Nursing test 4

True

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

Instillation of mineral oil

A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear?

Inner ear

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

The client has fistula formation.

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

All Sections

A client has a history of hearing loss and is returning for an annual hearing examination. During client education, the nurse explains that hearing involves which areas of the ear?

vertigo

A client is diagnosed with Meniere's disease. The nurse would most likely expect the client to report which of the following?

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

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

Assess the client's wound and vital signs.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

stage II

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

Squamous cell carcinoma

A nurse is assessing a client and finds a malignant lesion on the client's face. The nurse suspects this is what type of skin cancer?

Clean the wound from the top to the bottom and from the center to outside.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Which is not considered a skin appendage?

Connective tissue

facial nerve paralysis

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing which effect?

Every 48 to 72 hours

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

Kaposi sarcoma

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition?

a surgical incision with sutured approximated edges

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response

The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response?

Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

Keep the swab and the inside of the culture tube sterile.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

second degree or partial thickness

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:

Eustachian tube

The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?

Stage IV

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. How will the nurse categorize this pressure injury?

Keloid

The nurse prepares a patient with a benign skin lesion for surgical excision, intralesional corticosteroid therapy, and radiation. Which of the following is most likely the lesion described?

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

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss.

Which diagnostic test distinguishes between conductive and sensorineural hearing loss?

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

contusion

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

Presbycusis

Which terms refers to the progressive hearing loss associated with aging?

What is wound dehiscence?

"Dehiscence is when a wound has partial or total separation of the wound layers."

constriction of peripheral blood vessels.

Loud, persistent noise has been found to cause which symptom?

small, waxy nodule on sun exposed skin, crust and ulcer nodule, rare metastasize

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

Serosanguineous drainage is a mixture of serum and red blood cells.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document?

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

Stop removing staples and inform the surgeon

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

Erythromycin

A nurse is reviewing a client's medication history. Which drug would the nurse identify as placing the client at risk for ototoxicity.

Dehiscence of the wound

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Metastasis

Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?

A client who has a partial-thickness venous ulcer with moderate drainage

For which client would the application of a hydrocolloid dressing be most appropriate?

Describe the various types of hearing aids that are available

Which nursing intervention is appropriate for a client who plans to use a hearing aid?

"I will put a layer of cloth between my skin and the ice pack."

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack

The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?

Limit foods that are high in sodium.

The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care?

Discontinue the therapy and assess the client.

The nurse is performing 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 the nurse at this time?

Very little scar tissue will form."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

surgery

Which of the following is the treatment of choice for acoustic neuromas?

Desiccation

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

corticosteroids

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

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?

Use clean technique instead of sterile technique if the wound is closed.