Skills Test #2
Lab Values to Know
White blood cell = 5,000-10,000/mm3 Hemoglobin (heme carries oxygen) Men= 14-18 g/dl Women = 12-16 g/dl Hematocrit = % RBCs in plasma Men = 42-52% Women = 37=47% Erythrocyte count - evaluate for anemia & hemorrhage Men = 4.5-5.3 Women = 4.1-5.1
Normal Structure & Function of Healthy Skin
Epidermis Outermost layer of the skin; avascular Primary function: maintain barrier against loss of internal fluids and pathogenic invasion. Dermis Innermost layer of the skin; highly vascular, connective tissue Nourishes the basal layer of the epidermis. Provides sensory awareness. Contributes to temperature regulation. Composed of collagen and elastin fibers. Hypodermis (Subcutaneous layer) Consists primarily of adipose tissue and loose connective tissue/provides padding/weight distribution over bones Fascia-Fascia is a thin layer of connective tissue. Covers: Muscle layer which is composed of contractile fibers controlling position and movement. Muscle layer is the most metabolically active layer of the skin and soft tissues. Muscle layer is most vulnerable to ischemic damage. **fasciotomy - without
Wound Healing Phases
Inflammatory phase: lasts 3-6 days • Hemostasis-the stopping of bleeding by fibrin and blood clots, forms scab, • Phagocytosis- macrophages that eat up the debris from the wound. • Infection = temp & pus Proliferative phase: lasts from day 3-4 to 21st day (healing ☺) • collagen forms that adds strength to the wound; • granulation tissue = capillaries surrounded by fibrous collagen, tissue becomes translucent red, bleeds easily; • eschar (scab, crusting) forms if wound not sutured Maturation phase: begins about day 21 and can last up to 2 years; • wound and skin remodeled; scar formation (if hypertrophic scar = keloid)
Types of Wounds
Intentional (e.g. surgery, venipuncture) Unintentional (e.g. paper cut) Closed (e.g. simple bone fracture) Open (e.g. laceration) Clean (e.g.uninfected; usually closed wound) Clean-contaminated (e.g. surgical wound in respiratory, alimentary, genital, or urinary tract) Contaminated (e.g. surgical or accidental wound that has compromised sterility) Dirty or Infected (e.g contains dead tissue; purulent drainage)
Wounds Classified by Depth
Partial-thickness wounds • Affects dermis and epidermis, heals by regeneration Full-thickness wounds • Affects dermis, epidermis, and subcutaneous tissue. May also involve muscle and bone. Requires connective tissue repair
Types of Healing
Primary intention healing • Tissue edges approximated; minimal tissue loss, minimal granulation tissue or scarring (e.g. closed surgical incision) Secondary intention • Wound edges not able to be approximated; more susceptible to infection; more scarring; healing takes longer; granulation tissue forms (e.g. pressure ulcer) Tertiary healing • Wound left open to allow edema decrease, drainage etc.
Cartilaginous
-Cartilage joins bony components -ribs -sternocostal
Synostotic
-Infused bones - the pelvis and skull bones -bones jointed by bones.
Synovial
-Interphalangeal joints -Articular cartilage and ligaments
Which statement if made by the client or family member, would indicate the need for further teaching? 1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. 2. Putting foam pads under the heels or other bony areas can help decrease pressure. 3. If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours. 4. The skin should be washed with only warm water (not hot) lotion put on while it is still wet.
3. If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours. Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.
Which of the following would most immediately threaten an individual's safety? 1. 70% humidity 2. A sprained ankle 3. Lack of water 4. Unrefrigerated fresh vegetables
3. Lack of water
Thirty (30) minutes after the application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that: 1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired outcome (dilation). 2. It will be acceptable to leave the pad in place if the temperature is reduced. 3. It will be acceptable to leave to leave the pad in place for another 30 minutes if the site appears satisfactory when assessment. 4. It will be acceptable to leave the pad in place as long as it is moist heat.
1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired outcome (dilation). Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will being to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat-dry or moist- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.
Which of the following is a potential hazard that you should assess when the patient is in the prone position? 1. Plantar flexion 2. Increased cervical flexion 3. Internal rotation of the shoulder 4. Unprotected pressure points at the sacrum and heels
1. Plantar flexion Supports feet with pillow
A client tell the nurse, "This pill is a different color than the one that I usually take at home." Which is the best response by the nurse? 1. Go ahead and take your medicine. 2. I will recheck your medication orders. 3. Maybe the doctor ordered a different medication. 4. I'll leave the pill here while I check with the doctor.
2. I will recheck your medication orders. Rationale: If there is any doubt, the medication administration process should be interrupted until the question is clarified. Listen to the client.
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is 1. Risk for Impaired Skin Integrity 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection
2. Impaired Skin Integrity Rationale: The client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer "at risk". Because the damage is at the skin level, it is not impaired tissued integrity since that would involve deeper. Surface skin excoriation is also not prone to becoming infected.
A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: A. A safe environment promotes patient activity. B. Assessment focuses on environmental factors only. C. Teaching home safety is difficult to do in the hospital setting. D. Most accidents in the older adult are caused by lifestyle factors.
A. A safe environment promotes patient activity.
The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse's next action? A. Ask the patient's reason for refusal B. Explain that she must take the medication C. Take the medication away and chart the patient's refusal D. Tell the patient that her physician knows what is best for her
A. Ask the patient's reason for refusal
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? A. Ask the prescriber to change the order B. Crush the pill with a mortar and pestle C. Hide the capsule in a piece of solid food D. Open the capsule and sprinkle it over pudding
A. Ask the prescriber to change the order
An elderly patient with respiratory failure informs the nurse that she does not want to be placed on a ventilator. What should the nurse do next? 1. Consult with the patient's family. 2. Have the patient sign a DNR form. 3. Notify the hospice team. 4. Notify the physician.
4. Notify the physician. -The physician must determine patient competency before a DNR or DNI form can be signed. -A DNR order must be signed by the physician in order to make it valid. -The patient's family may only be consulted with consent from the patient. -The hospice team just be consulted by a physician order.
A blind patient is scheduled for a prostatectomy and an informed consent is needed. The nurse should do which of the following when obtaining an informed consent from a patient who is legally blind? 1. Ask the patient to thoroughly read the consent. 2. Get a verbal consent since a blind person cannot sign a consent form. 3. Have a family member or friend sign the consent. 4. Read the consent aloud with an impartial witness present.
4. Read the consent aloud with an impartial witness present.
A nurse preceptor is teaching a student how to properly administer an extended-release tablet. Which of the following is true about extended-release tablet? 1. They can be crush and administered through a nasogastric tube. 2. They can be crushed and combined with applesauce. 3. They should never be administered whole. 4. They should never be crushed or chewed .
4. They should never be crushed or chewed .
A patient is taking albuterol through a pressurized metered dose inhaler (pMDI) that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the pMDI last? __________ days
6, Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days., 16, Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days."
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) A. History of recent fall B. Neglect, spatial and perceptual abilities, C. Impulsive D. Requires assistance with activity, unsteady gait E. IV line, urinary catheter
A. History of recent fall C. Impulsive D. Requires assistance with activity,
At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? A. Prepare for an influx of patients B. Contact the American Red Cross C. Determine how to restore essential services D. Evacuate patients per the disaster plan
A. Prepare for an influx of patients
To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? A. Smoking is prohibited around oxygen. B. Demonstrate how to adjust the oxygen flow rate based on patient symptoms. C. Do not use electrical equipment around oxygen. D. Special precautions may be required when traveling with oxygen.
A. Smoking is prohibited around oxygen. C. Do not use electrical equipment around oxygen. D. Special precautions may be required when traveling with oxygen.
The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to: Hospital policy. A. The prescriber's orders. B. The type of medication ordered. C. The patient's size and muscle mass. D. Hospital Policy
A. The prescriber's orders.
How does the nurse support a culture of safety? A.Completing incident reports when appropriate. B. Completing incident reports for a near miss C. Communicating product concerns to an immediate supervisor. D. Identifying the person responsible for an incident
A.Completing incident reports when appropriate. C. Communicating product concerns to an immediate supervisor.
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A.Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.
A.Place a bed alarm device on the bed.
Eye instillation
Avoid cornea. Avoid touching eyelids or eye structures. Use dominant hand. Hold above conjunctival sac and drop the droplets into the conjunctival sac. Patient shouldn't squeeze eyes or blink. Let each eye soak for about 5 minutes. Ointment-Apply above lower lid margin, apply thin stream of ointment evenly along inner edge of lower eyelid on conjunctiva from the inner canthus to outer canthus. If not contraindicated have patient close eye and rub lid lightly in circular motion with cotton ball if rubbing is not contraindicated.
The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? A. Insert a urinary catheter. B. Leave a night light on in the bathroom. C. Ask the physician to order a restraint. D. Keep the bed in low position with upper and lower side rails up. E. Assign a staff member to stay with the patient. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear.
B. Leave a night light on in the bathroom. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear.
A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? A.Only the patient's physician can give this information. B. The student provides the name of the medication and a description of its desired effect. C. Information about medications is confidential and cannot be shared. D.He has to speak with his assigned nurse about this.
B. The student provides the name of the medication and a description of its desired effect.
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A. Give the child milk. B. Give the child syrup of ipecac. C. Call the poison control center. D. Take the child to the emergency department.
C. Call the poison control center.
A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? A. Set up the follow-up appointments with the physician for the patient. B. Ensure that someone will provide housekeeping for the patient at home. C. Ensure that the home care agency is aware of medication and health teaching needs. D. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.
C. Ensure that the home care agency is aware of medication and health teaching needs.
The nurse's first action after discovering an electrical fire in a patient's room is to: A. Activate the fire alarm. B. Confine the fire by closing all doors and windows. C. Remove all patients in immediate danger. D. Extinguish the fire by using the nearest fire extinguisher.
C. Remove all patients in immediate danger. RACE acronym R=Rescue
A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse: A. Continues to let the IV run. B. Applies a warm compress to the infiltrated site. C. Stops the administration of the medication and follows agency policy. D. Should not worry about this because vesicant filtration is not a problem.
C. Stops the administration of the medication and follows agency policy.
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? A.Give the medications B.Identify the patient using two patient identifiers C. Withhold the medications and verify the medication orders. D. Provide medication education to the mother to help her better understand her child's medications
C. Withhold the medications and verify the medication orders.
How are wounds acquired?
Incision Contusion Abrasion Puncture Laceration Penetrating wound
Ears
Side-lying position. Shake 10 seconds if the drops are cloudy. Ask patient to stay in side lying position for 2-3 minutes. UNDER 3 DOWN AND BACK UPWARD AND OUTWARD +3
Fibrous
-Tibia to fibula -Ligament or membrane joins bones
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? a) Stage I b) Stage II c) Stage III d) Stage IV
a) Stage I A stage I pressure ulcer 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 soft if the blood flow is compromised. The patient may report pain in the area.
When is an application of a warm compress indicated? (Select all that apply.) a) To relieve edema b) For a patient who is shivering c) To improve blood flow to an injured part d) To protect bony prominences from pressure ulcers
a) To relieve edema c) To improve blood flow to an injured part Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.
What should you try before restraints?
Redirections, distractions, and sitter.
Nasal administration
Caution about over-use because rebound effect can occur in which nasal congestion worsens. Be careful of swallowing. Have patient in supine position-tilt head back or to the side. Have patient remain in supine position for 5 minutes. Observe after administration for 15-30 minutes.
The following medications are listed on a client's medication administration record (MAR). Which medication order should the nurse question? 1. Lasix 40mg, po, STAT 2. Ampicillin 500mg q6hr IVPB 3. Humulin L (Lente) insulin 36 units subcutaneously every morning before breakfast. 4. Codeine q4-6hr po prn for pain.
Codeine q4-6hr po prn for pain.
A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? A. ½ tablet B. 1 tablet C. 1 ½ tablets D. 2 tablets
D. 2 tablets
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? A. 2 mL B. 5 mL C. 16 mL D. 30 mL
D. 30 mL
A nurse accidently gives a patient a medication at the wrong time. The nurse's first priority is to: A. Complete an occurrence report. Incorrect B. Notify the health care provider. C. Inform the charge nurse of the error. D. Assess the patient for adverse effects.
D. Assess the patient for adverse effects.
A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. D. Clear the area around the child to protect the child from injury.
D. Clear the area around the child to protect the child from injury....
The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity intolerance B. Impaired bed mobility C. Acute pain D. Risk for falls
D. Risk for falls
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? A. Outward B. Back C. Upward and back D. Upward and outward
D. Upward and outward
Kinds of Wound Drainage
Exudates- fluid & cells that leak from wound Serous- clear, watery (e.g. blister fluid) Purulent: thicker; pus present (leukocytes & fluid); indicates infection; color varies depending on organism (yellow, green) Sanguineous: bright red, contains blood Serosanguineous: pale, red, watery; mix of clear and red fluid Purosanguineous: pus and blood
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives with the family that are appropriate for this patient.
F. Discuss alternatives with the family that are appropriate for this patient.
Lab Values Meaning
Hemoglobin (Hgb)********** measures heme (a pigment that contains iron) that carries oxygen, and a protein of the erythrocyte. Can indicate anemia (low Hgb), or polycythemia (high Hgb) Values Males WNL 14-18 g/dl Females WNL 12-16 g/dl **Body size can play a role in this Dehydration*** Hgb levels rise due to hemoconcentration Fluid retention*** Hct levels decrease due to hemodilution Hematocrit (Hct)*** The percentage of RBC's in plasma Values WNL male 42-52% WNL female 37-47% Erythrocyte count*** to evaluate for hemorrhage and anemia WNL males- 4.5 to 5.3 WNL females 4.1 to 5.1 Platelet count*** Thrombocytosis- excess # of platelets (> 400,000) Thrombocytopenia- decreased # of platelets (< 100,000 cells) causes prolonged bleeding time Values- agency specific WNL - 150,000 to 400,000 cells/mm3 PLATELETS HELP WITH COAGULATION!
Proper technique for performing a wound culture includes which of the following? 1. Cleansing the wound prior to obtaining the specimen. 2. Swabbing for the specimen in the area with the largest collection of drainage. 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath. 4. Waiting 8 hours following a dose of antibiotic to obtain a specimen.
1. Cleansing the wound prior to obtaining the specimen. Rationale: Wound culture specimens should be obtained from a clean area of the wound. Microbes responsible for infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms.
Which description best fits that of serous drainage from a wound? a) Fresh bleeding b) Thick and yellow c) Clear, watery plasma d) Beige to brown and foul smelling
c) Clear, watery plasma Serous fluid generally is serum and presents as light red, almost clear fluid.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? a) Binder b) Ice bag c) Elastic bandage d) Absorptive diaper
b) Ice bag An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.
What does the Braden Scale evaluate? a) Skin integrity at bony prominences, including any wounds. b) Risk factors that place the patient at risk for skin breakdown c) The amount of repositioning that the patient can tolerate d) The factors that place the patient at risk for poor healing
b) Risk factors that place the patient at risk for skin breakdown. The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? a) Collection of wound drainage b) Reduction of abdominal swelling c) Reduction of stress on the abdominal incision d) Stimulation of peristalsis (return of bowel function) from direct pressure
c) Reduction of stress on the abdominal incision A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? a) Stage II b) Stage IV c) Unstageable d) Suspected deep tissue damage
c) Unstageable To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? a) Keeping the buttocks exposed to air at all times b) Using a large absorbent diaper, changing when saturated c) Using an incontinence cleaner, followed by application of a moisture-barrier ointment. d) Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel
c) Using an incontinence cleaner, followed by application of a moisture-barrier ointment. Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.
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 corrective intervention should the nurse do first? a) Allow the area to be exposed to air until all drainage has stopped b) Place several cold packs over the area, protecting the skin around the wound c) Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration d) Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
c) Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
Which of the following describes a hydrocolloid dressing? a) A seaweed derivative that is highly absorptive b) Premoistened gauze placed over a granulating wound c) A debriding enzyme that is used to remove necrotic tissue d) A dressing that forms a gel that interacts with the wound surface
d) A dressing that forms a gel that interacts with the wound surface A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? a) A local skin infection requiring antibiotics b) Sensitive skin that requires special bed linen c) A stage III pressure ulcer needing the appropriate dressing d)Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
d) Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. Rationale: When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? a) Necrotic tissue b) Wound drainage c)Drainage on the dressing d) Wound after it has first been cleaned with normal saline
d) Wound after it has first been cleaned with normal saline Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.
White shiny bands of fibrous tissue binding joints together and connecting various bones and cartilage types are known as: a. Joints b. Muscles c. Tendons d. Ligaments
d. Ligaments
The developmental stage that carries the highest risk of an injury from fall is: 1. preschool 2. adulthood 3. school age 4. older adulthood
4. Older adult hood
Wound Assessment
Assess: Healing Size and depth (use wood end of cotton tip applicator), appearance, approximation of wound edges, swelling, pain, drains Drainage/blood • Minimal drainage-stains • Moderate- saturates dressing but no leakage • Heavy- overflows dressing Undermining/sinus tract/tunnel Lab Data Low Hgb=poor oxygenation to tissues Low WBC=delay healing, increased risk of infection Prolonged coagulation time increases blood loss Hypercoagulation= increases blood clots Low albumin <3.5 g/dL = poor nutrition=poor healing & increased risk for infection Wound cultures- r/o infection and identify type of micro-organism Albumin = nutrition & healing status Low hemoglobin = hypoxia? Pressure Ulcers Definition: A localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction (Potter & Perry, 2009, p.1287) Cause = localized ischemia (lack of blood supply to the tissue resulting in tissue necrosis or death of tissue) due to pressure between hard surfaces (bony part & usually a bed) Pt too immobile - could be health care providers fault
The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? most appropriate next step for the nurse to take? A. Call a pharmacist to interpret the order B. Call the physician to have the order clarified C.Consult the unit manager to help interpret the order D. Ask the unit secretary to interpret the physician's handwriting
B. Call the physician to have the order clarified
After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: A. Follow ISMP guidelines for safe medication abbreviations. B. Explain to the physician that the order needs to be given to a registered nurse. C. Write down the order on the patient's order sheet and read it back to the physician. D. Ensure that the six rights of medication administration are followed when giving the medication.
B. Explain to the physician that the order needs to be given to a registered nurse.
If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: A. Sepsis. B.Phlebitis. C. Infiltration. D. Fluid overload.
B. Phlebitis
What is the removal of devitalized tissue from a wound called? a) Debridement b) Pressure reduction c) Negative pressure wound therapy d) Sanitization
Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.
Why do nurses use restraints?
Risk for harm to self or others.
A few terms
Route missing check with nurse guts-press dressing with saline call physician Staph wear a gown Thrombphelbitus early ambulation 60 mL Restraints 25 1/2
Restraints
Patients who are confused, disorientated or repeatedly fall or try to remove medical devices often require temporary use of restraints to keep them safe. Restraint alternatives include more frequent observations, involvement of family during visitation, frequent reorientation, and the introduction of meaningful stimuli. A physician's order is required, based on a face-to-face assessment of the patient. The order must be current, state state the type and location of the restraint, specify the duration and circumstances under which which it will be used. These orders need to be renewed with a specific time frame according to policy of the agency. In the hospital, each individual restraint order and renewal is limited to 4 HOURS FOR ADULTS, 2 HOURS FOR AGES 9-17, 1 HOUR FOR CHILDREN UNDER AGE 9. Order may be renewed to the time limits for a maximum of 24 consecutive hours. Restraints are not to be ordered as needed. You must conduct ongoing assessment of patients who are restrained prn.
Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed
1. Low-protein diet 3. Lengthy surgical procedures 4. Fever Rationale: Risk factors for pressure ulcers include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing.During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity.
