Tissue Integrity EAQ
A client with a spinal cord injury tends to assume the low-Fowler position excessively. Mark the area of the body that is most vulnerable to the development of a pressure ulcer in this client.
The sacrum bears the most pressure because it is the focal point of the weight of the body when in the low-Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low-Fowler position.
A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating? Correct1 Eat a mechanical soft diet 2 Liquefy food in a blender 3 Take frequent sips of water with meals 4 Use a local anesthetic mouthwash before eating
1 Eat a mechanical soft diet Scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body, including the esophagus and face; a mechanical soft diet includes foods that limit the need to chew and are easier to swallow. Liquefied foods are difficult to swallow; esophageal peristalsis is decreased, and liquids are aspirated easily. Taking frequent sips of water with meals will not help; it is equally difficult to swallow solids and liquids, and aspiration may result. Using a local anesthetic mouthwash before eating is not necessary; oral pain is not associated with scleroderma.
The nurse has completed a newborn's initial assessment and finds tiny white papules on the newborn's cheeks, chin, and nose. How should the nurse document the finding? Correct1 Milia 2 Lanugo 3 Mongolian spots 4 Harlequin color change
1 Milia Milia are distended sebaceous glands, which manifest as tiny white papules on the cheeks, chin, and nose. Lanugo is downy hair found on preterm babies. Mongolian spots are a medical condition that is characterized by the appearance of irregular, deep blue spots on the gluteal regions. Harlequin color change is related to the body lying on one side with the dependent side becoming pink.
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to: Correct1 Restore function and/or appearance. 2 Replace an organ or tissue. 3 Relieve or reduce symptoms. 4 Remove or excise an organ or tissue.
1 Restore function and/or appearance. The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; to relieve or reduce symptoms is known as palliation; and to remove or excise an organ or tissue is known as resection.
During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? Correct1 Turn and reposition the client every 2 hours. 2 Cover the ulcer with an occlusive transparent dressing. 3 Clean the ulcer with hydrogen peroxide and leave it open to the air. 4 Provide the client with a diet high in vitamin C, zinc, and protein.
1 Turn and reposition the client every 2 hours. Turning and repositioning immobile clients at least every 2 hours is the best initial nursing action for preventing further skin breakdown. Other measures should also be taken to relieve pressure on the area to prevent progression and promote healing. Covering the area with an occlusive transparent dressing or cleansing the area with hydrogen peroxide are not recommended for this situation. Providing a diet high in vitamin C, zinc, and protein will also aid in tissue healing and help prevent further breakdown but is not the priority action.
A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets
2 First convert 0.22 g to its equivalent in mg by multiplying by 1000 (move the decimal 3 places to the right). Use the "Desire over Have" formula of ratio and proportion to solve this problem. Desire 220 mg x tablets ------------------ = --------- Have 110 mg 1 tablet 110x = 220 x = 220 ÷ 110 x = 2 tablets
Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? 1 Have the prescription renewed every 48 hours Correct2 Assess the client's condition every hour 3 Provide range of motion to the client's elbows every shift 4 Document output from the tube and catheter every two hours
2 Assess the client's condition every hour A restraint impedes the movement of a client; therefore, a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally do not need to be documented as frequently as every two hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.
During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to: 1 Give the person sips of water Correct2 Assess the person's breathing 3 Cover the person with a warm blanket 4 Calculate the extent of the person's burns
2 Assess the person's breathing A patent airway is most vital; if the person is not breathing, CPR should be instituted. The person should be kept nothing by mouth because large burns decrease intestinal peristalsis and the person may vomit and aspirate. Covering the person with a warm blanket is not done until assessment for breathing is completed. Calculating the extent of the person's burns is not the priority ; this assessment is done after transfer to a medical facility. Test-Taking Tip: Pace yourself while taking a quiz or exam. Read the entire question and all answer choices before answering the question. Do not assume that you know what the question is asking without reading it entirely.
A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when use of the heating pad was initiated. Which principle would legally apply? 1 No one could be held liable for new equipment. Correct2 The nurse could be held liable for the injury that occurred. 3 The nurse did what a reasonable, prudent nurse would do. 4 The manufacturer is liable for new equipment.
2 The nurse could be held liable for the injury that occurred A nurse can be held responsible for any action performed that causes a client to be harmed. Legally, someone will assume liability for the action. If sued in this case, the nurse would have to prove that her actions were reasonable and prudent under the circumstances. The manufacturer may also be liable depending on whether the equipment was used correctly, but initially the actions of the nurse will be reviewed.
A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching? 1 Shower twice a day 2 Soak the affected areas in hot water Correct3 Apply moisturizing lotion several times a day 4 Cover affected areas when in contact with others
3 Apply moisturizing lotion several times a day Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, allowing the trapped water to hydrate the stratum corneum. Excessive exposure to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease and affected areas do not need to be covered when in contact with others.
Twenty-four hours after a penile implant the client's scrotum is edematous and painful. The nurse should: 1 Assist the client with a sitz bath 2 Apply warm soaks to the scrotum Correct3 Elevate the scrotum using a soft support 4 Prepare for an incision and drainage procedure
3 Elevate the scrotum using a soft support Elevating the scrotum using a soft support increases lymphatic drainage, reducing edema and pain. Assisting the client with a sitz bath and applying warm soaks to the scrotum increase circulation to the area, intensifying edema and pain in this client. Preparing for an incision and drainage procedure is not indicated; scrotal swelling is caused by the trauma of surgery, not infection.
A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? 1 Use a separate square gauze to cleanse each half of the wound. 2 Apply new Montgomery straps each time the dressing is changed. 3 Hold the wet gauze with the tips of the forceps higher than the wrist. Correct4 Cleanse the wound with wet sterile gauze from the center of the wound outward.
4 Cleanse the wound with wet sterile gauze from the center of the wound outward. Wounds should be cleansed from the center outward or from the top to the bottom; this ensures that cleansing is done from the least to the most contaminated area. A new sterile gauze square should be used for each swipe of the wound. More than two gauze squares will be needed to cleanse a large abdominal wound. Using the same gauze square again will contaminate the wound. Montgomery straps are changed only when they become soiled or begin to loosen from the client's skin. Montgomery straps are applied to each side of a wound. The central sections are folded back when the dressing is changed. When folded back in place over the new dressing and secured with a tie they keep the dressing in place without having to replace the tape each time the dressing is changed. Forceps should always be held with the tips lower than the wrist. If held with the wrist lower than the tips of the forceps, cleansing solution can flow down the instrument and hand and arm of the nurse, contaminating the fluid. When the wrist is then raised above the forceps, the contaminated fluid will flow back down the forceps into the wound. Test-Taking Tip: Start with answering all the questions that you feel confident in answering. If you cannot immediately think of the answer to a question, give it a few seconds of thought. If the answer comes to you, mark it and move on. If not, skip it, circle the number so you know to come back to it, and go to the next question.
A nurse is writing a teaching plan about osteoporosis. How should the nurse explain what osteoporosis is? 1 It is avascular necrosis. 2 It is caused by pathologic fractures. 3 It is hyperplasia of osteoblasts. Correct4 It involves a decrease in bone substance.
4 It involves a decrease in bone substance. Osteoporosis involves as defect in bone matrix formation that weakens the bones, making them unable to withstand usual functional stresses. Avascular necrosis is death of bone tissue that results from reduced circulation to bone. Pathological fractures can result from osteoporosis. Hyperplasia of osteoblasts is not related to osteoporosis. This occurs during bone healing.
The nurse identifies a 5-cm nodule on the upper arm of a client with type 1 diabetes. The client says to the nurse, "That is where I give myself insulin shots." The nurse concludes that the nodule, which is neither warm nor painful, is a result of: 1 Keratosis 2 An allergy 3 An infection Correct4 Lipodystrophy
4 Lipodystrophy Lipodystrophy is a noninflammatory reaction causing localized atrophy or hypertrophy and a localized increase in collagen deposits. Injections of insulin will not cause a horny growth such as a wart or callus. An allergic response will precipitate a localized or systemic inflammatory response. Hyperthermia and localized heat, erythema, and pain are associated with an infection.
An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1 "I can ride my bike in about a week." 2 "I don't have to go to gym class for 3 months." Correct3 "I can't perform any weightlifting for at least 3 weeks." 4 "I can never participate in football again."
Correct3 "I can't perform any weightlifting for at least 3 weeks." Weightlifting puts a strain on the incision and should be avoided for at least 3 weeks. Activities such as bike riding and physical education classes and football are contraindicated for approximately 3 weeks after uncomplicated surgery for an inguinal hernia. Refraining from these activities for this period of time prevents stress on the incision and promotes healing. However, the client should not participate in any of these activities until cleared by the surgeon.
