecting this lab specimen, which should the nurse take

rotate the swab several times over the wound surface to obtain an adequate specimen

the nurse is demonstrating oxygen administration. which teaching will she include about the humidifier

small water droplets come from this, thus preventing dry mucous membranes

the nurse is caring for a client with a sacral wound, upon assessment the wound is noted to be intact, reddened, and nonblanchable. what stage is this

stage 1 pressure injury

a client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. how would the nurse document this

stage 11

the nurse is caring for a client with a sacral wound, upon assessment the wound is noted to have slough and a bad odor, and it extends into the muscle. what stage is this pressure injury

stage 1V

a nursing instructor is teaching a student nurse about the layers of the skin. which layer should the student nurse understand is a potential source of energy in an undernourished client

subcutaneous tissue

a nurse is caring for a client in a wound care clinic, he has a wound on the right heel that is 2 cm x 4 cm. it is maroon color and looks like a blood blister, which stage is this wound

suspected deep tissue injury

the nurse and client are looking at the heel pressure injury. he asks why does my heel look black, what is the nurses response

that is necrotic tissue, which must be removed to promote healing

the nurse is caring for a penrose drain for a client post abdominal surgery, what nursing action reflects a step in the care of a penrose drain that needs to be shortened every day

the nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors

the nurse is caring for a client who has a pressure injury on the back, what nursing intervention would the nurse perform

the nurse uses positioning devices to maintain posture and distribute weight evenly for the client in a chair

the nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. what is a characteristic of vesicular breath sounds

they are low pitched, soft sounds heard over peripheral lung fields

the nurse is teaching about healing of a large wound by primary intention, what will she include

this is a simple reparative process, your wound edges are right next to each other, very little scar tissue will form

the rn observes the lpn applying a topical gel to a clients surgical wound during a dressing change. what instructions should the rn provide the lpn regarding this

to best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator

what intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples

to splint the area when engaging in activity

a client had a percutaneous tracheostomy (pct), following a motor vehicle accident and has been prescribed oxygen. what delivery device will the nurse select for him

tracheostomy collar

a nurse is caring for a client with dehydration at the health care facility, the client is receiving glucose intravenously, what type of dressing should the nurse use

transparent

t or f, after insertion of a chest tube, fluctuations in the water seal chamber that correspond with inspiration and expiration are an expected and normal finding

true

which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube

using a suction catheter with cm increments on it, insert the suction catheter into the tube no further than an additional 1 cm

the nurse is teaching the client about healing of a minor surgical wound by first intention, what teaching will the nurse include

very little scar tissue will form

during data collection the nurse auscultates low pitched soft sounds over the lungs peripheral fields. what is this called

vesicular

the expert clinician who treats complex wounds, ostomy issues, and incontinence

wound ostomy continence nurse

a client who uses portable home oxygen states i still like to smoke every now and then, what is the appropriate nursing response

you should never smoke when oxygen is in use

a client has a large surgical wound healing by secondary intention, the client asks why is my wound still open. which response is most appropriate

your wound will heal slowly as granulation tissue forms and fills the wound

the nurse is preparing to measure the depth of a clients tunneled wound. which implement should she use to measure the depth accurately

a sterile, flexible applicator moistened with saline

an older adult client has been admitted to the hospital with dehydration, and nurse has inserted a peripheral intravenous line, what type of dressing should the nurse apply over venous access site

a transparent film

a client is admitted to the hospital with shortness of breath, cyanosis, and an oxygen sat of 82 on room air. what action should the nurse do first

apply oxygen

a client recovering abdominal surgery sneezes and screams my insides are hanging out! what is initial nursing intervention

applying sterile dressings with normal saline over the protruding organs and tissue

a client who was prescribed cpap reports nonadherence to treatment. what is the priority intervention

ask the client what factors contribute to nonadherence

a client reports acute pain while negative pressure wound therapy is in place, what should the nurse do first

assess the clients wound and vitals

a nurse is admitting a client to a long term care facility, what should the nurse plan to use to assess the client for risk of pressure injury development

braden scale

the nurse is teaching about pulmonary disorder and deep breathing, client asks why is it important to breath through my nose but exhale through my mouth. what is the response

breathing through your nose first will warm, filter, and humidify the air you are breathing

the nurse is caring for an older adult on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. what is appropriate

check the fit of the oxygen mask

a nurse is cleaning the wound of a client who has been injured by gunshot, which is recommended for this procedure

clean the wound form the top to bottom, and from the center to outside

the nurse is assessing a client with lung cancer. what manifestations may suggest that the client has chronic hypoxia

clubbing

which is not considered a skin appendage

connective tissue

the nurse is monitoring a client with continuous pulse oximetry. what actions are important to obtain accurate results

correlate pulse ox reading with clients heart rate, use forehead sensor if cardiac output is low, determine if client has a pre existing condition affecting oxygen saturation

Upon review of a postoperative patient's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids

the nurse is performing a pressure injury assessment for clients, which client would the nurse consider to be at greatest risk for developing a pressure injury

critical care client

a wound's healing is delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. what is another term for localized dehydration in a wound

desiccation

a child is brought to the clinic, parent states that he has a rash on the face, arms, and legs, and it itches severely. how will the nurse describe the findings

diffuse dermatitis accompanied by pruritus

the nurse is preforming frequent skin assessment at the site where cold therapy has been in place, the nurse notes pallor at the site and the client reports it feels numb, what is the best action by nurse

discontinue the therapy and assess the client

to determine a clients risk for pressure injury development, it's most important for the nurse to ask the client which question

do you exercise incontinence

a nurse using a pulse ox obtains reading of 95%, what is the most appropriate action

document this expected assessment finding

the nurse is preparing to apply a roller bandage to the stump of a client who had a below the knee amputation, what is the nurses first action

elevating and supporting the stump

the client has an abdominal surgery wound that has viscera protruding through the abdominal wound opening. which best describes this

evisceration

a nurse is conducting a respiratory assessment on a 71 yo. which assessment finding should the nurse interpret as abnormal

fine crackles to the bases of the lungs

the nurse is helping a confused client with a large leg wound order dinner, which food item is most appropriate for the nurse to select to promote wound healing

fish

a client has been put on oxygen therapy because of low oxygen levels in the blood. what should the nurse use to regulate the amount of oxygen delivered to the client

flow meter