Chapter 35 Questions

A client presents to the emergency room after sustaining an injury where a nail entered the hand. Which questions should the nurse ask the client to determine if a tetanus shot is needed? Select all that apply. "Do you have any allergies to tetanus toxin?" "Have you had a tetanus shot in the past 2 years?" "Was the nail rusty or was it brand new out of the box?" "Have you sustained a puncture wound like this before?" "Can you tell me your current pain level on a scale of 1 to 10?"

"Do you have any allergies to tetanus toxin?" "Was the nail rusty or was it brand new out of the box?"

The nurse is assessing a client's risk for skin breakdown using the Braden scale. The nurse notes: The client is alert and oriented to person and is able to answer commands. The client has skin that is occasionally moist due to urinary incontinence. The client stays in the chair most of the day, needs assistance to get up. The client is unable to reposition on his or her own and frequently needs to be pulled up in bed. The client eats about 50% of breakfast and dinner but frequently skips lunch. What would the nurse rate as the client's Braden score? Enter numeral only.

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Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply. Irregular wound edges Wound bed beefy red Periwound area reddened Pain noted with ambulation Loss of hair to the periwound area

Irregular wound edges Wound bed beefy red Periwound area reddened

What should the nurse monitor in a client who is taking blood pressure medication? Ischemia Inhibited wound healing Hematoma Xerosis

Ischemia

You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers? A. A 72 year old female weighing 82 lbs with stress incontinence and dementia. B. A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities. C. A 6 month old with the flu. D. An ambulatory 88 year old with dementia who is admitted with shingles.

A

Which client is at highest risk for wound dehiscence? A 55-year-old obese female who underwent an abdominal hysterectomy A 75-year-old thin male who underwent a total hip replacement after a fall A 20-year-old thin female who underwent an emergency appendectomy A 40-year-old obese male who underwent back surgery for a herniated disk

A 55-year-old obese female who underwent an abdominal hysterectomy

Which patient is at risk for compartment syndrome due to a burn? A. A 25 year old with circumferential burn of the anterior and posterior left arm. B. A 7 year old with a burn of the left and right ear. C. A 55 year old with an electrical burn on the neck. D. A 15 year old with a chemical burn to the right foot.

A. Circumferential burns of the extremities produce a tourniquet like effect and leads to vascular problems.

A patient is undergoing a escharotomy. Which of the following is correct about the procedure? A. It is performed on circumferential burns and is usually performed at bedside without anesthesia. B. It is performed on radiation burns and requires general anesthesia. C. It is performed if tissue perfusion does NOT return after a fasciotomy. D. None of the options are correct.

A. Escharotomy are performed at the beside without anesthia because the nerves are already damaged. It is first performed when a patient has a circumferential burn and if tissue perfusion fails to return a fasciotomy is performed in the operating room.

A patient with 55% burns is groaing out in pain and rates pain 10 on 1-10 scale. You have PRN orders for the following medications. What is the best option for this patient? A. IV Morphine B. Oral Lortab liquid suspension C. IM Demerol D. Subcutaneous Demerol

A. IV route is the best option when a patient has burns. If a medication is given IM or subq, hypovolemia may disrupt absorption. In addition, oral route should be avoid due to potential GI dysfunction.

You have a patient who has multiple burns on their body. Using the rule of nines, what is the estimate extent of burn injury to the following patient. The following areas are burned: Anterior trunk, anterior left arm, and posterior left leg. A. 31.5% B. 36% C. 28.5% D. 30%

A. Using the rule of nines you would get 31.5%. The anterior trunk is: 18%, anterior left arm 4.5%, posterior left leg 9%....total equals 31.5.

The nurse is providing frequent dressing changes to an abdominal wound due to large amounts of drainage. The repeated use of tape is irritating the skin. Which intervention would be the best option for the nurse to use to alleviate the problem? Apply Montgomery straps. Leave the wound open to air. Decrease the dressing change frequency. Change to a different brand of adhesive tape.

Apply Montgomery straps.

The nurse is supervising a student nurse who is managing the care of a client who has lower extremity edema related to an arterial skin ulcer. Which action made by the nursing student requires correction? Elevating the lower extremity Applying compression stockings Instructing about smoking cessation Administering pain medications before dressing change

Applying compression stockings

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound? A. Area is red and does not blanch. B. Full-thickness skin loss to dermis and subcutaneous tissues. C. Partial thickness of dermis with shallow open ulcer. D. Full thickness with bone and tendon visible.

B. This question asks for the characteristics of a stage 3 pressure ulcer. Stage 3 pressures are full-thickness skin loss to dermis and subcutaneous tissues.

The nurse is working with a client with low total protein and serum albumin levels. The client presents with bilateral pitting lower extremity edema. Which education should the nurse provide to decrease and prevent edema formation? Increase cholesterol in the diet. Increase protein foods in the diet. Increase vitamin C and zinc content. Increase fluid intake during the day.

Increase protein foods in the diet.

A patient is being discharge after having autografting. What would you include in your discharge education? A. Avoid using splints or any type of support garment. B. Encourage for the site to be exposed to sunlight to promoted melanin production. C. Keep the site free from pressure and keep the site lubricated. D. Encourage weight-bearing exercise every 4 to 6 hours.

C. The patient should avoid the sunlight due to increase risk of sunburn to delicate skin. In addition, the patient should avoid weight-bearing activites to prevent damage to the newly grafted skin. It is best to encourage splints and support garments to protect the skin during acitiviy.

As a home care nurse, you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming? A. Exercise the extremities actively and passively. B. Turn and re-position the patient every 2 hours. C. Keep the skin moist and layer the sacral area with extra sheet layers. D. Use pillows to elevated bony prominences.

C. You will keep the pressure ulcer dry and clean and avoid extra sheets (this could increase the risk for moisture and form wrinkles and friction onto the skin. All the other options are correct education material.

A client reports to the nurse that there is drainage leaking around the Jackson-Pratt (JP) drain. The nurse notices the JP drain bulb is empty and the dressing is saturated with serosanguineous drainage. What should the nurse do first? Check the JP drain tubing for kinks. Compress the bulb and close the lid. Remove the JP drain from the abdomen. Notify the primary health-care provider.

Check the JP drain tubing for kinks.

The nurse is educating a client with new onset type 1 diabetes mellitus regarding microvascular and macrovascular complications. Which interventions should the nurse instruct the client to include in daily care to prevent skin breakdown? Select all that apply. Inspect the feet daily. Soak the feet every day. Dry the feet thoroughly. Wear well-fitting shoes. Clip the toenails every week.

Inspect the feet daily. Dry the feet thoroughly. Wear well-fitting shoes.

A preceptor is observing a nursing student provide care to a patient with major burns to the face and head. What nursing intervention does the student perform correctly? A. Assist the patient with eating food tray. B. Uses gloves and face mask when providing care. C. Places the patient in trendelenburg position. D. Elevates the head of the bead at 30'.

D. Due to edema and respiratory issues patient with facial burns should have the HOB at 30'. In addition, strict isolation protocol is implemented because they patient is at high risk for infection ( gloves and facial mask are not sufficient enough). In addition, the patient will not be eating but will be on tube feedings.

As a nurse working on a burn unit, which of your patients are at high risk for internal tissue damage? A. Patient in room 2101 with a chemical burn to face. B. Patient in room 2106 with a radiation burn on the abdomen. C. Patient in room 2103 with a thermal burn to peritoneal area. D. Patient in room 2101 with an electrical burn on torso.

D. Electrical burns are caused by heat generated by electrical current which is transferred through the body. This current burns the skin but also affects internal tissue as well.

The nurse is preparing a new skin care protocol for elderly residents in a nursing home. Which factors require specialized skin care for these clients? Select all that apply. Changed estrogen levels Decreases in lean body mass Impaired thermoregulation Thinning subcutaneous tissue layer Diminishing sweat and sebaceous glands

Decreases in lean body mass Thinning subcutaneous tissue layer Diminishing sweat and sebaceous glands

The nurse is reviewing laboratory results for a 55-year-old client with a venous stasis ulcer. Which result reflects the presence of chronic wound inflammation? Serum albumin level 4.0 g/dL White blood cell count (WBC) 8000/mm3 Partial thromboplastin time (PTT) 16 seconds Erythrocyte sedimentation rate (ESR) 40 mm/hour

Erythrocyte sedimentation rate (ESR) 40 mm/hour

The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply. Fever Nausea and vomiting Urinary incontinence Shearing and friction Continuous pressure

Fever Urinary incontinence

Place in order the steps for obtaining a sterile wound culture. Label the tube with the name, time, date, and source and send to the lab. Twist the top of the aerobic culturette tube to loosen the swab. Gather supplies and don nonsterile gloves. Place an emesis basin under the base of the wound. Insert the swab into the aerobic culturette container. Press the swab against a beefy red portion of the wound bed. Crush the bottom of the ampule to activate the culture medium. Irrigate the wound with a 35-mL syringe and 19-gauge angiocatheter.

Gather supplies and don nonsterile gloves. Place an emesis basin under the base of the wound. Irrigate the wound with a 35-mL syringe and 19-gauge angiocatheter. Twist the top of the aerobic culturette tube to loosen the swab. Press the swab against a beefy red portion of the wound bed. Insert the swab into the aerobic culturette container. Crush the bottom of the ampule to activate the culture medium. Label the tube with the name, time, date, and source and send to the lab.

The nurse is caring for a client who is deficient in protein and has poor skin turgor. Which skin cells would be causing this to happen? Dermis cells Melanocytes Keratinocytes Langerhans cells

Keratinocytes

A client presents to the clinic after falling in a parking lot and sustaining an injury. There is a break in the skin with jagged edges. There is no evidence of foreign debris in the wound. As the nurse documents the wound care, which term would the nurse use in the health record? Abscess Incision Crushing Laceration

Laceration

Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply. Location of the wound Length, width, and depth Nutritional status of the client Presence of undermining or tunneling Number and type of dressing supplies used Drainage amount, color, consistency, and odor

Location of the wound Length, width, and depth Presence of undermining or tunneling Drainage amount, color, consistency, and odor

A client with peripheral arterial disease presents to the clinic with an open wound to the left shin. Which clinical manifestations would the nurse expect to find during the assessment? Select all that apply. Pain Edema Loss of hair Tissue necrosis Jagged wound edges

Pain Loss of hair Tissue necrosis

What are the functions of the stratum corneum layer of the skin? Select all that apply. Prevents water loss Eliminates foreign material Protects from ultraviolet light Functions as a protective barrier Stops chemicals from entering the body

Prevents water loss Functions as a protective barrier Stops chemicals from entering the body

The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring? Primary intention Secondary intention Tertiary intention Inflammatory phase

Secondary intention

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record? Serous Purulent Sanguineous Serosanguineous

Serosanguineous

Which lifestyle choices can lead to alterations in skin integrity? Select all that apply. Smoking Tanning Exercise Daily bathing Adequate nutrition

Smoking Tanning

The nurse examines a wound on a client's hip and notes purulent drainage. The wound culture report states it has developed critical colonization. How should the nurse interpret these findings? The wound culture was contaminated. The bacteria have overwhelmed body defenses. The microorganisms are causing harm and releasing toxins. The report means there are microorganisms in the wound.

The bacteria have overwhelmed body defenses.

What is the primary purpose of swaddling a newborn for the first few weeks of life? Thermoregulation Sense of security Prevent accidental scratching Mimics the womb

Thermoregulation