NUR 304 Exam 3

Which blood cells are known as garbage cells? a. Neutrophils b. Erythrocytes c. Macrophages d. T-lymphocytes

c. Macrophages Macrophages = ingest bacteria, dead cells and debris from wounds Neutrophils= ingest bacteria and small debris Erythrocytes = red blood cells T-lymphocytes = play an important role in immunity

EAQ The nurse checks the distal circulation of a patient with a bandage twice in an 8-hour period. Which part of the nursing process is this? a. Planning b. Evaluation c. Assessment d. Implementation

b. Evaluation

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which change in the wound might have led the nurse to this conclusion? Select all that apply. One, some, or all responses may be correct. a. The wound is filled with granulation tissue. b. There is localized redness, edema, warmth, and throbbing. c. The wound contracts to reduce the area that requires healing. d. There is vasodilation of the surrounding capillaries and exudation of serum. e. There is reepithelialization of the wound surface.

A, C, E a. The wound is filled with granulation tissue. c. The wound contracts to reduce the area that requires healing. e. There is reepithelialization of the wound surface.

Which patient is at risk of a latex allergy? Select all that apply. One, some, or all responses may be correct. a. The patient with a history of spina bifida b. The patient who has diabetes mellitus c. The patient who has an allergy to apples d. The patient who has a spinal cord injury e. The patient who has a urogenital abnormality

A, D, E a. The patient with a history of spina bifida d. The patient who has a spinal cord injury e. The patient who has a urogenital abnormality

Which learning objective would be evaluated in the discharge notes of a patient with coronary artery disease? Select all that apply. One, some, or all responses may be correct. a. Able to state the signs of heart attack b. Understands the importance of exercises to improve heart function c. Verbalizes feelings of anxiety related to limitation of activity imposed by the condition d. Expresses knowledge about the lifestyle modifications required to prevent heart failure e. Able to perform exercises in the correct way that is necessary to improve cardiac function and prevent trauma as well

A, E a. Able to state the signs of heart attack e. Able to perform exercises in the correct way that is necessary to improve cardiac function and prevent trauma as well

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? Select all that apply. A. When there are visitors in the room B. When the patient's pain medications are working C. Just before lunch, when the patient is most awake and alert D. When the patient is talking about current stressors in his or her life E. In the evening, when the patient is tired but the floor is quiet

B, C B. When the patient's pain medications are working C. Just before lunch, when the patient is most awake and alert Rationale: Plan teaching when the patient is most attentive, receptive, alert, and comfortable.

A senior nurse is teaching a group of nursing students to assess skin changes related to development of pressure injuries. Which information should the students keep in mind when assessing dark-skinned patients? Select all that apply. One, some, or all responses may be correct. a. Darker skin is more vulnerable to tans and sunburns. b. Blanching is not a conclusive sign in these patients. c. Differentiate skin color changes with reference to baseline skin tone. d. Mongolian spots may not be present in dark-skinned patients because of sun exposure. e. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

B, C, E b. Blanching is not a conclusive sign in these patients. c. Differentiate skin color changes with reference to baseline skin tone. e. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

What stage is this pressure ulcer? This pressure ulcer is a ___________ extending through three layers of skin.

Stage III

When changing the soiled linen on the bed of a patient who is comatose, the nurse notices an unblanchable, reddened, intact area on her left buttock. The nurse's immediate, initial skin breakdown intervention is to:

Position the patient on her right side

The nurse understands an appropriate method of performing dressing changes on a patient with multiple wounds includes

Change gloves after removing soiled dressing

An immobilized patient in this position prone to skin breakdown in which areas? Select all that apply! (Patient is lying on their left side)

Left side of head including ear Left shoulder Left ilium and greater trochanter Left malleolus (medial and lateral) -A patient in this position is prone to skin breakdown in all areas on the left touching the bed.

Which patient group would be at increased risk of wound dehiscence? Select all that apply. One, some, or all responses may be correct. a. Malnourished patients b. Obese patients c. Young adults d. Female patients e. Patients with wound infections

a. Malnourished patients b. Obese patients e. Patients with wound infections

EAQ Which action would be inappropriate when applying an abdominal binder? a. Placing the patient in a prone position b. Keeping the head of the bed elevated c. Helping the patient roll onto the side d. Instructing the patient to slightly flex the knees

a. Placing the patient in a prone position

Which level of prevention describes the nurse participating at a health fair in the local mall by administering influenza vaccines to senior citizens? a. Primary b. Secondary c. Tertiary d. Quarternary

a. Primary The level of prevention is primary. Primary prevention is aimed at health promotion and includes health education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protections, such as immunization for influenza. Secondary prevention is diagnosing and treating an illness and limiting disabilities; it does not include giving vaccines. Tertiary prevention includes restoration and rehabilitation; it does not focus on vaccine administration. There are only three levels of prevention; the quaternary level does not exist.

Purulent would drainage is? a. Clear and watery b. Thick, yellow, green, tan or brown c. Bright red d. Pale, pink and water with a mixture of clear and red fluid

b. Thick, yellow, green, tan or brown Serous = clear and watery Sanguineous = bright red Serosanguineous = pale, pink and watery mixture of clear and red fluid

Which nutrient supports healing by promoting wound closure? a. Protein b. Vitamin A c. Vitamin C d. Zinc

b. Vitamin A Protein & Vitamin C = promote collagen formation and immunity Zinc =.promote collagen formation and protein synthesis

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply. One, some, or all responses may be correct. a. Skin tag b. Bedsore c. Skin wound d. Pressure sore e. Pressure ulcer f. Decubitus ulcer

b, d, e, f b. Bedsore d. Pressure sore e. Pressure ulcer f. Decubitus ulcer

The nurse determines that after teaching first grade children about healthy nutrition, the students will be able to name three examples of foods that are fruits. Which phrase does this describe? a. A teaching plan b. A learning objective c. Reinforcement of content d. Enhancing the children's self-efficacy

b. A learning objective

The edges of a patient's surgical incision are approximated, and no drainage is noted. Which type of healing does this signify? a. Granulation b. Primary intention c. Tertiary intention d. Secondary intention

b. Primary intention Primary intention is the use of sutures or other wound closures to approximate the edges of an incision or a clean laceration. This reduces the risk of infection. Granulation tissue is formed to fill the gap between the edges of a wound and eventually fills in the surface of the wound. Healing by tertiary intention occurs with injuries and wounds and results in scar formation. Secondary intention wound healing occurs more slowly than primary intention.

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? a. Low-air-loss surface b. Nonpowered surface c. Lateral rotation surface d. Air-fluidized bed

c. Lateral rotation surface Low-air-loss and non powered support surfaces help in preventing and treating skin breakdown Air-fluidized bed support surface prevents skin breakdown and may also be used to protect newly flapped or grafted surgical sites.

A dark-skinned hospitalized patient is bedridden. While examining the patient, which characteristic will determine that the patient has developed a pressure injury? Select all that apply. One, some, or all responses may be correct. a. The skin color remains unchanged on application of pressure. b. The localized area of the skin appears purple. c. There is blanching of the skin. d. The area of the skin with a pressure injury appears darker. e. As the tissue changes color, the intact skin becomes warm.

A, B a. The skin color remains unchanged on application of pressure. b. The localized area of the skin appears purple.

Which statement is true regarding the hemostasis phase of blood clotting? Select all that apply. a. Clots form a fibrin matrix. b. Blood vessels constrict, and platelets gather. c. Blood loss is controlled, establishing bacterial control. d. Epithelial cells migrate from a wound's edges to resurface. e. Collagen fibers go through remodeling before assuming a normal appearance.

A, B, C a. Clots form a fibrin matrix. b. Blood vessels constrict, and platelets gather. c. Blood loss is controlled, establishing bacterial control.

The nurse is preparing a diet plan for a patient admitted to a wound care unit. After the nurse explains the diet plan to the patient, the patient asks the reason for an increase in the intake of citrus fruits. Which information would the nurse share with the patient? Select all that apply. One, some, or all responses may be correct. a. Citrus fruits have antioxidant properties. b. These fruits help in collagen synthesis. c. They help in protein synthesis. d. The fruits provide an essential fluid environment. e. Citrus provides fuel for cell energy.

A, B, E a. Citrus fruits have antioxidant properties. b. These fruits help in collagen synthesis. e. Citrus provides fuel for cell energy.

A 36-year-old man is admitted to the hospital after a motor vehicle accident. He has sustained multiple injuries to the forehead, right elbow, and left knee. An x-ray of the knee shows a hairline fracture of the left patella. When giving cold therapy to this patient, which factor would the nurse keep in mind? Select all that apply. One, some, or all responses may be correct. a. Patient has to adjust the temperature settings whenever required. b. Patient should be informed that a change in sensation is normal. c. Patient should be within the reach of the nurse call system. d. Position of the patient should allow him to move away from the cold source. e. Patient should remove the application if he becomes uncomfortable.

B, C, D b. Patient should be informed that a change in sensation is normal. c. Patient should be within the reach of the nurse call system. d. Position of the patient should allow him to move away from the cold source.

In the context of teaching an infant's mother about the child's developmental capacity, which statement(s) by the nurse would be most appropriate? Select all that apply. A. "Encourage learning through the use of pictures." B. "Keep consistent routines of feeding and bathing." C. "Use role play and imitation to make learning fun." D. "Speak softly to convey a sense of trust to the baby." E. "Use simple words to promote the child's understanding."

B, D B. "Keep consistent routines of feeding and bathing." D. "Speak softly to convey a sense of trust to the baby."

What are two risk assessment tools used to evaluate a patient's risk for skin problems? Choose all that apply.

Braden scale Norton scale

Which condition may increase the risk of infection in a patient after surgery? Select all that apply. One, some, or all responses may be correct. a. Dementia b. Atelectasis c. Chemotherapy d. Diabetes mellitus e. Bone marrow alterations

C, D, E c. Chemotherapy d. Diabetes mellitus e. Bone marrow alterations chemotherapy or bone marrow alterations → Immunodeficiecy may increase the risk of infection in a patient after surgery. Diabetes mellitus → may be more susceptible to infection because of hypergiycemia. Dementia and atelectasis do not compromise a patient's immune system and increase the incidence of infection

The nurse is caring for older-adult patients in a nursing home. The nurse understands that older adults are susceptible to development of pressure injuries and other wounds. Which factor makes older adults more vulnerable to developing pressure injuries? Select all that apply. One, some, or all responses may be correct. a. Increased skin elasticity b. Increased inflammatory response c. Increase of the hypodermis in size with age d. Diminished inflammatory response e. Loss of collagen and thinning of muscles

D, E d. Diminished inflammatory response e. Loss of collagen and thinning of muscles

Which statement by the nurse would make the patient pay more attention to the care being provided? A. "You should learn about the medical tests." B. "You should ask questions if you do not understand something." C. "You should ask a trusted family member to be your advocate." D. "You should make sure that you are getting the right treatment from the right health care professional."

D. "You should make sure that you are getting the right treatment from the right health care professional."

A patient with limited mobility presents with an ischial wound that extends to the epidermis. When documenting the depth of the wound, how would the nurse classify it?

Partial-thickness wound - An ischial wound that extends to the epidermis involves only partial thickness.

What does the Braden Scale evaluate?

Risk factors that places the patient at risk for skin breakdown.

Choose the appropriate descriptions of the pressure ulcer shown. Pick all that apply.

Skin surrounding ulcer is erythematous Sacral Ulcer Unstageable

What stage is this pressure ulcer? This pressure ulcer is a ___________ because it creates a crater or dip in skin contour which is full thickness

Stage III

What stage is this pressure ulcer?

Stage IV - This is a stage-4 pressure ulcer extending through all four layers of the skin.

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?

Stage IV pressure ulcer, healing - Stage IV pressure ulcer and healing because the stage of the ulcer should not change.

Which model that consists of five stages of health behavior change would the nurse usè to manage a patient who needs to exercise? a. Health belief model b. Holistic health model c. Transtheoretical model d. Maslow's hierarchy of needs

The Transtheoretical Model of Change describes the five stages of health behavior change that a patient undergoes while trying to change a behavior (in this case, exercising). The health belief model helps the nurse understand the patient's beliefs, behaviors, and perceptions of illness and plans to provide an appropriate intervention; it does not have five stages. While the holistic health model is an approach in which the nurse creates conditions to promote the patient's fitness and well-being, it does not have five stages. Maslovt's hierarchy of needs helps nurses understand the importance of and relationships among basic human needs; it does not focus on changing health behaviors.

What stage is this pressure ulcer? This pressure ulcer is _____________ due to the black eschar and the puralent dishcharge preventing the provider from determining the depth of the ulcer.

Unstageable

A patient hospitalized in a long-term rehabilitation facility is immobile and has a pressure ulcer on her coccyx. The area is covered with 100% black eschar. What would the nurse identify this as?

Unstageable pressure ulcer

This patient is a quadriplegic and needs total nursing care, which areas of the skin are prone to skin breakdown in this position? Select all that apply!

Vertebrae Sacrum Heels Pelvic - The bony areas touching the surface of the chair are prone to skin breakdown in this position, vertebrae, sacrum, heels and a portion of pelvic girdle along the lower back.

After interacting with the wife of a patient who has terminal cancer, the nurse anticipates that the patient is experiencing denial. Which statement by the wife supports the nurse's conclusion? a. "My husband wants to get another opinion, even after a clear diagnosis." b. "My husband is blaming the health care provider for his condition." c. "My husband is not showing any interest in his favorite games and movies." d. "My husband says he wants to spend as much time as possible with the family.

a. "My husband wants to get another opinion, even after a clear diagnosis."

Which stage of pressure injury can be dressed with transparent or hydrocolloid dressing? a. 1 b. 2 c. 3 d. 4

a. 1 Stage 1 A stage 1 pressure injury is an intact injury that can be dressed with a transparent or hydrocolloid dressing. Stage 2 Composite film, hydrocolloid, and hydrogel dressings are appropriate for stage 2 pressure injuries. Stage 3 Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings are appropriate for stage 3 pressure injuries. Stage 4 Hydrogel covered with foam, calcium alginate, and gauze dressings are appropriate for stage 4 pressure injuries.

Which stage of pressure injury is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? a. 1 b. 2 c. 3 d. 4

a. 1 Stage 1 pressure injury does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or may feel soft if the blood flow is compromised. The patient may report pain in the area. Stages 2, 3, and 4 all have breaks in the skin at different degrees of depth.

Which domain of learning occurs when a patient is both verbally and nonverbally participating in group activities? a. Affective b. Cognitive c. Attentional d. Psychomotor

a. Affective affective learning = exhibit good responding behavior, verbal and nonverbal responses in group activities cognitive learning = acquiring any knowledge about new factors or new facilities using his or her mental or muscular activity to acquire a skill = psychomotor development

Which finding is characteristic of a stage 3 pressure injury? Select all that apply. One, some, or all responses may be correct. a. It has full-thickness skin loss. b. The subcutaneous fat may be visible. c. The wound may present as an open, serum-filled blister. d. There may be a reddish-pink wound bed without slough. e. Neither the bone, tendon, nor muscle is exposed.

a. It has full-thickness skin loss. b. The subcutaneous fat may be visible. e. Neither the bone, tendon, nor muscle is exposed.

The nurse understands that a protein deficiency can adversely affect wound healing. Which parameter should be measured to determine this deficiency in the patient? Select all that apply. One, some, or all responses may be correct. a. Serum albumin b. Serum transferrin c. Serum prealbumin d. Hemoglobin levels e. Serum creatinine levels

a. Serum albumin b. Serum transferrin c. Serum prealbumin

Which characteristic differentiates a friction injury from a shear injury? Select all that apply. One, some, or all responses may be correct. a. Type of force b. Location of the injury c. Involvement of tissue d. Condition of the patient e. Presentation of the injury

a. Type of force c. Involvement of tissue e. Presentation of the injury

EAQ Which closures are used to secure an abdominal binder? a. Velcro strips b. Metal staples c. Adhesive tapes d. Montgomery ties

a. Velcro strips Velcro strips = secure an abdominal binder Metal staples = may be used to close an incision Adhesive tape= may be used to secure dressings Montgomery ties = may be used to secure a dressing that requires frequent changing

EAQ Which responsibility can be delegated to an assistive personnel (AP) during would care? Select all that apply. One, some, or all responses may be correct. a. Assessing the wound b. Applying an elastic bandage c. Reporting any movement restrictions of the patient d. Assessing circulation to the extremity with bandage e. Assisting the patient in passive exercises if pain increases

b, c, d b. Applying an elastic bandage c. Reporting any movement restrictions of the patient d. Assessing circulation to the extremity with bandage

EAQ Which task in applying an abdominal binder may be delegated to assertive personnel (AP)? Select all that apply. One, some, or all responses may be correct. a. Assessing the wound b. Applying the abdominal binder itself c. Reporting wound drainage d. Removing the binder at specified intervals e. Assessing the patient's ability to move independently

b, c, d b. Applying the abdominal binder itself c. Reporting wound drainage d. Removing the binder at specified intervals

Which response would the nurse make to help a patient move through the stages of change when the patient states, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" a. "Walking is okay, but I really think running is better because it burns more calories." b. "Yes, walking is gregt exercise. Do you think you could go for a 5-minute walk next week?" c. "Yes, I want you to begin walking. Walk for 30 minutes every day, and eat more fruits and vegetables." d. "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes walking if you are going to do any good."

b. "Yes, walking is gregt exercise. Do you think you could go for a 5-minute walk next week?"

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development? a. Gaskin's Nursing Assessment of Skin Color (GNASC) tool b. Braden Scale c. Bates-]ènsen Wound Assessment Tool (BWAT) d. Wound, Ostomy, and Continence Nurses Society (WOCN) scale

b. Braden Scale Braden Scale= used tool for risk assessment of pressure injury development and is composed of six subscales that are moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. GNASC tool = used to assess stage 1 pressure injuries in patients with dark skin tone. BWAT = used to assess the wound status. WOCN = does not provide any measurement or assessment tools.

According to the World Health Organization (WHO), what is the definition of health? a. Being free from illness or injury b. Complete physical, mental, and social well-being c. Absence of signs and symptoms with normal laboratory reports d. Total absence of all diseases, disorders, and syndromes

b. Complete physical, mental, and social well-being

EAQ For which reason would the nurse form a cuff on a waterproof bag and place it near the bed while performing wound irrigation? a. Protecting the bedding b. Holding the contaminated dressings to be discarded c. Reducing the transmission of microorganisms d. Protecting the nurse from splashes of blood and body fluids

b. Holding the contaminated dressings to be discarded Cuffing a waterproof bag allows for a large opening, permitting placement of contaminated dressings without the nurse having to touch the refuse bag itself. Bedding may be protected by placing padding or an extra towel on the bed. Transmission of microorganisms is reduced by the nurse wearing sterile gloves.

Which term describes people reacting in different ways because of attitudes about illness? a. Health belief b. Illness behavior c. Health promotion d. Illness prevention

b. Illness behavior

Which criteria does the Braden Scale evaluate? a. Skin integrity at bony prominences, including any wounds b. Risk factors that place the patient at risk of pressure injury c. The amount of repositioning that the patient can tolerate d. The factors that place the patient at risk of poor wound healing

b. Risk factors that place the patient at risk of pressure injury

While assessing a wound, the nurse notes red-tinged, watery drainage. What type of drainage will the nurse document this as? a. Sanguineous b. Serosanguineous c. Serous d. Purosanguineous

b. Serosanguineous

Which statement regarding the skin is true? a. The stratum corneum prevents entrance of topical medications. b. The dermis and the inner layer of the skin provide tensile strength. c. The basal layer of the epidermis is responsible for collagen formation. d. The three layers of the skin are the epidermis, dermis, and endodermis.

b. The dermis and the inner layer of the skin provide tensile strength. -The dermis and the inner layer of the skin provide tensile strength and mechanical Support to the muscles, bones, and inner organs. - Stratum corneum promotes, not prevents, absorption of topical medications. - Fibroblasts, not the basal layer of the epidermis, are responsible for collagen formation. - The skin has two layers only: the epidermis and the dermis.

EAQ Which patient may require a pulsatile high-pressure lavage for wound irrigation? a. A patient who has graft sites b. The person who has a necrotic wound c. One who has exposed blood vessels d. The individual who has exposed muscle, tendon, or bone

b. The person who has a necrotic wound

Based on the Transtheoretical Model of Change, which response would a nurse make to a patient who states, "Me, exercise? I haven't done that since junior high gym class, and I hated it then"? a. "I don't exercise either because I hate it, too, and I don't think it's helpful." b. "I want you to walk 3 miles four times a week, and I'll see you in 1 month." c. "I understand. Can you think of one reason why being more active would be helpful for you?" d. "I would like you to ride your bike three times this week and then four times by next week."

c. "I understand. Can you think of one reason why being more active would be helpful for you?"

EAQ Which item would be required for a wound irrigation delivery system? a. 25- mL syringe b. Capacity for pressure of 18 psi c. 19-gauge angiocatheter d. 2% normal saline solution

c. 19-gauge angiocatheter A 35-ml, not 25 mL, syringe is used for irrigation delivery system. The pressure settings on the irrigation delivery system should range from 8 to 15 psi; 18 psi is too high. Normal saline solution may be used, but other irrigation solutions are preferred.

Which intervention is classified as an active strategy of health promotion? a. Fortification of milk with vitamin D b. Fluoridation of municipal drinking water c. A weight reduction program for obese people d. Fortification of cereals with vitamin A

c. A weight reduction program for obese people

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? a. Pallor or molting b. Dark red or purple discoloration c. Blanchable erythema d. Nonblanchable erythema

c. Blanchable erythema Blanchable erythema= early indication of pressure that resolves without tissue loss if the pressure is removed. Pallor or molting = a sign of persistent hypoxia. Dark red or purple discoloration = may indicate potential damage to blood vessels and tissue. Nonblanchable erythema = a sign of a stage 1 pressure injury.

The nurse tells the health care provider that a patient scheduled for surgery is receiving active radiation therapy. The patient is at risk of which condition? a. Shock b. Arrhythmias c. Poor wound healing d. Confusion and delirium

c. Poor wound healing Radiation thins the layers of the skin, destroys collagen, and impairs tissue perfusion → putts the patient at risk of poor wound healing. Blood loss→ increases the risk of shock. Arrhythmias → may occur in a patient who has a fluid and electrolyte imbalance. Confusion and delirium → common in older adults after they have been administered anesthesia.

Which role does vitamin A play in wound healing? a. Quickens fibroplasia b. Acts as an antioxidant c. Promotes wound closure d. Acts as immune function

c. Promotes wound closure Vitamin A promotes epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. Protein quickens fibroplasia and acts as immune function. Vitamin C acts as an antioxidant.

Which level of prevention describes a patient who experienced a myocardial infarction (heart attack) 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center? a. Primary b. Secondary c. Tertiary d. Quaternary

c. Tertiary

Which nutrient is an antioxidant that promotes wound healing? a. Protein b. Vitamin A c. Vitamin C d. Zinc

c. Vitamin C Vitamin C= antioxidant that is useful in wound healing by promoting collagen synthesis, capillary wall integrity, fibroblast function, and immunity. Zinc = essential nutrient that promotes collagen formation, protein synthesis, and cell membrane and host defenses. Proteins = support healing with fibroplasia, angiogenesis, collagen formation, and wund remodeling while boosting immunity. Vitamin A = supports healing with epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation.

Which statement made by a young adult patient with an amputation indicates a problem with body image? a. "I just don't have any energy to get out of bed in the morning. b. "I've been attending church regularly with my wife since I got out of the hospital." c. "My wife has taken over paying the bills since I've been in the hospital." d. "I don't go out very much because everyone stares at me."

d. "I don't go out very much because everyone stares at me."

EAQ Which color would be sanguineous drainage on a patient's dressing? a. Pink b. Clear c. Yellow d. Bright red

d. Bright red Sanguineous drainage = fresh bleeding and is bright red Serosanguineous drainage = is pink Serous draining = is clear Purulent drainage = is thick and yellow

EAQ Which function would pressure dressings perform when applied with an elastic bandage? a. Adheres to any areas of undamaged skin b. Wicks away any excess wound exudate c. Exerts localized upward pressure over the bleeding site d. Eliminates the dead space in underlying tissues to allow healing

d. Eliminates the dead space in underlying tissues to allow healing Pressure dressings = Eliminates the dead space in underlying tissues to allow healing Pressure dressings = Exerts localized DOWNWARD, not upward, pressure over the bleeding site Transparent film dressing = Adheres to any areas of undamaged skin Gauze sponges = Wicks away any excess wound exudate

EAQ Which items would be required for wound irrigation? a. Clips b. Bandages c. Safety pins d. Gauze dressing supplies

d. Gauze dressing supplies Clips, safety pins and bandages are required for applying elastic bandages, not wound irrigation.

In supine position, which site has the least risk of a pressure injury? a. Ischium b. Elbow c. Occipital bone d. Medial knee

d. Medial knee

EAQ Which nursing action would be appropriate when the skin under the elastic bandage breaks? a. Assess the pulse b. Palpate the extremity c. Reapply the bandage on the same area with less pressure d. Reapply the bandage at a different area with less pressure

d. Reapply the bandage at a different area with less pressure

While assessing a patient who has a pressure injury, the nurse finds black wound tissue. In which stage is this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Unstageable

d. Unstageable Stage 1= localized nonblanchable redness over intact skin Stage 2= partial-intact skin Stage 3= full-thickness skin loss to the extent that subcutaneous fat may be visible

While providing perioperative care to a 78-year-old patient, the nurse instructs the patient to ambulate and then sit in the chair every 2 hours following surgery. Which rationale explains this, nursing intervention? Select all that apply. One, some, or all responses may be correct. a. To reduce the risk of diabetes b. To maintain optimal residual capacity of the lungs c. To decrease gastric reflux and indigestion d. To reduce the risk of pressure ulcers e. To maintain a healthy blood pressure level

B, C, D b. To maintain optimal residual capacity of the lungs c. To decrease gastric reflux and indigestion d. To reduce the risk of pressure ulcers

2. Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.) 1. "Are you experiencing any pain?" 2. "Do you exercise on a daily basis?" 3. "When do you regularly take your medications?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"

1. "Are you experiencing any pain?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"

9. What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1. Debridement

10. A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient's pain report. Unmanaged surgical pain can lead to which of the following problems? (Select all that apply.) 1. Delayed ambulation 2. Reduced ventilation 3. Catheter-associated urinary tract infection 4. Retained pulmonary secretions 5. Reduced appetite

1. Delayed ambulation 2. Reduced ventilation 4. Retained pulmonary secretions 5. Reduced appetite

7. Which is the best intervention the nurse should implement to promote bowel function? 1. Early ambulation 2. Deep-breathing exercises 3. Repositioning on the left side 4. Lowering the head of the patient's bed

1. Early ambulation

6. A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority? 1. Elevate the head of the patient's bed. 2. Give ordered oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.

1. Elevate the head of the patient's bed.

5. Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

Arrange the phases of wound healing in the correct order. a. Inflammatory phase b. Remodeling c. Hemostasis d. Proliferative phase

1. Hemostasis 2. Inflammatory phase 3. Proliferative phase 4. Remodeling hemostasis phase= constriction of the injured blood vessels and aggregation of platelets to stop bleeding. The blood clots form a matrix for further tissue repair. inflammatory phase = involves secretion of histamine by damaged tissue and mast cells. The surrounding capillaries dilate and the serum rich in white blood cells reaches the wound. The release of growth factors àttracts fibroblasts that synthesize collagen. This phase establishes a clean wound bed. proliferative phase = proliferation of blood vessels and epithelialization with contraction of wound remodeling phase = the collagen scar continues to reorganize and gain strength for several months.

9. A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.) 1. Notify surgeon. 2. Maintain the intravenous fluid infusion. 3. Provide 2 L/min of oxygen via nasal cannula. 4. Monitor the patient's vital signs every 5 to 10 minutes. 5. Reinforce the dressing.

1. Notify surgeon 5. Reinforce the dressing

3. After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1. Notify the health care provider. 4. Cover the area with sterile, saline-soaked towels immediately.

1. The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 5 feet, 2 inches in height. Which factors increase this patient's risk for surgical complications? (Select all that apply.) 1. Obesity 2. Prolonged bleeding time 3. Delayed wound healing 4. Ineffective vital capacity 5. Immobility secondary to height

1. Obesity 3. Delayed wound healing

8. Match the nursing interventions on the left with the complication to be prevented on the right. An intervention may apply to more than one complication. Nursing Intervention 1. Offering glasses or hearing aid 2. Early ambulation 3. Strict aseptic technique 4. Deep breathing exercise 5. Hydration Complication a. Deep vein thrombosis b. Wound infection c. Delirium d. Atelectasis

1. Offering glasses or hearing aid > c. Delirium 2. Early ambulation > a. Deep vein thrombosis + c. Delirium 3. Strict aseptic technique > b. Wound infection 4. Deep breathing exercise > d. Atelectasis 5. Hydration > a. Deep vein thrombosis + d. Atelectasis

Arrange the stages of change that a patient with stress goes through, resulting in finally attending a relaxation class. a. Precomtemplation b. Preparation c. Action d. Comtemplation

1. Precomtemplation 2. Comtemplation 3. Preparation 4. Action

2. Match the pressure injury stages with the correct definition. 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. c. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. d. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

1. Stage 1 - b Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. 2. Stage 2- a Partial-thickness loss of skin with exposed dermis. 3. Stage 3- d Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. 4. Stage 4- c Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.

5. An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? (Select all that apply.) 1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 3. Increased laryngeal reflexes 4. Reduced blood flow to kidneys 5. Increased cholinergic transmission

1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 4. Reduced blood flow to kidneys

8. When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area

1. To relieve edema 3. To improve blood flow to an injured part

10. Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device (e.g., transfer board) 3. Have head of bed flat when repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine

7. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Providing support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision

3. Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? (Select all that apply.) 1. Documenting assessment findings in the medical record 2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 4. Giving specific information to a transport technician 5. Listening to the OR nurse's questions

2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 5. Listening to the OR nurse's questions

4. Which postoperative intervention best prevents atelectasis? 1. Use of intermittent compression stockings 2. Heel-toe flexion 3. Use of the incentive spirometer 4. Abdominal splinting when coughing

3. Use of the incentive spirometer

6. Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4. A dressing that forms a gel that interacts with the wound surface

1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4. Place biohazard bag near bed. 3. Fill syringe with irrigation fluid. 2. Attach 19-gauge angiocatheter to syringe. 5. Position angiocatheter over wound. 1. Use slow, continuous pressure to irrigate wound.

While assessing a wound, the nurse notes red-tinged, watery drainage. What type of drainage will the nurse document this as?

Serosanguineous - Serosanguineous is considered red-tinged, watery drainage from a wound.

What stage is this pressure ulcer? This is _____________ pressure ulcer because the skin is not broken

Stage 1

What sage is this pressure ulcer? When assessing this picture notice that the skin is not broken and is considered a _____________ pressure ulcer.

Stage I

A 25 year old patient suffers a spinal cord injury and paraplegia due to a motor vehicle accident. The nurse recognizes the patient is at risk for pressure ulcers due to which of the following factors? Pick all that apply.

Impaired cognition Pressure Impaired sensation Immobility