NUR 204 Exam 2

A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1) Chest pain, pneumonitis, and inflammation of the mouth 2) Intestinal obstruction and numbness of the hands 3) Hypotension, oliguria, and tingling of the feet 4) Tachycardia, hematuria, and diaphoresis

1) Chest pain, pneumonitis, and inflammation of the mouth

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1) Encourage the child to continue coughing. 2) Deliver upward abdominal thrusts with a fisted hand. 3) Deliver five rapid back blows between the shoulder blades. 4) Perform a blind finger sweep of the childs mouth.

1) Encourage the child to continue coughing.

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately.

1) Remove the contaminated clothing immediately.

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning)

1) Risk for Falls

1 pt = ? oz

16 oz

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate tsp and tbsp. How many tsp should the nurse instruct the parent to give the child?

2 tsp

A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next? 1) Perform the Get Up and Go Test. 2) Ask the patient if he has fallen in the past year. 3) Refer the patient for a comprehensive fall evaluation. 4) Administer the Timed Up and Go Test.

2) Ask the patient if he has fallen in the past year.

A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first? 1) Apply a cloth vest restraint. 2) Encourage a family member to stay with the patient. 3) Administer lorazepam (an antianxiety medication). 4) Keep the patients bed side rails up.

2) Encourage a family member to stay with the patient.

A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient? 1) Avoid giving the patient a complete bed bath. 2) Limit the amount of time spent with the patient. 3) Allow extra time for the patient to express feelings. 4) Do not allow anyone to visit the patient.

2) Limit the amount of time spent with the patient.

When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease? 1) Take a calcium supplement twice a day. 2) Start a weight-bearing exercise program. 3) Avoid strenuous activity that puts stress on the bones. 4) Schedule regular healthcare checkups.

2) Start a weight-bearing exercise program.

A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first? 1) Administer a dose of syrup of ipecac. 2) Administer activated charcoal immediately. 3) Give water to the child immediately. 4) Call the nearest poison control center.

3) Give water to the child immediately.

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a rx for an isotonic enteral nutrition formula.

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

"I'll wear non-sterile gloves"

A nurse is teaching a client who is post-op about the importance of turning, coughing and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"If I do this often, I won't get pneumonia." This promotes lung expansion and secretion removal.

Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? 1) Alginate dressing 2) Dry gauze dressing 3) Hydrogel 4) Hydrocolloid dressing

1) Alginate dressing Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin.

The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, I feel so light-headed and weak, as her knees begin to buckle. The nurses best action at this time would be to: 1) Assist the patient to slide down his leg as he guides her to a seated or lying position. 2) Grab her under the arms and hold her up as he calls for assistance. 3) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall. 4) Instruct the patient to grab the rail in the hallway while he calls for assistance.

1) Assist the patient to slide down his leg as he guides her to a seated or lying position.

Pressure ulcers are directly caused by which of the following conditions at the site? 1) Compromised blood flow 2) Edema 3) Shearing forces 4) Inadequate venous return

1) Compromised blood flow Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing? 1) Fowlers position 2) Sims position 3) Lateral recumbent position 4) Lateral position

1) Fowlers position

A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time she has not had a bowel movement, although normally, passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? 1) Immobility often causes constipation. 2) A stool softener daily will relieve the problem. 3) Use of a bedpan results in bloating and constipation. 4) A low-fiber diet will resolve the problem.

1) Immobility often causes constipation.

Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incisional site 2) Dehiscence of the wound 3) Hematoma under the skin 4) Formation of granulation tissue

1) Infection at the incisional site

Why is an accurate description of the location of a wound important? Choose all that apply. 1) Influences the rate of healing 2) Determines the appropriate treatment choice 3) Will affect the frequency of dressing changes 4) Affects patient movement and mobility

1) Influences the rate of healing 4) Affects patient movement and mobility Wounds in highly vascular areas heal more rapidly than wounds in less vascular regions. Wounds that can be stabilized also heal more readily than those in areas of stress. Treatment choices and frequency of dressing changes will be dependent on the condition of the wound, not the location.

When applying heat or cold therapy to a wound, what should the nurse do? 1) Leave the therapy on each area no longer than 15 minutes. 2) Leave the therapy on each area no longer than 30 minutes. 3) When using heat, ensure the temperature is at least 135F (57.2C) before applying it. 4) When using cold, ensure the temperature is less than 32F (0C) before applying it.

1) Leave the therapy on each area no longer than 15 minutes.

An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis? 1) Loss of bone density that increases the risk of fracture 2) Degenerative joint disease that produces pain and decreased function 3) Chronic inflammatory joint disease that must be treated with steroids 4) Acute infection in the bone that must be treated with antibiotics

1) Loss of bone density that increases the risk of fracture

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? 1) Partial-thickness wound 2) Penetrating wound 3) Superficial wound 4) Full-thickness wound

1) Partial-thickness wound Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

What would be the most appropriate goal for a frail, elderly patient with a nursing diagnosis of Risk for Injury after hip surgery? 1) Remain free from injury or falls throughout hospital stay. 2) Increase activity tolerance by discharge from hospital. 3) Demonstrate effective breathing when ambulating. 4) Increase mobility by discharge from hospital.

1) Remain free from injury or falls throughout hospital stay. Remaining free from injury or falls is a measurable goal, and it is directly related to the patients nursing diagnosis, Risk for Injury. Increasing activity tolerance and mobility by the time of discharge is not specific and measurable. Additionally, these outcomes do not relate to Risk for Injury. A goal of effective breathing for a frail, elderly patient after hip surgery does not relate to Risk for Injury.

What is the primary goal that the nurse should establish for a patient with an open wound? 1) The wound will remain free of infection throughout the healing process. 2) Client completes antibiotic treatment as ordered. 3) The wound will remain free of scar tissue at healing. 4) Client increases caloric intake throughout the healing process.

1) The wound will remain free of infection throughout the healing process.

Which of the following are examples of nonselective mechanical dbridement methods? Choose all that apply. 1) Wet-to-dry dressings 2) Sharp dbridement 3) Whirlpool 4) Pulsed lavage

1) Wet-to-dry dressings 3) Whirlpool 4) Pulsed lavage Wet-to-dry dressings, sharp dbridement, and pulsed lavage are all forms of mechanical dbridement. They are nonselective forms, which means that healthy tissue as well as devitalized tissue can be removed with their use. Sharp dbridement is a selective form of dbridement. With sharp dbridement, only devitalized tissue is removed.

Which of the following describes the difference between dehiscence and evisceration? 1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. 3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. 4) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

1 gr =

1000 mg

How many mL are in a tbsp?

15mL

1 lb = ? oz

16 oz

A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1) Steri-Strips 2) Abdominal binder 3) T-binder 4) Paper tape

2) Abdominal binder An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be needed for an approximated incision that has intact staples, sutures, or surgical glue.

What is a common characteristic of aging skin? 1) Increased permeability to moisture 2) Diminished sweat gland activity 3) Reduced oxygen-free radicals 4) Overproduction of elastin

2) Diminished sweat gland activity Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infants skin is thinner and more permeable to moisture in the environment.

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Choose all that apply. 1) Granulation 2) Hemostasis 3) Epithelialization 4) Inflammation

2) Hemostasis 4) Inflammation During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site.

Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity. 2) Increase the risk of ischemia. 3) Delay wound healing. 4) Predispose to hematoma formation.

2) Increase the risk of ischemia.

Which of the following body systems must interact to produce mobility and locomotion? Choose all that apply. 1) Digestive system 2) Muscles 3) Skeleton 4) Nervous system

2) Muscles 3) Skeleton 4) Nervous system

Which is the most commonly reported incident in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays

2) Patient falls

A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? 1) Risk for Infection related to subcutaneous injuries 2) Risk for Impaired Skin Integrity related to immobility 3) Impaired Tissue Integrity related to ventilator dependency 4) Impaired Skin Integrity related to ventilator dependency

2) Risk for Impaired Skin Integrity related to immobility This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1) Primary intention healing. 2) Secondary intention healing. 3) Tertiary intention healing. 4) Approximation healing.

2) Secondary intention healing. Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges.

While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? 1) Sanguineous 2) Serosanguineous 3) Serous 4) Purosanguineous

2) Serosanguineous Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged.

Which of the following patients would you expect to be at risk for decreased activity? Choose all that apply. 1) Older adult who walks at the mall for physical activity 2) Someone living in a skilled nursing facility 3) Healthy adult who works as a computer programmer 4) Obese child who enjoys video games

2) Someone living in a skilled nursing facility 3) Healthy adult who works as a computer programmer 4) Obese child who enjoys video games

An 82-year-old patient is unsteady on her feet when walking about the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate? 1) Crutches 2) Transfer belt 3) Cane 4) Walker

2) Transfer belt Crutches are commonly used when the patient has an injured lower extremity. A cane or walker is generally used for the patient with a lower extremity injury or weakness. The most appropriate equipment to use would be a transfer belt. A transfer belt allows the patient the greatest amount of independence while ensuring safety.

1 kg = ? lb

2.2 lbs

How many mL are in 1 cup?

240 mL

What action is most important in limiting the nurses risk of back injuries? 1) Use good body mechanics at all times. 2) Work with another nurse or an aide when lifting and turning patients. 3) Avoid manual lifting by using assistive devices as often as possible. 4) Develop a lift team at the clinical site.

3) Avoid manual lifting by using assistive devices as often as possible. Back injuries are the leading cause of injury among nurses. Good body mechanics and teamwork limit the risk of injury. However, the American Nurses Associations (ANA) Handle with Care program advocates the regular use of assistive devices as well as avoiding manual lifting.

What are two risk assessment tools used in the United States to evaluate a patients risk for pressure ulcers? Choose all that apply. 1) Pressure ulcer healing chart 2) PUSH tool 3) Braden scale 4) Norton scale

3) Braden scale 4) Norton scale The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the risk for pressure ulcers based on the patients physical condition, mental state, activity, mobility, and incontinence. These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer.

In order to achieve balance, body mass must be distributed around which point? 1) Center of body alignment 2) Center of balance 3) Center of gravity 4) Base of support

3) Center of gravity

What intervention would be most appropriate for a wound with a beefy red wound bed? 1) Mechanical debridement 2) Autolytic debridement 3) Dressing to keep the wound moist and clean 4) Removal of devitalized tissue and a sterile dressing

3) Dressing to keep the wound moist and clean

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) Transparent film dressing 2) Sheet hydrogel 3) Frequent turn schedule 4) Enzymatic dbridement

3) Frequent turn schedule The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic dbridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure.

A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? 1) Dry gauze dressing changed twice daily 2) Nonadherent dressing with daily wound care 3) Hydrocolloid dressing changed as needed 4) Wet-to-dry dressings changed three times a day

3) Hydrocolloid dressing changed as needed A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic dbridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical dbridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well.

Which client does the nurse recognize as being at greatest risk for pressure ulcers? 1) Infant with skin excoriations in the diaper region 2) Young adult with diabetes in skeletal traction 3) Middle-aged adult with quadriplegia 4) Older adult requiring use of assistive device for ambulation

3) Middle-aged adult with quadriplegia The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal.

What is the function of the stratum corneum? 1) Provides insulation for temperature regulation 2) Provides strength and elasticity to the skin 3) Protects the body against the entry of pathogens 4) Continually produces new skin cells

3) Protects the body against the entry of pathogens The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals.

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? 1) The patient will need to take antibiotics until the wound is completely healed. 2) Because the patients wound was left open, the wound will likely become infected. 3) The patient will have more scar tissue formation than for a wound closed at surgery. 4) The patient should expect to remain hospitalized until complete wound healing occurs.

3) The patient will have more scar tissue formation than for a wound closed at surgery. Because the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.

For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? 1) Client will maintain intact skin throughout hospitalization. 2) Client will limit pressure to wound site throughout treatment course. 3) Wound will close with no evidence of infection within 6 weeks. 4) Wound will improve prior to discharge as evidenced by a decrease in drainage.

3) Wound will close with no evidence of infection within 6 weeks. The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

A frail 78-year-old man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight-bearing on his left lower leg. What is the best intervention to help him use his walker? 1) Aerobic exercise with deep breathing 2) Quadriceps and gluteal repetitions 3) Isometric toning of lower legs 4) Arm resistance training

4) Arm resistance training

A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer? 1) Antibiotic therapy for 2 weeks 2) Normal saline irrigation of the ulcer daily 3) Debridement to the left heel 4) Elevation of the left heel off the bed

4) Elevation of the left heel off the bed

What is the primary difference between acute and chronic wounds? Chronic wounds: 1) Are full-thickness wounds, but acute wounds are superficial. 2) Result from pressure, but acute wounds result from surgery. 3) Are usually infected, whereas acute wounds are contaminated. 4) Exceed the typical healing time, but acute wounds heal readily.

4) Exceed the typical healing time, but acute wounds heal readily.

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? Choose all that apply. 1) Is actively bleeding 2) Has swollen, tender insect bite 3) Has just sprained her ankle 4) Has lower back pain

4) Has lower back pain Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain.

Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: 1) Remove all of the soiled dressings before beginning wound treatment. 2) Cleanse wounds from most contaminated to least contaminated. 3) Treat wounds on the patients side first, then the front and back of the patient. 4) Irrigate wounds from least contaminated to most contaminated.

4) Irrigate wounds from least contaminated to most contaminated. To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery who also has a history of emphysema. 1) Impaired Mobility related to weakness 2) Ineffective Breathing Pattern related to disease process 3) Activity Intolerance related to injury 4) Risk for Injury related to medical condition

4) Risk for Injury related to medical condition The patients medical condition places him at an increased Risk for Injury: He is at risk for falls and for further injury to his hip. The patient does have Impaired Mobility; however, his Impaired Mobility puts him at Risk for Injury. A diagnosis of Impaired Mobility would focus the outcomes on improving his mobility rather than protecting him from further injury. We have no data other than a diagnosis of emphysema to indicate that he is experiencing Ineffective Breathing Pattern. He is experiencing Activity Intolerance, but this is not his primary safety risk. A diagnosis of Activity Intolerance would focus the goals on increasing his endurance and conserving his energy.

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? 1) Stage I pressure ulcer, healing 2) Stage II pressure ulcer, healing 3) Stage III pressure ulcer, healing 4) Stage IV pressure ulcer, healing

4) Stage IV pressure ulcer, healing Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? 1) Primary intention 2) Regenerative healing 3) Secondary intention 4) Tertiary intention

4) Tertiary intention Tertiary intention is a technique used when a wound is clean contaminated or dirty (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed.

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: 1) The ulcer is completely healed with minimal scarring. 2) The patient reports no pain at the site. 3) A minimal amount of drainage is noted. 4) The wound bed contains 100% granulated tissue.

4) The wound bed contains 100% granulated tissue. A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, and bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently and has developed strong upper-body strength to maximize his independence. Which transfer device should be used when transferring him from the bed to his wheelchair? 1) Mechanical lift 2) Transfer belt 3) Draw sheet 4) Transfer board

4) Transfer board A transfer board is used by patients with longstanding mobility problems; it offers them the greatest amount of independence while ensuring safety. Patients using a transfer board should have sufficient upper-body strength to perform the transfer safely. A mechanical lift could be used, but it does not promote independence. A transfer belt is used for clients who are able to stand. A draw sheet is useful for moving a patient in bed rather than from bed to wheelchair.

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? 1) Stage II pressure ulcer 2) Stage III pressure ulcer 3) Stage IV pressure ulcer 4) Unstageable pressure ulcer

4) Unstageable pressure ulcer An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1) Draw a circle around the area of drainage on a dressing. 2) Classify drainage as less or more than the previous drainage. 3) Weigh the patient at the same time each day on the same scale. 4) Weigh dressings before they are applied and after they are removed.

4) Weigh dressings before they are applied and after they are removed. By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound, but it does not provide information how much fluid is draining.

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: 1) begins an aggressive exercise program. 2) follows a diet plan of 1,200 calories per day. 3) is fitted for deep-depth diabetic footwear. 4) remains free of foot wounds.

4) remains free of foot wounds.

1 lb = ? grams

454 grams

How mL are in a tsp?

5mL

How many oz are in 1 cup?

8 oz

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?

Assessment

A nurse is teaching a client with lower extremity weakness to use a 4 point crutch gait. Which of the following instructions should the nurse include in the teaching?

Bear weight on both of your legs The client should keep 3 points on the ground at all times. Therefore, he must be able to bear weight on both legs.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse is caring for a client who requires a dressing change. Which of the following action should the nurse take?

Clean the drain site from the center outward? The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound.

A nurse is teaching a client who is post op how to use a flow oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough Deeply after each use. Proper use loosens the secretions in the client's lungs. The client should cough deeply to facilitate the removal of the secretions from his lungs.

A nurse is caring for a client who is postoperative following abd sx. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated.

Cover the incision with a moist sterile dressing.

A nurse is caring for a client who is immobile. The nurse should recognize that mobility places the client at risk of which of the following health alterations?

Decreased cardiac output

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning?

During the admission process

A nurse is caring for an adult client who has an NG tube in place and a rx for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration?

Elevate the head of the bed to 30 to 45 degrees.

A nurse is caring for a client who has an NG tube for intermitten enteral feedings. Which of the following action should the nurse take?

Elevate the head of the client's bed to 45 degrees before the feeding

A nurse is preparing to administer a feeding via a NG tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding?

Elevate the head of the client's bed. Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Establish Client Outcomes. The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care.

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?

Evacuate the client from the room. The acronym RACE can help nurses remembered the order of the actions to take in the event of a fire. The components of RACE are rescue, activate, confine and extinguish. The priority is rescuing or removing the client from immediate danger. The second action is activation of the fire alarm system. Third action is confining the fire by closing doors and windows. The final action is extinguishing the fire, if possible, using an available fire extinguisher.

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility?

Evacuate the clients from the unit

_________ is total separation of the layers of a wound with internal viscera protruding through the incision.

Evisceration

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following finding places the client at risk of impaired skin integrity

Faint Pedal Pulses

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowler's Sitting upright promotes full expansion of both lungs and facilitates ventilation and perfusion.

A nurse is performing a comprehensive physical assessment of a client. Thee nurse should use inspection to assess which of the following?

Gait

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, Which should occur within 5 to 21 days. Open wounds increase the risk of wound infection.

A nurse is teaching a client who is recovering from galbladder sx how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

Hold the breath for 5 seconds after goal volume is reached The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia.

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid The nurse should apply a hydrocolloid dressing to the stage II pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin.

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statement by the client indicates an understanding of the teaching?

I will put a night light in the hallways.

A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further teaching is required.

If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself.

A nurse is in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hours while awake to help prevent thrombophlebitis.

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

Keep the rubber crutch tips securely in place. The client should never use crutches w/o the rubber crutch tips. The client should inspect that tips regularly, replace them when they show signs of wear, and remove and dry them thoroughly with paper towels if they come wet.

A nurse is receiving a client from the PACU who is post-op following abd sx. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher.

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head. To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or another soft object under the client's head.

A nurse is caring for a client who had a stroke and is at risk for of fallings. Which of the following actions should the nurse take?

Monitor the client at least once every hour.

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour.

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition Nutrition, sensory perception, moisture, activity, mobility and friction and shear are the parameters on the braden scale for determining a client's risk of developing pressure ulcers.

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside?

O2 equipment

A nurse on a med-surg unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information The nursing process is bases on scientific process. The first step is collecting data. Therefore. the 1st step in the nursing process is assessing and obtaining info about the client.

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques.

Palpation With palpation, the nurse uses touch to help detect unusual or expected sensations including texture, temp, masses or moisture.

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Perform Blanch Test

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Perform a blanch test The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

A nurse is preparing to provide chest physiotherapy for a client who has lower left lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in the trendelenburg position. The nurse should place the client in a right sided trendelenburg position to promote drainage from the client left lower lobe.

A nurse on a rehab unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed. Positioning the wheelchair at a 45 degree angle allows the patient to pivot. lessening the amt of rotation required.

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?

Position the client for drainage of secretions by gravity.

A nurse is planning care for a client who has a single lumen NG tube for gastric decompression. Which of the following action should the nurse include in the plan of care?

Provide oral hygiene frequently Measure the amt of drainage from the NG tube every shift Secure the NG tube to the client's gown.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly. The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is changing the dressings for a client who is 3 days post-op following the cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent Exudate Purulent Exudate on the client's dressings include thick yellow, green, or brown drainage and usually indicates wound sloughing or infection.

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure.

Raise your index finger if you need to pause during the insertion.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the clients is in restraints?

Remove the restraints one at a time. The nurse should remove one restraint at a time for a client who is violent or noncompliant.

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher.

A nurse is planning care for a client who is confused and requires a rx for wrist restraints. Which of the following intervention should the nurse include in the plan of care?

Renew the rx for the use of restrains within 24 hours. The nurse should plan to renew the rx for the restraints within 24 hours, only after the provider has evaluated the client.

A nurse is planning to perform PROM exercise for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session. To maintain the clients joint mobility, the nurse should repeat each motion 3 to 5 times.

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg Test When using the Romberg test, the nurse instructs the client to stand with the feet together and arms at the sides, first with the eyes open and then with eyes closed.

A community health nurse is conducting a class about body mechanics for county workers. Which of the following instructions should the nurse include? Select all that apply.

Sit with your back supported Keep your knees are hip level Use a ergonomically designed computer keyboard. Lumbar support in a straight back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic positioning of the wrist can help prevent carpal tunnel syndrome.

A nurse on a med surge unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

Suction Equipment

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicated safe useage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches.

The nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches. The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not the axillae.

A nurse is assisting a client who has right sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground When ambulating with a cane, the client should keep 2 points of support on the ground at all times. Which can be either both feet or a foot and the cane.

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures.

A nurse is caring for a client who has a rx for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick release knot.

A nurse is caring for a client who was admitted to a long term care facility for rehab after total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation. Nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement?

Verify the initial xray exam measure the length of the exposed tube determine the pH of the aspirated fluid.

A nurse is planning for a client who has a wound infection following abd sx. To promote healing and fight infection, whic of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and Zinc.

A nurse is reviewing measures to prevent back injuries with an AP. Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support. The AP should spread the feet apart because a wide base of support increases stability.

A nurse is assessing a 74-year-old male patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, I have to stop. I cant do this anymore. The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? 1) Anxiety 2) Orthostatic hypotension 3) Limited activity tolerance 4) Respiratory distress

3) Limited activity tolerance

A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? 1) Active ROM 2) Turning the patient every 2 hours 3) Passive ROM 4) Administering glucosamine supplements

3) Passive ROM Passive ROM involves moving the joints through their ROM when the patient is unable to do so for himself. Passive ROM promotes joint mobility. Active ROM would not be possible for a quadriplegic patient. Turning the patient every 2 hours prevents skin breakdown but does not promote mobility or prevent contracture. Glucosamine is a building block for the formation and repair of cartilage. However, there is inconclusive, scientific evidence regarding the benefit of this substance to improve joint function.

What is the correct method for turning an adult patient who recently sustained a spinal cord injury? 1) Ask the patient to assist with the turn by holding the side rails of the bed. 2) Place a draw sheet under the patient to assist with turning. 3) Request help from another nurse to perform the logrolling technique. 4) Use a mechanical lift for safe turning and protecting the nurses back.

3) Request help from another nurse to perform the logrolling technique.

The nurse planning the care for a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patients integument? 1) Offering the patient six small meals a day 2) Assisting the patient to sit in a chair three times a day 3) Turning the patient at least every 2 hours 4) Administering fluid boluses as directed by the healthcare provider

3) Turning the patient at least every 2 hours

1 oz = ? grams

30 grams

1 fl oz = ? mL

30 mL

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel? 1) Assessing the patients status 2) Determining the need for restraint 3) Evaluating the patients response to restraints 4) Applying and removing the restraints

4) Applying and removing the restraints

The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3) A small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair.

4) Clearly label the pump and send it for repair.

Despite less-restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation? 1) Obtain a physicians order before applying restraints. 2) Monitor the patients status every 4 hours while restrained. 3) Release the restraints and check circulation every hour. 4) Continually reevaluate the patients need for restraint.

4) Continually reevaluate the patients need for restraint.

Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning? 1) Store medications on countertops out of the childs reach. 2) Purchase medication in child-resistant containers 3) Take medications in front of the child, and explain that they are for adults only. 4) Never leave the child unattended around medications or cleaning solutions.

4) Never leave the child unattended around medications or cleaning solutions.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client. The nurse should apply the least invasive priority setting framework when caring for this patient, which assigns priority to nursing interventions. Informing the client about the procedure reduces the fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.

A nurse is preparing to administer a bolus feeding to a client through an NG Tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?

Request an x ray of the clients abdomen. The nurse should request an x ray to verify the placement of the NG tube both after the initial insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG tube placement prior to administering a bolus feeding.

A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?

The client holds the hand with the palm up. The nurse should identify the client holding the hand with the palm up as a demonstration of the supination of the hand.

A nurse is applying antiembiolitic stockings for a client who has a hx of DVT. Which of the following actions should nurse take when applying the stocking?

Turn the stocking inside out up to the heel before applying. easier application and causes fewer constrictive wrinkles.