Nutrition and skin integrity (N-510 Exam 2)

The nurse is caring for a patient with surgical incision that is well approximated (closed) with sutures or staples, healing by epithelialization, low risk for infection The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention b. Partial-thickness wound repair c. Full-thickness wound repair d. Tertiary intention

A

Which potential complication of enteral feeding are you most concerned for when a patient O2 saturation becomes low. a. Refeeding syndrome b. Occluded tube c. Aspiration pneumonia d. Delayed gastric

C

Slight in movement of a skin and subcutaneous 's tissue while underline muscle and bone stationary is the definition of a. Friction b. Pressure injury c. Decrease sensory perception d.shear

D

Which lab value is the most accurate indicator of acute nutrition status a. albumin b. Hemoglobin c. Sodium d. Pre- albumin

D

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? a. removing dead or infected tissue to promote wound healing b. removing purulent drainage from the wound bed in order to accurately assess it c. removing excess drainage and wet tissue to prevent maceration of surrounding skin d. stimulating the wound bed to promote the growth of granulation tissue

a

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? a. Braden Scale b. Glasgow Scale c. Morse Scale d. FLACC Scale

a

A nurse is collaborating with the interdisciplinary team to develop a nutritional plan for a patient with a nonfunctional GI tract due to a massive small bowel resection. Which of the following nutrition interventions would be most appropriate? a. Parenteral nutrition b. Enteral nutrition c. High fiber diet d. Regular diet

a

How would thee nurse document the appearance of a wound bed that is red moist tissue. a. Granulation b. Slough c. Eschar d. Exuduate

a

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? a. Thorough hand hygiene b. Adequate sleep and rest c. Proper intake of food and fluids d. Taking medications as prescribed

a

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? A. Suction her mouth and throat B. Turn her on their side C. Put on oxygen at 2-L nasal cannula D. Stop feeding her and place on NPO

a

The nurse is completing an assessment of the skin's integrity and Braden scale, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.

a

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? a. From the tip of the nose to the earlobe to the xiphoid process b. From the tip of the earlobe to the mouth to the xiphoid process c. From the tip of the earlobe to the xiphoid process d. From the tip of the nose to the earlobe

a

Which inpatient diet order eliminates wheat, oats, and barley a. Gluten free (used for cyaky disease) b. Mechanical soft c. diabetic d. Full liquid

a

what is the best way for nurse to assess feeding tube placement at bedside? a. assess pH content of aspirated GI contents b. Air auscultation c. Measure gastric residual volume (GRV) d. Assess post void residual (PVR)

a

Select all the apply: what are common potential complication of enteral feeding?

aspiration pneumonia (life threatening), diarrhea, occluded clogged tube and referring syndrome

A nursing student is cleaning a wound during a dressing change which of the following would cause the clinical instructor to intervene a. The student use sterile normal saline b. The student cleans from the most contaminated area towards the incision c. The student is carefully not to clean across the incision twice d. Student cleans from inside out to the surrounding area

b

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. Ulcer look partial thickness skin loss with exposed dermis, wound bed visible, pink or red, moist and shallow. Intact or ruptured serum filled blister. This pressure ulcer would be staged as stage a. I b. II c. III d. IV

b

The nurse is caring for a patient in with stage 2 pressure injury, burn, severe laceration (not approximated). Healing by granulation issue formation. Wound left open until it heals takes, longer to heal and higher chance for infection. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

b

A nurse is caring for a patient receiving enteral nutrition through a gastrostomy tube. The nurse is aware to monitor for which potential complications? (Select all that apply) a. Hypercapnea b. diarrhea c. Serum electrolyte imbalance d. Pulmonary aspiration e. Epistaxis

b, c and d

A nurse is feeding a patient. Which statement would help a person maintain dignity while being fed? a. 'I wish I had more time so I could feed you all of your meal.' b. 'I am going to feed you your cereal first and then your eggs.' c. What part of your dinner would you like to eat first?' d. 'I know you don't like me to feed you, but you need to eat.'

c

After Impaired Skin Integrity, which of the following NANDA-I nursing diagnoses would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? a. Anxiety b. Ineffective Coping c. Risk for Infection d. Risk for Situational Low Self-Esteem

c

How would the nurse document of wound draining that appears pale pink and watery a. Serous (clear) b. purulent (thick yellow) c. Serosanginuous d. Sanguineous (red; bloody)

c

The nurse is caring for a patient while assessing nurse see red, moist tissue, composed of new blood vessels. Which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage

c

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? a. Measure length, width, and depth of the wound. b. Massage the healthy tissue surrounding the wound. c. Document the color, odor, amount, and type of wound drainage. d. Determine the extent of wound undermining.

c

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? a. visible subcutaneous fat b. exposed bone with eschar c. nonblanchable redness d. a shallow open injury

c

Which of the following factor affect the nutritional status of older adults a. Decreased risk of dehydration b. increase peristalsis c. Decrease thirst sensation d. increase metabolic rate

c

Which of the following patients will have an increased metabolic rate and require nutritional interventions? a. A healthy young adult who works in an office b. A retired person living in a temperate climate c. A person with a serious infection and fever d. An older, sedentary adult with painful joints

c

which of the following feeding tube is considering long term? a. Nasogastric (NG) b. Nasojejunal (NJ) c. Gastrostomy (G-tube) d. Peripheral inserted central Catheter (PICC)

c

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? a. Frequently orient client to place and situation b. Perform passive range-of-motion exercises c. Massage skin surfaces daily, especially areas under pressure and bony prominences d. Implement a 2-hour repositioning schedule

d

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? a. mixture of serum and red blood cells b. large numbers of red blood cells c. clear, watery blood d. white blood cells, debris, bacteria

d

The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take first? a. Change the tube feeding to a high-fat formula. b. Consult with the health care provider about prokinetic medication. c. Instill cold formula to "numb" the stomach. d. Slow the rate of tube feeding.

d

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? a. improving the client's hydration b. lubricating the area with skin oil c. pulling the client up from under the arms d. preventing the client from sliding in bed

d

Name two components of aspiration precautions

elevated head (30-45 degree) and diet restriction

Branden scale interpretation

greater 18 not a risk

what are complication of wound healing?

hemorrhage, infection, dehiscence (separation of wound layers) and Evisiceration

Nursing intervention for dressing

maintains moist environment, "wet moist", hydrocolloid, hydrogel and calcium alginate

what is nursing intervention of evisceration (organ through wound)

place gauze soaked in sterile saline over extruding tissue to reduce bacterial invasion and drying out of tissues. Notify surgical team, makes pt NPO and assess vitals.