NUR 3110 EXAM 2

A male client who has had outpatient surgery is unable to void while lying supine. Which intervention would be most effective in assisting the client to urinate? A. Assist the client to a standing position. B. Tell the client he has to void to be discharged. C. Ask the spouse to assist with the urinal. D. Run water in a nearby sink.

A

A woman informs the nurse that when she is experiencing stress it is difficult to void, and wonders why this happens. What is the nurse's best explanation? A. "Stress causes the muscles to become tense." B. "You require greater privacy to void." C. "You might have a neurologic condition." D. "What medications are you taking?"

A

During a visit to the pediatrician's office, a parent inquires about toilet training the 2-year-old child. Which toilet training readiness factor should the nurse include in teaching the parent about toilet training? A. When your child can recognize bladder fullness. B. When your child expresses interest in the toilet. C. When your child can hold the urine for 4 to 5 hours. D. When you child continues playing when diapers are wet.

A

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? A. Disconnect the nasogastric tube from suction during the assessment of bowel sounds. B. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. C. Allow the low intermittent suction to continue during the assessment of bowel sounds. D. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.

A

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next? A. Shower, bathe, or wash peristomal area with mild soapy water. B. Fold and clamp bottom of pouch. C. Attach new pouch to the ring of the faceplate. D. Measure the stoma using a stomal guide.

A

The nurse is teaching the Crede maneuver to a client who has difficulty urinating. Which nursing teaching is appropriate? A. "Bend forward and apply pressure over your bladder." B. "Run water from your faucet while you are attempting to urinate." C. "Visualize an ocean or a river as you sit on the toilet." D. "Attempt to void as soon as you wake from sleep."

A

Use of an indwelling urinary catheter leads to the loss of bladder tone. A. True B. False

A

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate? A. briefly clamping the tubing while the client breathes deeply B. reassuring the client that cramping is normal C. removing the tubing immediately D. stopping the infusion

A

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? A. The client is lactose intolerant. B. The client is dehydrated. C. The client has a history of osteoarthritis. D. The client is on a low protein diet.

B

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed? A. irritates local tissue B. lubricates and softens stool C. distends rectum and moistens stool D. distends rectum and irritates local tissue

B

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? A. Ensure the tip of the tubing is touching the tip of the client's penis. B. Fasten the condom securely enough to prevent leakage without constricting blood flow. C. Remove the catheter every 8 hours, or more often in humid weather. D. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application.

B

Occult blood testing has been ordered for a hospitalized client. Which meal would be acceptable for a client receiving occult blood testing? A. pot roast with potatoes, carrots, and gravy; applesauce; and gelatin with bananas B. macaroni and cheese, corn, lettuce salad, and vanilla pudding C. tofu with peanut sauce, snow peas, cauliflower, and ginger snaps D. spaghetti with meat sauce, garlic bread, and chocolate cake

B

The health care provider has requested a urine sample from a female client for urinalysis. Which method should the nurse instruct the client to use to obtain a clean-catch urine? A. "Begin to urinate while continuing to hold the labia apart. Catch all urine in the container." B. "Begin to urinate while continuing to hold the labia apart. Allow the first urine to flow into the toilet." C. "Urinate directly into the specimen container, filling it half full." D. "Catch your first urine of the day directly into the specimen container."

B

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? A. 5 in (12.5 cm) B. 3 in (7.5 cm) C. 2 in (5.0 cm) D. 1 in (2.5 cm)

B

Which client is most likely to require interventions in order to maintain regular bowel patterns? A. a woman 59 years of age who has recently begun hormone replacement therapy B. a client whose neuropathic pain requires multiple doses of opioids each day C. a client with hypertension who takes a diuretic and adrenergic blocker each morning D. a client who has a history of atrial fibrillation requiring daily anticoagulants

B

A nurse is collecting a urine specimen for urinalysis. Which factors should the nurse consider when performing this procedure? Select all that apply. A. A sterile urine specimen is required for a routine urinalysis. B. Sterile urine specimens may be obtained by catheterizing the client's bladder. C. Urine should be left standing at room temperature for a 24-hour period before being sent to the laboratory. D. If a woman is menstruating, a urine specimen cannot be obtained for urinalysis. E. Strict aseptic technique must be used when collecting and handling urine specimens. F. A clean-catch specimen of urine may be collected in midstream.

B E F

A nurse prepares a client with a recently created ileal conduit to be discharged from the hospital. Which is an expected assessment finding? A. Stoma is pale to light pink in color. B. Stoma is flush with the abdominal surface. C. Mucus in the urine is a normal finding. D. Stoma is fully stable.

C

A school nurse is educating a class of female middle school students on how to promote urinary system health. Which statement by one of the girls indicates understanding? A. "I will wear tight pants to prevent germs from entering." B. "I will tell my parents if I have any symptoms like burning or pain." C. "I will wipe from front to back after going to the toilet." D. "I will drink more water to make sure germs do not stay in my body."

C

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? A. Remove the catheter from the vagina and attempt to insert it into the bladder. B. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. C. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. D. Ask the client to bear down until the catheter is expelled.

C

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? A. 67-year-old client with constipation B. 33-year-old client who reports painful elimination C. 50-year-old client with a family history of polyps D. 42-year-old client with diarrhea twice weekly

C

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? A. barium studies, fecal occult blood test, endoscopic examination B. barium studies, endoscopic examination, fecal occult blood test C. fecal occult blood test, barium studies, endoscopic examination D. endoscopic examination, barium studies, fecal occult blood test

C

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? A. "This test will show if you have an infection in the bowel." B. "This test will show if you have colorectal cancer." C. "This test detects heme, a type of iron compound in blood in the stool." D. "This test will determine whether foods are contributing to rectal bleeding."

C

While reading a client's history, the nurse notes that a client has a colostomy. When assessing the client, the nurse notes that the output is formed stool. What should the nurse do? A. Contact the physician immediately. B. Give the client the ordered laxative. C. Document the output; this is normal. D. Assess for obstruction.

C

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? A. need to void is perceived frequently, with short-lived ability to sustain control of flow B. loss of small amount of urine when intra-abdominal pressure rises C. loss of urine control because a toilet is not accessible D. loss of urine without any identifiable pattern or warning

D

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client? A. "How often do you have a bowel movement?" B. "Are you on any blood pressure medications?" C. "Are you on any type of special diet at home?" D. "How frequently do you urinate each day?"

D

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? A. return-flow enema B. retention enema C. carminative enema D. cleansing enema

D

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? A. Checking for blood return in the CVC B. Obtaining laboratory studies C. Placing the client as N.P.O. status D. Notifying the health care provider of the assessment findings

D

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? A. Turn off the suction for 30 minutes and then turn it on again. B. Remove the NG tube and replace it with a larger-bore tube, as ordered. C. Instill digestive enzymes, as ordered. D. Attempt to irrigate the NG tube with water or normal saline.

D

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states, "I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse? A. "There may be something wrong since your child should be toilet trained by 2 years-old." B. "You are putting too much pressure on yourself and your child to toilet train." C. "There is nothing to worry about. Just keep the child in diapers until they stop having accidents." D. "Children vary in their readiness but daytime bowel control may be attained at 30 months."

D

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? A. before bedtime B. evening C. afternoon D. first thing in the morning

D

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: A. deep palpation. B. light palpation. C. percussion. D. auscultation.

D

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education? A. "At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night." B. "I've made a point of scheduling when I drink water instead of waiting until I'm thirsty." C. "I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper." D. "I make sure to limit how much I drink so that I don't have accidents."

D

The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take? A. Gather appropriate supplies to teach the client to perform straight catheterization. B. Continue to place the indwelling catheter because it has been prescribed. C. Inform the client that the health care provider will be contacted. D. Ask the client why he or she does not want a catheter.

D

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? A. strongly aromatic, amber B. light yellow, clear C. clear, dark amber D. cloudy, foul odor

D

The nurse is caring for a client who reports having cloudy, foul-smelling urine. Which assessment question should the nurse ask the client? A. "Are you having episodes of clear urine mixed with episodes of cloudy urine?" B. "Do you have difficulty starting the stream of urine?" C. "Do you have constipation?" D. "Are you experiencing burning and frequency?"

D

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? A. The stoma is on the abdominal surface. B. The stoma has a small amount of bleeding. C. The stoma is pink. D. The stoma is prolapsed.

D

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? A. suprapubic catheter B. indwelling urethral catheter C. Foley catheter D. straight catheter

D

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? A. Nurses find the procedure distasteful and difficult to perform. B. Most clients will not consent to have digital removal of stool. C. It often causes rebound diarrhea and electrolyte loss. D. Digital removal of stool may cause parasympathetic stimulation.

D

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? A. Daytime continence is usually not achieved by boys until age 5. B. Boys may walk by 1 year and should be continent by 3 years. C. Incontinence after the age of 3 years is not normal. D. Boys may take longer for daytime continence than girls.

D

The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn? a. gauze b. tape with eyelets c. transparent d. hydrocolloid

a

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? a. "Very little scar tissue will form." b. "The margins of your wound are not in direct contact." c. "The surgeon will leave your wound open intentionally for a period of time." d. "This is a complex reparative process."

a

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? a. incision b. avulsion c. abrasion d. laceration

a

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. a. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. b. incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes c. a wound that forms exudate due to the inflammatory response d. . a wound that does not feel hot and tender upon palpation e. a wound with increased swelling and drainage that may occur during the first 5 days of wound healing f. a wound that takes approximately 2 weeks for the edges to appear approximated and heal together

a c d

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply. a. A nurse uses aseptic techniques when changing a dressing. b. A nurse places a Surgipad directly over an incision. c. A nurse places a drainage dressing around a drain insertion site. d. A nurse places a transparent dressing over a central venous access device insertion site. e. A nurse applies Telfa to a wound to keep drainage from passing through to a secondary dressing. f. A nurse places a transparent dressing over an ABD pad to help keep the wound dry.

a c d

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? a. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. b. Rotate the swab several times over the wound surface to obtain an adequate specimen. c. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. d. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station.

b

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? a. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b. "Your wound will heal slowly as granulation tissue forms and fills the wound." c. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." d. "As soon as the infection clears, your surgeon will staple the wound closed."

b

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? a. Gently rub and massage the area to warm it up. b. Discontinue the therapy and assess the client. c. Document the findings in the client's medical record. d. Notify the health care provider of the findings.

b

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

b

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

b

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? a. Evisceration b. Desiccation c. Necrosis d. Maceration

b Desiccation is localized wound dehydration. Maceration is localized wound over hydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The wound care nurse is performing assessment of clients. Which wound complications does the nurse report to the health care provider? Select all that apply. a. a wound with approximated edges 3 days after a surgical procedure b. a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5 c. partial disruption of wound layers d. a wound with a pink wound bed and no drainage present e. viscera protruding through the incisional area f. fistula formation

b c e f

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. a. Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. b. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. c. Apply a nonabsorbent material over the first layer of absorbent material. d. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. e. Apply an absorbent dressing material as the first layer of the dressing. f. Change the dressing midway between meals.

b d f

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? a. The event leading up to the trauma b. If there is contamination of dirt and debris c. The status of the client's tetanus immunization d. Staging the wound for assessment

c

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? a. primary intention b. maturation c. secondary intention d. tertiary intention

c

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? a. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. b. Do not attempt to remove the sutures because the wound needs more time to heal. c. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. d. Carefully pick the crusts off the sutures with the forceps before removing them.

c

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? a. "That is called slough, and it will usually fall off." b. "This is normal tissue." c. "Necrotic tissue is devitalized tissue that must be removed to promote healing." d. "You are seeing undermining, a type of tissue erosion."

c

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. a client who must remain on the back for long periods of time b. a client who lifts himself up on the elbows c. a client sitting in a chair who slides down d. a client who lies on wrinkled sheets

c

A client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment? a. "Douching is recommended so that you are clean for the examination." b. "Plan to begin douching routinely immediately after your procedure." c. "The Pap procedure includes application of a douche." d. "Do not douche for 24-48 hours before the procedure."

d

A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document? a. Staging of the surgical wound b. Cardiac and respiratory function c. Length, width, and depth of the wound d. Presence of abnormalities that would impede healing

d

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? a. sanguineous b. serous c. purulent d. serosanguineous

d

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? a. stage IV b. stage I c. stage II d. stage III

d

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? a. hydrocolloid b. bandage c. gauze d. transparent

d

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 in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? a. a gauze dressing premedicated with antibiotics b. a gauze dressing precut halfway to fit around the IV line c. a dressing with a nonadherent coating d. a transparent film

d

Which is not considered a skin appendage? a. Sebaceous gland b. Eccrine sweat glands c. Connective tissue d. Hair

c

Which term refers to the inability to recognize objects through a particular sensory system? a. Ataxia b. Dementia c. Agnosia d. Aphasia

c

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? A. dark brown, cloudy B. reddish-brown, clear C. aromatic, green D. clear, light yellow

A

A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced? A. total B. urge C. stress D. reflex

A

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? A. The client will have to wear an external appliance to collect urine. B. This urinary diversion is only temporary. C. Urination can be voluntarily controlled after the stoma heals from the initial surgery. D. The client will need to change the urinary pouch every 4 hours.

A

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation? A. Prime the tubing with the solution. B. Empty the balloon with a syringe. C. Place the sterile solution on the bed. D. Clean around the urinary meatus.

A

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter? A. a flexible sheath that is rolled around the penis B. a urine drainage tube that is left in place over a period of time C. a bag attached by adhesive backing to the skin around the genitals D. a urine drainage tube inserted but not left in place

A

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action? A. Check electronic health record for medical order. B. Assess urine characteristics. C. Explain the procedure to the client. D. Gather equipment and supplies.

A

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine? A. blood B. infection C. stasis D. dehydration

A

A client has not voided for 8 hours after surgery. Which finding indicates the client has a distended bladder? A. A bulge over the costovertebral region of the flank B. A bulge between the symphysis pubis and the umbilicus C. A bulge in the left lower quadrant of the abdomen D. A bulge between ribs 11 and 12 and the umbilicus

B

The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? A. Large urine collection bag B. Bedpan C. Urinal D. Specimen hat

C

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action? A. The appliance will fit securely to the client's skin. B. The appliance will need to be changed daily. C. A heightened risk that the stoma will prolapse D. A risk that the peristomal skin will become excoriated

D

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? A. Perform these exercises two times daily for a week. B. Loosen the internal muscles used to prevent or interrupt urination. C. Relax muscles for at least 5 minutes between Kegels. D. Keep muscles contracted for at least 10 seconds.

D

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a. applying sterile dressings with normal saline over the protruding organs and tissue b. assessing for impaired blood flow to the area of evisceration. c. contacting the surgeon d. monitoring for pallor and mottled appearance of the wound

a

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product? a. The dressing allows oxygen exchange between the wound and environment. b. The dressing provides a sterile wound environment. c. The dressing may safely be left in place for up to 10 days. d. The dressing allows for absorption of drainage.

a

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? a. alginate b. hydrocolloid c. hydrogel d. transparent

a

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury? a. 65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest b. 70-year-old client with Alzheimer disease who wanders the nursing unit using a walker and refuses to sit and eat meals c. 35-year-old client who was admitted after a motor vehicle accident, is on a liquid diet, and has bilateral casts on the upper extremities d. 45-year-old client who has cancer, is receiving chemotherapy, is incontinent, and is being admitted with leukopenia

a

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? a. Depth b. Size c. Direction d. Tunneling

a

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a. Notify the health care provider of the pain. b. Assess the client's wound and vital signs. c. Administer the prescribed analgesic. d. Document the pain and vital signs.

b

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? a. Stage III b. Stage II c. Stage I d. Stage IV

b

A skin infection caused by beta-hemolytic streptococci common in children is: a. herpes. b. impetigo. c. scabies. d. acne vulgaris.

b

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

c

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? a. "How many meals a day do you eat?" b. "Do you experience incontinence?" c. "Do you use any lotions on your skin?" d. "Have you had any recent illnesses?"

b