NUR200

The nurse is educating an adult client who weighs 132 lbs on their new prescription for a six-month regimen of isoniazid to treat latent tuberculosis. The prescription reads "Isoniazid 5 mg/kg PO daily, not to exceed 300 mg per dose." Isoniazid is available in tablets containing 100 mg. How many tablet(s) should the nurse instruct the client to take per dose? Use a leading zero if it applies. Do not use a trailing zero. Any rounding should be completed at the end of the calculation. The answer must be numeric only. Do not add any units of measurement.

3

The nurse learns in a report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply. A. Dermis B. Subcutaneous tissue C. Muscle D. Eschar

A, B

The home-health nurse learns that an elderly client isn't able to get to the grocery store. They don't have much food in their home, and they eat and drink little. Most of their time is spent sitting in their chair watching television, often not realizing that they have had bladder leakage. Which nursing actions would be implemented to reduce the risk of this client developing a pressure injury? Select all that apply. A. Encourage the client to wear incontinence products B. Help the client to get out of the chair every 2 hours C. Change the client's clothing frequently D. Promote intake of green tea throughout the day

A, B, C

Why is an accurate description of the location of a wound important? Select all that apply. A. Influences the rate of healing B. Provides clues to wound etiology C. Affects client movement and mobility D. Determines the appropriate treatment choice E. Will affect the frequency of dressing changes

A, B, C, D

A patient who had surgery is receiving patient-controlled analgesia (PCA). Which statement by the patient indicates an understanding of PCA use? A. "I will be the only one that presses the button." B. "I will use this button to help me sleep better." C. "I will not push the button too many times, so I won't get overdosed." D. "I will need to be careful not to roll over the button when I sleep."

A. "I will be the only one that presses the button."

The nurse assesses assigned clients and determines which of the following has the highest risk for altered skin integrity? A. An adolescent in bed with influenza, having periods of high fever and diaphoresis B. A middle-aged adult with metabolic syndrome taking antihypertensives C. An older client diagnosed with well-controlled type 2 diabetes D. A young adult in traction who has a low-protein diet and dehydration

A. An adolescent in bed with influenza, having periods of high fever and diaphoresis

A 58 year old female patient is 6 weeks post op from a complete hysterectomy due to ovarian cancer. The client returned home 5 hours ago from her healthcare provider visit in which all the staples from the transverse abdominal incision were removed. The home health nurse opens the client's bedroom to find the patient sitting in a chair, disoriented and staring at the wall. Upon lifting the client's gown, the incision is found open with intestines protruding out. Match the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the client's care at this time. A. Place abdominal binder on client B. Have patient walk to the nurse car C. Call emergency services D. Teach client about wound care E. Cover with sterile saline soaked gauze F. Push abdominal contents back in

A. Contraindicated B. Contraindicated C. Indicated D. Nonessential E. Indiacted F. Contraindiacted

The nurse is providing care to the client who is 2 days post-cerebrovascular accident with residual decreased left-sided mobility. During the assessment, the nurse discovers a stage 1 pressure area on the client's left heel. What is the initial treatment for this pressure ulcer? A. Elevation of the left heel off the bed B. Debridement to the left heel C. Antibiotic treatment for 2 weeks D. Normal saline irrigation of the ulcer daily

A. Elevation of the left heel off the bed

A client has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage 1 pressure ulcer. What would be the most important treatment for this client? A. Frequent turn schedule B. Enzymatic debridement C. Transparent film dressing D. Hydrogel

A. Frequent turn schedule

The patient reports pain after surgery, ranking it 6 on a scale of 1 to 10. The patient tells the nurse, "I don't want to be all doped up. My family is coming to visit and I want to be alert enough to visit with them." Which medication would most likely be effective for postoperative pain relief without excessive sedation? A. Ibuprofen PO B. Fentanyl IV C. Morphine IV D. Hydrocodone PO

A. Ibuprofen PO

The nurse is developing a plan of care for the client with a stage 4 pressure injury. What would an appropriate goal/outcome be? A. Pressure at the pressure injury site will be minimized. B. Wound will close with no evidence of infection within 6 weeks. C. Client skin will remain intact throughout hospitalization. D. Clients will be repositioned at least every 2 hours.

A. Pressure at the pressure injury site will be minimized.

The nurse is assessing the client's wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse's note? A. Proliferative B. Inflammation C. Hemostasis D. Maturation

A. Proliferative

Match the image with the correct term. A, B, C, D

A. Serous B. Serosanguineous C. Sanguinous D. Purulent

The nurse is preparing to apply cold therapy. Which of the following diagnoses are contraindicated for cold therapy? A. The client with a pressure ulcer B. The client with a bleeding wound C. The client with an infected wound D. The client with a sprained wrist

A. The client with a pressure ulcer

What is the most useful tool for delegating pressure injury prevention to unlicensed assistive personnel (UAP)? A. Turning chart at the bedside B. Braden scale C. Norton scale D. At-risk sticker on the patient chart

A. Turning chart at the bedside

A client with rheumatoid arthritis is educated to take ibuprofen to relieve the symptoms. Which of the following must the nurse educate the client on the safety of the analgesic drug? Select all that apply. A. May be taken with asthma medications. B. Do not take with ginkgo supplements. C. Do not take with vitamin E supplements. D. May be taken with omega 3 fatty acid supplements. E. Do not take on an empty stomach.

B, C, E

Which of the following clients must avoid using non-steroidal anti-inflammatory drugs (NSAIDs)? Select all that apply. A. A client with rheumatoid arthritis. B. A client with a recent nephrectomy. C. A client with asthma. D. A client with gout. E. A client with peptic ulcer disease.

B, C, E

Which of the following clients does the nurse recognize as being at greatest risk for pressure injury? A. A young adult with diabetes in skeletal traction. B. A middle-aged adult with quadriplegia. C. An older adult requiring use of assistive device for ambulation. D. An infant with skin excoriations in the diaper region.

B. A middle-aged adult with quadriplegia.

A patient suddenly develops right-lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain? A. Neuropathic B. Acute C. Chronic D. Intractable

B. Acute

Which of the following is the most common long-term side effect of opioid use? A. Pruritis. B. Constipation. C. Nausea. D. Vomiting.

B. Constipation.

You receive report that your patient who will be admitted to your unit has a stage 4 pressure injury. Which figure above represents this type of injury? A. None of the above B. Figure II C. Figure I D. Figure III

B. Figure II

The nurse is preparing to provide wound care to a client with many open wounds. Which of the following actions would be the most appropriate method for dressing changes of multiple open wounds that require treatment? A. Cleanse wounds from the most contaminated area to the least contaminated area. B. Irrigate wounds from the least contaminated area to the most contaminated area. C. Remove all of the soiled dressings before beginning wound treatment. D. Treat wounds on the client's side first and then the front and back of the client.

B. Irrigate wounds from the least contaminated area to the most contaminated area.

The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described? A. Straw colored B. Red, watery, clear C. Bloody D. Purulent drainage

B. Red, watery, clear

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? A. Stage IV B. Stage III C. Stage I D. Stage II

B. Stage III

The nurse is preparing to apply cold therapy to a wound. In which case is this not appropriate? A. An 8-year-old patient post-tonsillectomy B. A 36-year-old male waiting on an x-ray of the right ankle C. A 92-year-old patient on antihypertensives D. A 24-year-old patient 12 hours post-vaginal delivery

C. A 92-year-old patient on antihypertensives

Which is a priority nursing intervention for a client receiving IV opioids for pain? A. Client education on constipation. B. Administration of medicine as ordered. C. Assess for respiratory depression. D. Pain reassessment.

C. Assess for respiratory depression.

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? A. Temperature 100.6°F (38.1°C) B. Heart rate 80 beats/min C. Blood pressure 160/82 mm Hg D. Oxygen saturation 95%

C. Blood pressure 160/82 mm Hg

The nurse caring for a patient who is 24 hours post-op after a major abdominal surgery is assessing the operative site. The nurse observes internal viscera protruding through the incision site. The nurse acts quickly and should complete all of the following, except: A. Having the patient bend their knees and remain in bed. B. Immediately notifying the surgeon. C. Putting a binder on the patient. D. Covering the wound with a sterile saline dressing.

C. Putting a binder on the patient.

A client underwent emergency abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: A. Tertiary intention healing B. Approximation intention healing C. Secondary intention healing D. Primary intention healing

C. Secondary intention healing

A patient was prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen, for the treatment of arthritis and reports stomach upset after taking the medication. What should the nurse instruct the patient to do? A. Take the medication on an empty stomach. B. Take the medication before bedtime. C. Take the medication with food. D. Take the medication with 8 ounces of water.

C. Take the medication with food.

The nurse is preparing to provide care to the client who has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more," they will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? A. Regenerative healing B. Primary intention C. Tertiary intention D. Secondary intention

C. Tertiary intention

The nurse working in the emergency department is preparing heat therapy for one of the clients in the unit. Which one is it most likely to be? A. The client who has a swollen, tender insect bite B. The client who has just sprained their ankle C. The client who has lower back pain D. The client who is actively bleeding

C. The client who has lower back pain

A client presents with muscle aches and is prescribed a topical analgesic with capsaicin. Which of the following statements from the client ensures the proper understanding of the use of the medication? A. Apply a heating pad to the affected area after application. B. Wait 15 minutes after application prior to showering. C. This medication will cause local irritation and this is normal. D. This medication relaxes muscle spasms.

C. This medication will cause local irritation and this is normal.

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer 1st ? A. Pour sterile saline onto the new dry dressings after the wound has been packed. B. Apply antimicrobial ointment before repacking the wound with moist dressings. C. Soak the old dressings with sterile saline 30 minutes before the dressing change D. Administer prescribed PRN hydrocodone 30 minutes before the change.

D. Administer prescribed PRN hydrocodone 30 minutes before the change.

The nurse understands that the client who takes blood pressure medications is at risk for compromised skin integrity and poor wound healing. What is the rationale for that understanding? A. Blood pressure medications can delay wound healing. B. Blood pressure medications can cause cellular toxicity. C. Blood pressure medications increase the risk of ischemia. D. Blood pressure medications predispose to hematoma formation.

D. Blood pressure medications predispose to hematoma formation.

The nurse is assessing the client with a chronic wound. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute? A. Chronic wounds are the result of pressure, but acute wounds result from surgery. B. Chronic wounds are often full-thickness wounds, but acute wounds are superficial. C. Chronic wounds are usually infected, whereas acute wounds are contaminated. D. Chronic wounds do not heal within an expected time frame, but acute wounds heal within 2 to 4 weeks.

D. Chronic wounds do not heal within an expected time frame, but acute wounds heal within 2 to 4 weeks.

The nurse is reviewing the client's surgical report and notes that the client has a history of evisceration. The nurse researches the differences between dehiscence and evisceration. Which of the following describes the difference between dehiscence and evisceration? A. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. B. Dehiscence involves the protrusion of internal viscera from the incision site; evisceration involves a separation of one or more layers of wound tissue. C. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue. D. Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

D. Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? A. Apply a warm moist pack to the ankle. B. Assess the ankle's passive range of motion (ROM). C. Ask the patient to try bearing weight on the ankle. D. Elevate the ankle above heart level.

D. Elevate the ankle above heart level

The nurse recognizes that pressure injuries are directly caused by which of the following processes? A. Advanced age B. Impaired circulation C. Edema D. Ischemia

D. Ischemia

A patient develops a respiratory rate of 6 breaths/min after receiving 2 mg of intravenous hydromorphone. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? A. Meperidine B. Piroxicam C. Oxycodone D. Naloxone

D. Naloxone

A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client's coccyx measuring 5 x 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? A. Stage 4 pressure injury B. Stage 3 pressure injury C. Stage 2 pressure injury D. Unstageable pressure injury

D. Unstageable pressure injury

A 70-year-old client arrives in the emergency department. The client's history included chairfast, paralysis from a diving injury, two stage 3 healed pressure injuries to sacrum and right hip, weight loss of 25 pounds in the past 3 weeks, nausea and vomiting for the past week, and type 2 diabetes for 20 years. If the client's Braden Scale Score was an 8, list 3 nursing interventions you would implement for this patient?

Low air loss bed, wound care consult, turning every two hours, heel protectors, elevation of the heels, dietary consult

please complete the pain assessment steps using the acronym : P- Q- R- S- T-

Palliative, quality, region, severity, time

list the 5 cardinal signs of inflammation: ( you must have all 5 correct to receive credit)

Redness/rubor, heat/calor, pain/dolor, edema/swelling, loss of function