test 6 questions

A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation?

"Atrial fibrillation is caused by electrical signals outside of the SA node."

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should report pain at my wound site.

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

A nurse is teaching a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps?

"Take a deep breath" is the first step. The client should take a deep breath to promote lung expansion."Hold your breath for several seconds" is the second step. The client should hold their breath for several seconds to promote lung expansion."Exhale slowly" is the third step. The client should exhale slowly to promote alveolar inflation. "Brace the incision with a pillow and try to cough deeply" is the fourth step. The client should brace the incision for comfort and support and try to cough to clear secretio

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

"Your staples will be removed in about 2 weeks."

use incentive spirometer how many times each session

10

Suction the tracheostomy for

10 to 15 seconds

proliferative phase

3 days after injury up to 24 days

Hold your breath for how long when using incentive spirometer

3-5 seconds

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate MY ANSWER By the seventh postoperative day, the incision site should appear bright pink and drainage should have subsided.

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? client who has a Braden Scale score of 9 A client who has a Braden Scale score of 23 A client who has a Braden Scale score of 12 A client who has a Braden Scale score of 15

A client who has a Braden Scale score of 9

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply.)

A diet high in saturated fats is correct. A diet high in saturated fats can increase blood pressure and cholesterol. This increases the risk for heart disease.A history of an overactive bladder is incorrect. A history of an overactive bladder is not a contributing factor for heart disease.A history of smoking for 25 years is correct. A history of smoking increases blood pressure and the risk for heart disease.A sedentary lifestyle is correct. A sedentary lifestyle increases the risk for heart disease.A waist circumference of 84 cm (33 in) is incorrect. A waist circumference of 102 cm (40 in) or greater for men and 89 cm (35 in) or greater for women increases the risk for heart disease.

narrowed valve.

A narrowing and stiffening of the valves can cause hypertension, not hypotension.

A nurse is assessing a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following?

A normal breathing pattern is regular, quiet, and shows no manifestations of discomfort.

client who requires10 to 15 L/min.

A partial rebreather mask delivers oxygen at high concentrations of 10 to 15 L/min.

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?

A transparent film Due to their reduced ability to absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate.

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.

A walking cane A walker

A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following?

A whooshing or blowing sound indicates a murmur and can be low-, medium-, or high-pitched.

A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take?

Administer 100% oxygen before the procedure.

Alginate

Alginate dressings are made from algae and are recommended for moderate to high exudative wounds. They provide hemostasis and can remain in a wound for several days, thus requiring less frequent dressing changes.

An alginate dressing

An alginate dressing is recommended for moderate to high exudative wounds. This client has a stage 1 pressure injury. Therefore, there is no need for a dressing with high absorptive capabilities.

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Empty and measure the drainage. MY ANSWER The bulb of the portable wound bulb suction device should be emptied at least every 8 hr or when it is more than half full.

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

Flex the client's knees while in bed. The nurse should include in the discharge teaching to flex the client's knees while in bed. This takes the pressure off the sacral area and prevents the client from sliding down in bed, which can cause shearing and further injury to the skin.

Gallop

Gallops are additional heart sounds of S3 or S4 and are often described as sounding like "Ken-tuck-y" or "Ten-nes-see." A gallop can indicate aortic stenosis, hypertension, or a history of myocardial infarction.

primary healing

Healing over an injury that is evenly closed (incision). Edges are held in close approximation; little granulation tissue formed.

what are the universal skin prevention measures utilized in skin care plans

Hydration nutrition hygiene circulation

Hydrofiber

Hydrofiber dressings are used for moderate and highly exudative wounds. Hydrofiber dressings provide high absorbency and can stay in the wound for several days.

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

Hydrogel Hydrogel can be successfully used for debridement of wounds with necrotized tissue and eschars, and causes minimal trauma to the healing wound bed. Hydrogels work differently than other dressings in that they can provide moisture to or draw moisture away from the wound dependent upon the needs of the wound.

Cheyne-Stokes breathing

In Cheyne-Stokes breathing, the client has periods of apnea, then deep and rapid breathing, followed by slower breathing.

Kussmaul breathing

In Kussmaul breathing, respirations are rapid and deep.

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Increased blood glucose The nurse should identify that hypotension, rather than hypertension, is a potential manifestation of sepsis.The nurse should identify that an increased white blood cell count, rather than a decreased white blood cell count, is a potential manifestaThe nurse should identify that an increased BUN level can be an indication of impaired kidney function, rather than sepsis.tion of sepsis.

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? (Select all that apply.)

Inspect the feet every da Wear closed-toe shoes Manage glucose levels

type 1 diabetes mellitus how to count carbohydrates.

Limit to 45g

A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take?

Listen for a hollow sound when performing chest percussion therapy.The nurse should hear a hollow sound when performing chest percussion therapy. This indicates proper technique is being used to loosen the secretions.

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.)

Loop diuretics NSAIDs is correct Aminoglycoside antibiotics

assess for Somogyi phenomenon?

Monitor blood glucose levels during the night. Somogyi phenomenon is fasting hyperglycemia that occurs in the morning in response to hypoglycemia during the nighttime. The nurse should assess for this phenomenon by monitoring blood glucose levels during the night.

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Monitor the client for subcutaneous emphysema. The nurse should monitor the client for subcutaneous emphysema, which can indicate a leak or blockage of the system. The nurse should identify that continuous bubbling in the water seal chamber indicates that there is an air leak in the chest tube system. The nurse should keep the drainage system below the client's chest to reduce the risk of drainage flowing back into the client's pleural space. The nurse should not clamp the chest tube tubing because this can cause a tension pneumothorax.

A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use?

Nasal cannula The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be delivered at low concentrations of 1 to 4 L/min.

client who requires10 to 15 L/min.

Nonrebreather mask A nonrebreather mask delivers oxygen at high concentrations of 10 to 15 L/min.

A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first?

Obtain the oxygen saturation.

Manifestations of dysphagia

Painful swallowing dis interest in eating may lead to malnutrition clients voice changes after eating

best source of zinc?

Pinto beans

A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include?

Post a "No Smoking" sign inside the home is correct. A "No Smoking" sign should be posted inside and outside a home where oxygen is in use to reduce the risk of fire. Attach oxygen containers to a fixed object is correct. Oxygen containers should be attached to a fixed object to keep them from falling over. Notify the fire department that oxygen is used in the home is correct. The fire department and the electric company should be notified of oxygen use in the home to ensure client safety in case of a power outage or a fire. Ensure oxygen tubing is no longer than 60 feet in length is incorrect. Oxygen tubing should be no longer than 50 feet in length to reduce the risk of falls from tripping.

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change?

Presbyopia Presbyopia is the decrease in the ability to focus clearly on objects that are up close. Presbyopia typically begins during middle adulthood due to a loss of flexibility of the lens of the eye.

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."

client who is dehydrated and is receiving intermittent enteral feeding. Which of the following actions should the nurse plan to take?

Provide the formula as a continuous infusion Provide the formula as a continuous infusion. A client who is experiencing dehydration should receive a continuous infusion to prevent receiving a high carbohydrate load with each feeding

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss.

sequence of electrical conduction in the heart

SA node is the first step AV node is the second step. Bundle of His is the third step Right and left bundle branches is the fourth step. Purkinje fibers is the fifth step. The e

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?

SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin." SPD is a sensory disorder in which a client experiences a hypersensitive response to normal stimuli, such as the sound of a television, or the feel of fabric on their skin.

A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use?

Simple face mask

client who requires5 to 8 L/min.

Simple face mask simple face mask delivers oxygen at medium concentrations of 5 to 8 L/min.

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply.)

Sour Bitter Salty i

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect?

Stenosis The nurse should expect a client who has heart disease and a narrowed valve to have stenosis. Stenosis is a narrowing or stiffening of the heart valve that causes backflow of the blood.

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output?

Stroke volume The nurse should use stroke volume to calculate the client's cardiac output. Cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min. Cardiac output is calculated by multiplying the client's heart rate by the client's stroke volume.

Stroke volume

Stroke volume is the amount of blood ejected from the ventricles during a systolic contraction.

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis?

Surfactant The nurse should identify that surfactant is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. A lack of surfactant can result in atelectasis.

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?

The AP places the client in high-Fowler's position. Placing the client in the high-Fowler's position increases the risk for shearing and alterations in skin integrity.

zinc

The body uses zinc to build proteins and aid the immune response.

Bronchial tubes

The bronchial tubes allow air to move in and out of the lungs during ventilation.

Which of the following findings should the nurse identify as a risk factor for impaired wound healing?

The client consumes 1,000 kcal daily.1,500 kcal daily to meet energy and build protein for tissue healing.

if they feel like something "popped" or "gave way."

The client should be placed in bed in the supine position with their knees bent to alleviate pressure to the abdomen.

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis.

Diaphragm

The diaphragm contracts and relaxes to facilitate ventilation.

A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity?

The maximum volume of air that is expired after a maximum inspiration.he vital capacity is the amount of air that is forcibly expelled after a maximal inspiration.

Check the client's gastric residual.

The nurse should check the client's gastric residual routinely to reduce the risk for aspiration and monitor the absorption of the feeding.

To collect a wound culture

The nurse should collect the drainage from the center of the wound and avoid touching the area surrounding the wound.

Flush the client's feeding tube.

The nurse should flush the client's feeding tube before and after giving medications or if the tube is clogged.

A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?

This type of dressing will need a secondary dressing for reinforcement."

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

This type of healing begins in the wound bed with the generation of granulation tissue."

A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Tilt the client on their side at 30°.The nurse should include in the client's plan of care to tilt the client on their side at 20° to 30°. This prevents the client from sliding down in bed, which can cause shearing of the skin, while also relieving pressure to the client's hip.

A wet gauze dressing

Wet dressings are moistened in normal saline and used for wound packing when continuous debridement is needed. This client has a stage 1 pressure injury. Therefore, there is no need for wound debridement.

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?

You should shift your weight off your buttocks at intervals throughout the day."

A client who is experiencing distention and bloating should receive

a low-fat formula.

Trachea

allows air to move in and out of the lungs during ventilation.

The tidal volume

amount of air inspired and expired with each regular breath.

A systolic murmur

associated with a valve problem

celiac disease

avoid gluten. such as rye.

Health promotion for cancer prevention

avoid high calories eat at least 2.5 cups of friuts and veggies a day engage in at least 150 min of exercise a day limit alcohol to one to two drinks per day

remodeling phase

begins around day 21 can last around a yr

vitamins for wound healing

c a zinc omega 3 protein

CPAP machine."

can be used with or without supplemental oxygen.

A rapid, irregular heart rate

can indicate atrial fibrillation.

Right-sided heart failure

causes blood to back up into the systemic veins, causing lower extremity edema.

Client has dumping syndrome what instructions should you include

consume liquids between meals Complex carbohydrates are better tolerated than simple.

Secondary healing, or second intention,

is a wound healing process that takes place when the wound is left open to heal and granulation tissue forms from the bottom up in the wound bed. The healing process is prolonged, and the wound bed needs to be kept moist for proper healing to occur. The risk of infection in these wounds is much higher as the wound bed is in direct contact with the environment.

Apnea

it is the absence of respirations.

postop day 1-4

may appear red with a small to moderate amount of exudate.

A nurse is planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first? A client who reports dyspnea when walking to the bathroom

might be experiencing hypoxia due to inadequate oxygenation, which requires further intervention by the nurse.

Wounds healing by secondary intention require

moist wound bed, not a dry wound bed, for proper healing to occur.

The inspiratory reserve volum

mount of additional air that can be inspired after a regular inspiration.

Stage 2

pressure injuries are described as partial-thickness skin loss with pink or red viable tissue in the wound bed.

Stage 4,

ressure injuries are described as full-thickness tissue loss. The fascia, muscles, tendons, ligaments, cartilage, and/or bone are visible

An alginate dressing

s not self-adhesive and needs a secondary dressing for reinforcement.

vitamins not needed for wound healing

selenium b carbohydrates calcium

dietary teaching to the guardians of a 3-year-old child.

spread peanut butter in a thin layer to decrease the risk of choking. avoid foods that are easy to swallow whole, such as popcorn or hard pretzels, until the child is 4 years old after 2 yrs of age lowfat or skim milk

After collection of the wound drainage

the applicator should be placed in a vial containing a solution that keeps the swab moist until lab cultures are complete.

Total lung capacity i

the volume of air remaining in the lung after maximal inspiration.

performing chest percussion therapy

up to four times each day. cup their hands t

suctioning a client's tracheostomy using

use sterile technique

secondary healing

wound healing that happens when the wound is left open to heal

suctioning a client's tracheostomy using

intermittent suction

diabetic ketoacidosis.

Check for urinary ketones at the same time each day for 1 week.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?

Check the client's visual acuity using a Snellen chart. Cranial nerve II is the optic nerve, which provides the sensory function for vision. The nurse should assess the cranial nerve by checking the client's visual acuity and visual fields.

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9% sodium chloride. To collect a wound culture using a sterile cotton applicator, the nurse should first clean the wound with 0.9% sodium chloride to rinse away any resident bacteria that may be present.

to diagnose diabetes and measure compliance and therapeutic effect

Compare current glycosylated hemoglobin level with the level at time of diagnosis.

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take?

Cover the client's wound with a sterile saline dressing. The nurse should place a sterile, saline-soaked dressing over the client's wound to prevent the dressing from adhering to the tissue and protect the organs until the client is taken back to surgery.The nurse should keep the client in bed in the supine position with their knees bent. This prevents applying pressure to the client's abdomen.

A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include?

Cover your nose with the CPAP mask."The nurse should instruct the client to cover their nose with the CPAP mask to create a seal to treat obstructive sleep apnea. CPAP is used for obstructive sleep apnea to keep the upper airway open and increase a client's oxygenation.

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Crackles in the lungs The nurse should expect the client who has left-sided heart failure to have crackles in the lungs. Left-sided heart failure causes the blood to back up into the pulmonary circulation, causing crackles in the lungs.

client who is receiving a continuous enteral feeding and has diarrhea. Which of the following actions should the nurse take to reduce the client's diarrhea?

Decrease the rate of the feeding. To prevent diarrhea, the nurse should decrease the rate of the tube feeding, which allows for better absorption of the enteral formula.

Lab findings for client with acute pancreatitis

Decreased calcium increased bilirubin Increased glucose Increased alkaline phosphate

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?

Dermatitis The nurse should monitor the infant for dermatitis. During infancy and early childhood when the skin is immature, dermatitis develops when the skin is exposed to urine and feces. The infant will be at an even greater risk for dermatitis due to the frequency of stools.

factors influencing wound healing

Diabetes decreases peripheral perfusion infections break down collagen steroids prevent formation of collagen and fibroblasts malnourishment means pt doesnt have the needed vitamins. Tissue necrosis decreases blood supply to the wound hypoxia multiple wounds

Transparent film

Due to their reduced ability to absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate.

Low-fat diet

decrease amount of oil in cooking

Angina and myocardial infarction can cause

diaphoresis

Chronic kidney disease should limit intake of what

dietary calcium intake

Stage 1

escribed as non-blanchable areas of erythema.

Osteomalacia

haracterized by a lack of vitamin D

Correct bed positioning to minimize risk of shear

head of bed below 30 flex knees place pillows under arms

A hydrogel dressing

hydrogel dressing is used for debridement of wounds with necrotized tissue and eschars. This client has a stage 1 pressure injury. Therefore, there is no need for wound debridement.

indicate oxygen toxicity?

hyperventilation and dyspnea,Ringing in the ears shivering,blurred vision and double vision

3 phases of wound healing

inflammatory, proliferative, remodeling