PrepU: Tissue Integrity and Thermoregulation

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

"I will become unconscious."

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?

"I'll be sleepy but able to respond to your questions."

The client asks the nurse about possible ill effects from general anesthesia. Which of the following is the best response by the nurse?

"Some possible negative effects include oversedation and bradycardia."

A new scrub technician is being orientated to the operating room. The scrub technician states to the nurse, "You can skip the fire safety information because I have worked in hospitals for the last 10 years." What is the best response by the nurse?

"The operating room has some unique circumstances that increases the chances of fire."

A patient is undergoing a lumbar puncture. The nurse educates the patient about surgical positioning. Which of the following statements by the nurse is appropriate?

"You will be lying on your side with your knees to your chest."

The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which of the following statements is true about Penrose drains?

A Penrose drain promotes drainage passively into a dressing.

In which situations has the nurse used a dressing properly? (Select all that apply.)

A nurse places OpSite over a central venous access device insertion site. A nurse uses appropriate aseptic techniques when changing a dressing. A nurse places Sof-Wick around a drain insertion site.

You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately?

A sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention?

A surgical incision with sutured approximated edges

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

A wound that is characterized by oozing from the tissue covering the wound A wound with drainage that is a beige color A wound that requires wound cleaning and irrigation

Which of the following characteristics should the nurse include when teaching the client about moderate sedation?

Ability to respond to verbal commands

A client's risk for the development of a pressure ulcer is most likely due to which lab result?

Albumin 2.5 mg/dL

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?

Allow unnecessary personnel to enter the OR environment.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse would recognize which of the following patients as being particularly susceptible to impaired wound healing?

An obese woman with a history of type 1 diabetes mellitus

A patient undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The patient is ready for rewarming procedures. Which of the following actions by the nurse is appropriate?

Apply a warm air blanket, gradually increasing body temperature.

A 78-year-old woman is undergoing right hip surgery to repair a hip fracture. What nursing action is appropriate during the intraoperative phase?

Appropriately position the patient using adequate padding and support.

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure?

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

Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.

Upon review of a postoperative patient's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Corticosteroids

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?

Decreased lean tissue mass

A postoperative client is being transferred from the bed to a gurney and states, ?I feel like something has just given away.? What should the nurse assess in the client?

Dehiscence of the wound

The anesthesiologist administered a transsacral conduction block. Which of the following documentation by the nurse is consistent with the anesthesia being administered?

Denies sensation to perineum and lower abdomen

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline and 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?

Depth

The wound care nurse evaluates a patient's wound after being consulted. The patient'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 patient's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

Do you experience incontinence?

The circulating nurse is documenting all medications administered during a surgical procedure. The anesthesiologist administers an opioid analgesic. What medication would the nurse check as having being administered?

Fentanyl (Sublimaze)

A patient has been administered ketamine (Ketalar) for moderate sedation. What is the priority nursing intervention?

Frequent monitoring of vital signs

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?

Headache

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which of the following statements indicates that the client understands?

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

Which stage of anesthesia is termed surgical anesthesia?

III

A nurse is reviewing the medical record of a patient who is to receive general anesthesia and notes a nursing diagnosis of anxiety related to surgical concerns. The nurse implements measures to reduce the patient's anxiety based on the understanding of which of the following?

Increased anxiety can increase the patient's postoperative pain level.

An obese patient is undergoing abdominal surgery. A surgical resident states, "The amount of fat we have to cut through is disgusting" during the procedure. What is the best response by the nurse?

Inform the resident that all communication needs to remain professional.

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 of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile.

A nurse is caring for a client on a medical surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which of the following types of debridement does the nurse understand has been ordered on this client?

Mechanical debridement

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?

Metabolic acidosis

A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures

A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

What is the priority action by the scrub nurse when the surgeon is starting to close the surgical wound?

Obtain a sponge count.

A patient is to receive general anesthesia with sevoflurane. The nurse anticipates the need for which of the following?

Oxygen

A patient is undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate?

Place the patient in lithotomy position.

A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

Primary intention

The circulating nurse is unsure if proper technique was followed when placing an object in the sterile field during a surgical procedure. What is the best action by the nurse?

Remove the entire sterile field from use.

A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action?

Removing dead or infected tissue to promote wound healing

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure

A patient receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?

Roll the patient on his or her side.

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?

Scrub role

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which of the following drainage types should the nurse document?

Serosanguineous

In which position would a patient undergoing a lumbar puncture be placed?

Side-lying, knee to chest

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

A nurse is assessing a pressure ulcer 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 of the following stages should the nurse assign to this client's wound?

Stage III

A nursing instructor is teaching a student nurse about the layers of the skin. Which of the following layers should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

Which of the following activities should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed

Which of the following clinical manifestations is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate above 150 beats per minute)

The nurse caring for a postoperative patient is cleaning the patient's wound. Which nursing action reflects the proper procedure for wound care?

The nurse works outward from the wound in lines parallel to it.

A female patient who is being treated for self- inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk?

Total lymphocyte count of 1,500/mm3

True or False A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon.

True

A patient is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?

Verify consent.

Which of the following is an inappropriate nursing action by the surgical nurse?

Wearing sterile gloves over artificial nails

A registered nurse who is responsible for coordinating and documenting patient care in the operating room is a

circulating nurse.

The nurse recognizes older adults require lower doses of anesthetic agents due to:

decreased lean tissue mass.

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function

Hypothermia may occur as a result of

open body wounds.

When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force