Foundations Exam 1 Prep U Review (pt 2)

A client is to do quadriceps drills as an isometric exercise after surgery. The nurse provides which information about this exercise? Select all that apply.

"The muscle you are tightening is the one on the front of the thigh." "Do not hold your breath while tightening the muscle."

The wound should be cleansed at least ______________ beyond the end of the new dressing. Also, the wound should be cleansed in......

1 inch (2.5 cm), in full or half circles, beginning in the center and working toward the outside.

splenic rub

A rough, grating noise over this area and can accompany splenic infarction.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Apply a skin protectant to the skin around the incision.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?

It is a splenic rub.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?

Place the tape measure behind the client and measure at the umbilicus

The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following?

Splenic percussion sign

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? then following actions

The nurse will first elevate and support the stump, apply bandage distally to proximally with equal tension at each turn; keep the bandage free from gaps between turns.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

Which of the following acute abdominal symptoms could be life threatening?

abdominal pain

The umbilicus should be the starting point when measuring the abdomen especially when _________ is apparent. Abdominal measurement is generally taken in the _________ after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is __________

distention, morning, standing not sitting.

Maturation is the_____ stage of full-thickness wound healing, in which

final, the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

Vasoconstriction, platelet aggregation, and clot formation are part of the ___________ of wound healing

first phase, hemostasis

The wound should be cleaned

from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound.

Kyphosis is _______ and common in...

increased convexity in the thoracic spine from disk shrinkage and decreased height, older adults.

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance

Appendicitis is common in the young and usually presents with ....

periumbilical pain that localizes to the right lower quadrant in an area known as McBurney's point,

Which best describes the proliferative phase, the third phase of the wound healing process?

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

scoliosis

A change in the percussion note from tympany to dullness on inspiration in this location suggests _________

splenic enlargement.

When cleansing a wound, the nurse should .....

use a new gauze or swab on each downward stroke of the cleansing agent.

the second phase, inflammatory is marked by....

vasodilation and phagocytosis as the body works to clean the wound.

Remote rebound or Rovsing's sign is also seen commonly ....

when the course of appendicitis is advanced.