Test 9 PrepU

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.

"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

A client who recently underwent amputation of a leg reports pain in the amputated part. What would be the nurse's best response?

"Your pain is a real experience."

A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?

0 to 10 numeric rating scale

The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply.

29-year-old who has a speech impediment 34-year-old with schizophrenia 41-year-old who is from a different country 60-year-old with early onset dementia

For which client would the application of a hydrocolloid dressing be most appropriate?

A client who has a partial-thickness venous ulcer with moderate drainage

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL (28.0 g/L)

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation.

What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter?

Avoid irrigation unless needed to relieve an obstruction.

A client is receiving opioid analgesia for pain control. The nurse is assessing the client for possible respiratory depression. Which method would be most reliable for the nurse to use to identify impending respiratory depression?

Capnography

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity?

Clean perineal area daily but do not bathe full body on a daily basis

During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care?

Condom catheter

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply.

Difficulty voiding Urinary retention Burning or irritation while voiding

The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time? Select all that apply.

Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Arrange for a consult with a wound nurse

The nurse provides a cool glass of water to a client with inflamed throat tissue. What condition should the nurse caution the client to avoid when drinking very hot liquids while having an inflamed throat?

Hyperalgesia

Which client populations are at high risk for inadequate pain management? Select all that apply.

Neonates and infants Young children Clients with dementia Older adults with chronic pain

A 92-year-old woman is on an inpatient unit following hip replacement surgery. The nurse asks her if she is in pain, and she tells the nurse that she is fine. The nurse knows what to be true regarding pain in the older adult? Select all that apply.

Older adults have decreased opioid receptors. Older adults often believe that pain is a consequence of growing older. Older adults are more likely to be disabled by pain than younger adults.

An older adult client is experiencing urinary retention. What age-related physiologic change does the nurse discuss with the client that may be a contributing factor?

Older adults may have a decrease in contraction of the bladder.

The nurse has received an order to catheterize a female client. What action should the nurse perform?

Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm).

A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain?

Placebos involve the use of deception and are considered unethical in most circumstances.

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?

Prime the tubing with the solution.

The nurse is performing an assessment of a client that is experiencing pain after a surgical procedure. What symptoms does the nurse assess based on the pain response?

Pupils are dilated.

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs continuous bladder irrigation. Which intervention should the nurse perform when providing continuous bladder irrigation?

Purge air from the tubing.

The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action?

Recompress the drain before replacing the cap

The nurse is preparing to catheterize a client who is incontinent of urine following bladder surgery. What fact should the nurse keep in mind when performing catheterization?

The bladder normally is a sterile cavity.

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

The client has fistula formation.

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?

The nurse should apply adhesive wound closure strips after removing staples.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?

Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.

A nurse is preparing to give a client a massage. What action should the nurse perform during this intervention?

Using a light, gliding stroke, apply lotion to the client's shoulders, back, and sacral area.

The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet?

Zinc

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

cleanse with a new gauze for each stroke

The nurse is preparing to place a Foley catheter for a female client who will soon have surgery. Into what position will the nurse place the client?

dorsal recumbent

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply.

proper client nutrition 2-hour turn schedule pressure redistribution support surfaces client repositioning with a lift

Which best describes the proliferative phase, the third phase of the wound healing process?

reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

stage III

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Neuromatrix Theory?

teaching client to remove items from home that remind them of work

The nurse desiring to use laughter as a therapeutic modality for pain should assess for which therapeutic effects?

Decreased levels of epinephrine Increased pain threshold Increased ability to face difficult procedure

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client?

Intractable

The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects?

It activates the immune system

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan?

Record the quantity of drainage once per shift and document on the intake and output record.

A client who is a paraplegic as a result of an auto accident has incontinence. The nurse correctly recognizes that which type of incontinence is most likely?

Reflex

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?

alginate