HHIC Exam 2

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

A patient's temperature has been 101 F for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. If the metabolic rate increase 7% for each Fahrenheit above 100 degrees in body temperature, how many total calories should the patient receive each day?

2140

A patient how has an infected abdominal wound develops a temperature of 104 F. all of the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions. a- administer IV antibiotics b- sponge patient with cool water c- perform wet-to-dry dressing change d- administer acetaminophen

a, d, b, c

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a- elevate the ankle above heart level b- apply a warm moist pack to the ankle c- ask the patient to try bearing weight on the ankle d- assess the ankle's passive range of motion ROM

a- elevate the ankle above heart level

Which finding is most important for the nurse to communicate to the HCP when caring for a patient who is receiving negative-pressure wound therapy? a- low serum albumin levels b- serosanguineous drainage c- deep red and moist wound bed d- cobblestone wound appearance

a- low serum albumin levels

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority? a- maintaining the patient's blood glucose within normal range b- ensuring the patient has an adequate dietary protein intake c- giving antipyretics to keep temperature less than 102 F d- redressing the surgical incision with a dry, sterile dressing twice daily

a- maintaining the patient's blood glucose within normal range

A woman receiving chemotherapy for the breast cancer develops a Candida albicans oral infection. Which intervention should the nurse anticipate? a- nystatin tablets b- antiviral agents c- referral to a dentist d- hydrogen peroxide rinses

a- nystatin tablets

A patient with an open leg lesion has a WBC of 13,500 and a band count of 11%. What prescribed action should the nurse take first? a- obtain cultures of the wound b- begin antibiotic administration c- continue to monitor wound for drainage d- redress the wound with wet-to-dry dressings

a- obtain cultures of the wound all should be done, but cultures should be done first

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a- uninsured or underinsured status b- easy access to health screenings c- high cost of medications d- inadequate nutrition e- mostly female gender

a- uninsured or underinsured status c- high cost of medications d- inadequate nutrition

Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours

b - BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

A patient who has GERD is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed? a- "I quit smoking years ago, but I chew gum" b- "I eat small meals and have a bed time snack" c- "I take antacids between meals and at bedtime at night" d- "I sleep with the head of the bed elevated on 4-inch blocks"

b- "I eat small meals and have a bed time snack"

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a- use sunscreen even on cloudy days b- avoid cigarettes and smokeless tobacco c- complete antibiotic courses used to treat throat infections d- use antivirals to treat HSV infections

b- avoid cigarettes and smokeless tobacco

Which item should the nurse offer to the patient restarting oral intake after being NPO due to nausea and vomiting? a- glass of orange juice b- dish of lemon gelatin c- cup of coffee with cream d- bowl of hot chicken broth

b- dish of lemon gelatin clear cool liquids are usually the first foods started after a patient has been nauseated.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a- obtain wound cultures b- document the assessment c- notify the health care provider d- assess the wound every 2 hours

b- document the assessment incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention.

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a- blood glucose 136 mg/dL b- separation of proximal wound edges c- oral temperature of 101F d- patient reports increased incisional pain

b- separation of proximal wound edges

After receiving change-of-shift report, which patient should the nurse assess first? a- the patient who has multiple leg wound with eschar to be debrided b- the patient receiving chemotherapy who has a temperature of 102 F c- the patient who requires analgesics before a scheduled dressing change d- the newly admitted with a stage 4 pressure injury on the coccyx

b- the patient receiving chemotherapy who has a temperature of 102 F

When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing? a- the patient has had the injuries for 6 months b- the patient takes oral hypoglycemic agents daily c- the patient states that the injuries are very painful d- the patient has several incisions that formed keloids

b- the patient takes oral hypoglycemic agents daily

The nurse is caring for a patient with a diagnosed case of C. diff. The nurse expects to implement which of the following interventions? (select all that apply) a- administration of protease inhibitors b- use of personal protective equipment c- patient teaching methods on transmission d- preventing visitors from entering the room e- administration of intravenous fluids f- strict monitoring of intake and output

b- use of personal protective equipment c- patient teaching methods on transmission e- administration of intravenous fluids f- strict monitoring of intake and output

A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following? a- "When travelling outside of the country, I need to be sure that I receive appropriate vaccinations" b- Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has not resistance" c- "If I don't feel sick, then I don't have to worry about transmitted diseases" d- "I need to be sure to have good hygiene practices when traveling in crowded planes and trains"

c- "If I don't feel sick, then I don't have to worry about transmitted diseases"

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a- Bleeding during tooth brushing b- Painful blisters at the lip border c- Red, velvety patches on the buccal mucosa d- White, curdlike plaques on the posterior tongue

c- Red, velvety patches on the buccal mucosa

A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace has sever pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a- keep the patient NPO for 2 hours before the dressing changes b- give the prescribed prochlorperazine before dressing changes c- administer prescribed morphine sulfate before dressing changes d- avoid performing dressing changes close to the patient's mealtimes

c- administer prescribed morphine sulfate before dressing changes

a 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of GERD, what should the nurse plan to assess more frequently than is routine? a- apical pulse b- bowel sounds c- breath sounds d- abdominal girth

c- breath sounds

A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instruction are most important for the nurse to teach the patient and family? a- change the patient's bedding frequently b- apply to a hydrocolloid dressing over the injury c- change the patients position every 1 to 2 hours d- record the size and appearance of the injury weekly

c- change the patients position every 1 to 2 hours

A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). The patient denies any comfort. Which action by the nurse is appropriate. a- apply a cooling blanket b- notify the health care provider c- check the patient's temperature again in 4 hours d- give acetaminophen prescribed as-needed for pain

c- check the patient's temperature again in 4 hours Mild to moderate temp doesn't harm young patients, and may benefit host defense mechanisms. Continue to monitor.

Which patient choice for a snack 3 hours before bedtime indicates the nurse's teaching about GERD has been effective? a- chocolate pudding b- glass of low-fat milk c- cherry gelatin with fruit d- peanut butter jelly sandwich

c- cherry gelatin with fruit

A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a- dry gauze dressing b- nonadherent dressing c- hydrocolloid dressing d- transparent film dressing

c- hydrocolloid dressing

While reviewing CBC of a patient on her unit, the nurse notes elevated basophils and eosinophil readings. The nurse realizes that this is most indicative of which type of infection. a- bacterial b- fungal c- parasitic d- viral

c- parasitic

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks chain of infection by eliminating which element. a- host b- mode of transmission c- portal of entry d- reservoir

c- portal of entry

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a- skin flushing b- muscle cramps c- rising body temperature d- decreasing blood pressure

c- rising body temperature

A patient from a LTC facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury? a- stage 1 b- stage 2 c- stage 3 d- stage 4

c- stage 3 a stage 3 pressure injury has full-thickness damage and extends into the subcutaneous tissue. a stage 1 pressure injury, skin is intact with some redness on skin. a stage 2 is partial thickness skin loss. stage 4 has full-thickness damage with necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

The nurse should plan to use a wet-to-dry dressing for which patient? a- A patient who has a pressure ulcer with pink granulation tissue b-A patient who has a surgical incision with pink, approximated edges c- A patient who has a full-thickness burn filled with dry, black material d- A patient who has a wound with purulent drainage and dry brown areas

d- A patient who has a wound with purulent drainage and dry brown areas

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a- Soak the old dressings with sterile saline 30 minutes before removing them. b- Pour sterile saline onto the new dry dressings after the wound has been packed. c- Apply antimicrobial ointment before repacking the wound with moist dressings. d- Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

d- Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a- The family member uses a lift sheet to reposition the patient. b- The family member uses clean tap water to clean the wound. c- The family member places contaminated dressings in a plastic grocery bag. d- The family member dries the wound using a hair dryer set on a low setting.

d- The family member dries the wound using a hair dryer set on a low setting.

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a- The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b- The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c- The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d- The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

d- The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide. pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a- monitor WBC b- check the skin areas for redness c- measure the temperature every 2 hours d- ask about feelings of fatigue or malaise

d- ask about feelings of fatigue or malaise

How should the nurse explain esomeprazole (Nexium) to a patient with recurring heartburn? a- it reduces gastroesophageal reflux by increasing the rate of gastric emptying b- it neutralizes stomach acid and provide relief of symptoms in a few minutes c- it coats and protects the lining of the stomach and esophagus from gastric acid d- it treats GERD by decreasing stomach acid production

d- it treats GERD by decreasing stomach acid production

What should the nurse anticipate teaching a patient with a new report of heartburn? a- a barium swallow b- radionuclide tests c- endoscopy procedures d- protein pump inhibitors

d- protein pump inhibitors

In order to provide and intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a- whether a patient has an infection b- where an infection is located c- the type of cells that are being utilized by the body to attack an infection d- the specific type of pathogen that is causing an infection

d- the specific type of pathogen that is causing an infection

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a- eschar b- slough c- maceration d- undermining

d- undermining