Foundations Review Content 5

A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best? "As long as you focus on protein intake, you will get the nutrition you need." "Can you share an example of what you ate yesterday?" "Be sure to eat a large amount of carbohydrates so you can have energy." "It does not matter which foods you eat, as long as you always make sure you get 2,400 calories."

"Can you share an example of what you ate yesterday?"

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? "I will alternate between positive and negative pressure every 2 hours." "I will squeeze the chamber and apply the cap to maintain negative pressure." "I will check and empty the drain every 6 hours." "I will apply a dressing at the end of the drain to catch any drainage."

"I will squeeze the chamber and apply the cap to maintain negative pressure."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Take in a small amount of air very quickly and then exhale as quickly as possible." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "You should never smoke when oxygen is in use." "Oxygen is a flammable gas." "I understand; I used to be a smoker also." "An occasional cigarette will not hurt you."

"You should never smoke when oxygen is in use."

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles. Use an aquathermia pad during the treatment to create heat and circulate the water. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development? Albumin 2.8 mg/dL (28.0 g/L) Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) White blood cell count 14,800 mm3 (14.8 x 109/L) Hemoglobin A1C 5%

Albumin 2.8 mg/dL (28.0 g/L)

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? Oxygen tent Nasal cannula Ambu bag Oxygen mask

Ambu bag

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Apply saline solution-moistened gauze over the protruding area. Inform the client that this is an expected occurrence and not to worry. Allow the wound and intestinal contents to remain open to air. Pack the wound with gauze pads and a dry sterile dressing.

Apply saline solution-moistened gauze over the protruding area.

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? Assess oxygen tubing connection Reposition client Assess lung sounds Elevate head of the bed

Assess oxygen tubing connection

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? Morse scale Glasgow scale FLACC scale Braden scale

Braden scale

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take? Chop the client's food to make it easier to swallow. Replace the client's meal tray with soft foods available on the unit. Check the medical record for the client's prescribed diet. Offer the client a sip of liquid in between each bite.

Check the medical record for the client's prescribed diet.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Clean the wound from the top to the bottom and from the center to outside. Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

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

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information? Continue with care; this is a normal fluid intake. Post a sign limiting fluids to 1,000 mL every 24 hours. Change the plan of care to include forcing fluids. Ask the client to drink more water during the day.

Continue with care; this is a normal fluid intake.

A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet? Tomato soup Orange juice Low-fat milk Cranberry juice

Cranberry juice

The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider? Wheezing Frequent coughing Cyanosis Decreased level of consciousness

Decreased level of consciousness

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? Evisceration of the viscera Infection of the wound Herniation of the wound Dehiscence of the wound

Dehiscence of the wound

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? Evisceration Maceration Desiccation Necrosis

Desiccation

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

Document the color, odor, amount, and type of wound drainage.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? Lying with the head slightly lowered Supine with one pillow Side-lying with head slightly elevated High Fowler's position

High Fowler's position

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? Perfusion Atelectasis Hypoxia Hyperventilation

Hypoxia

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? Massage skin surfaces daily, especially areas under pressure and bony prominences Frequently orient client to place and situation Perform passive range-of-motion exercises Implement a 2-hour repositioning schedule

Implement a 2-hour repositioning schedule

A nurse is teaching a preoperative client how to use an incentive spirometer. Which instruction should be included in the teaching plan? Inhale normally and then place the lips securely around the mouthpiece. Insnhale slowly and as deeply as possible through the mouthpiece without using the nose. Perform incentive spirometry hourly, if possible. When you cannot inhale anymore, hold your breath and count to 10.

Insnhale slowly and as deeply as possible through the mouthpiece without using the nose.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? It can result in an inconsistent amount of oxygen. It can create a risk of suffocation. It can cause the nasal mucosa to dry in case of high flow. It can cause anxiety in clients who are claustrophobic.

It can cause the nasal mucosa to dry in case of high flow.

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? Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile prior to collecting the culture. Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. Monitor the client's respiratory rate. Check the symmetry of the client's chest. Check the devices used to deliver oxygen. Observe the breathing pattern and effort. Note the amount of oxygen administered.

Monitor the client's respiratory rate. Check the symmetry of the client's chest. Observe the breathing pattern and effort.

The nurse would recognize which of these devices as an open drainage system? Hemovac Penrose drain Negative pressure dressing Jackson-Pratt drain

Penrose drain

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer? Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. Place the mouthpiece near your mouth. Inhale the medicine into your lungs. Place the mouthpiece in your mouth. Intermittently breathe through your nose and mouth so that all of the medicine goes into your lungs Place the mouthpiece in your mouth. Breath in the medication then remove the mouthpiece to breathe the medicine out.

Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.

The nurse caring for a client with emphysema has determined that a priority nursing concern for this client is the risk for malnutrition related to difficulty breathing while eating. Which nursing intervention is appropriate to include in the client's care plan? Provide three large meals daily. Encourage the client to alternate eating and using a nebulizer during mealtime. Encourage the client to eat immediately before breathing treatments. Provide six small meals daily.

Provide six small meals daily.

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? SpO2 96% heart rate 110 beats/minute clubbing of fingers respirations 26 breaths/minute

SpO2 96%

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? Stop removing staples and inform the surgeon Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision. Apply adhesive wound closure strips after each staple is removed.

Stop removing staples and inform the surgeon

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To turn the head away from the area whenever coughing To remain in bed for the next 4 hours

To splint the area when engaging in activity

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change? Try eating 2 to 3 foods at a time. Try eating foods that are attractive and at the proper temperature. Try eating foods with the same textures and aromas. Use spicy condiments to add flavor.

Try eating foods that are attractive and at the proper temperature.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? When holding the airway on the side of the client's face, it should reach from the tip of the ear to the nostril times two. The airways come in standard sizes determined by the height and weight of the client. When holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw. When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client who lifts himself up on the elbows a client sitting in a chair who slides down a client who must remain on the back for long periods of time a client who lies on wrinkled sheets

a client sitting in a chair who slides down

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a 10-year-old client with a surgical incision a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs an older adult who is confined to bed a client who eats a diet high in vitamins A and C

a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs an older adult who is confined to bed

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site? a dressing with a nonadherent coating a gauze dressing premedicated with antibiotics a transparent film a gauze dressing precut halfway to fit around the IV line

a gauze dressing premedicated with antibiotics

Which client will have an increased metabolic rate and require nutritional interventions? an older, sedentary adult with painful joints a retired person living in a temperate climate a healthy young adult who works in an office a person with a serious infection and fever

a person with a serious infection and fever

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a wound healing naturally that becomes infected. a wound left open for several days to allow edema to subside a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally

a surgical incision with sutured approximated edges

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: high cardiac output. heart failure. adequate tissue perfusion. diminished stroke volume.

adequate tissue perfusion.

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: hypercapnia. apnea. orthopnea. dyspnea.

apnea.

What does pulse oximetry measure? peripheral blood flow arterial oxygen saturation venous oxygen saturation cardiac output

arterial oxygen saturation

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? preventing scar formation so it does not limit joint movement assisting the client in moving to prevent strain on the suture line administering pain medications on a PRN and regular basis telling the client that a mild fever is a normal response

assisting the client in moving to prevent strain on the suture line

The nurse is teaching an older adult client about different types of proteins that can be eaten. Which foods will the nurse identify as containing dietary protein? Select all that apply. beans nuts fish butter poultry

beans nuts poultry fish

For which client does the nurse anticipate the need for a pureed diet? client whose stroke has resulted in difficulty swallowing client with dementia who is unable to follow instructions client who required gallbladder surgery postoperative client after bariatric surgery

client whose stroke has resulted in difficulty swallowing

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: wheezes. bronchovesicular. crackles. vesicular.

crackles.

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently? pursed-lip breathing diaphragmatic breathing deep breathing incentive spirometry

deep breathing

A full-thickness or third-degree burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.

eschar.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication? dehiscence hemorrhage fistula evisceration

evisceration

A nurse is assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected? skin pallor eschar formation blister formation full-thickness skin loss

full-thickness skin loss

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: age. hemoglobin level. blood pH. sodium and potassium levels.

hemoglobin level.

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? high respiratory rate low pulse rate low blood pressure high temperature

high respiratory rate

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet? regulation of osmotic pressure in the blood production of hemoglobin to carry oxygen to tissues promotion of energy storage in adipose tissue maintenance of normal bowel elimination

maintenance of normal bowel elimination

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? face tent nonrebreather mask simple mask nasal cannula

nasal cannula

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

nonblanchable redness

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? nonrebreather mask simple mask nasal cannula Venturi mask

nonrebreather mask

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? document the assessments and intervention administer pain medications intramuscularly notify the health care provider and prepare for surgery reinforce the dressing with additional layers

notify the health care provider and prepare for surgery

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding? pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation pH less than 7.35; HCO3 low; PaCO2 low pH greater than 7.45; HCO3 high; PaCO2 high

pH less than 7.35; HCO3 high; PaCO2 high

The nurse is educating a client with chronic anemia about their recommended diet. What will the nurse include in the teaching? yellow vegetables citrus fruits red meat dairy products

red meat

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

removing dead or infected tissue to promote wound healing

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? tertiary intention primary intention maturation secondary intention

secondary intention

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

serosanguineous

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of pressure injuries. What is the name given to the factor responsible for this risk? necrosis of tissue shearing force ischemia friction

shearing force

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound? stage 1 pressure injury stage 2 pressure injury stage 4 pressure injury stage 3 pressure injury

stage 2 pressure injury

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? stage I stage IV stage II stage III

stage III

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? eschar dehiscence undermining slough

undermining

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

white blood cells, debris, bacteria