week 5 quiz practice

The nurse considers the impact of shearing forces in the development of pressure injury in patients. Which patient would be most likely to develop a pressure injury from shearing forces? a. A patient sitting in a chair who slides down b. A patient with cardiovascular disease c. A patient who lies on wrinkled sheets d. A patient who must remain on his back for long periods of time

a. A patient sitting in a chair who slides down

The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention? a. A surgical incision with sutured approximated edges b. A large wound with considerable tissue loss allowed to heal naturally c. A wound left open for several days to allow edema to subside d. A wound healing naturally that becomes infected

a. A surgical incision with sutured approximated edges

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. b. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify the masses, fluid, or air in the abdomen. c. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. d. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take? A. Put on sterile gloves B. Assist the client to the left Sims' position C. Hang the enema container 60 cm (24 in) above the anus D. Insert the tubing about 15 cm (6 in) into the anus

B. Assist the client to the left Sims' position

A nurse is caring for an older client. The nurse informs the client that straining while defecating can cause which of the following? A. Dilated pupils B. Dysrhythmias C. Diarrhea D. Gastric ulcer

B. Dysrhythmias

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take? A. Discontinue the enema B. Slow the flow of the enema solution briefly C. Continue the enema and reassure the client D. Pause the enema and administer oral pain medication

B. Slow the flow of the enema solution briefly

A nurse is assessing a client who has had a staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs B. Assess the client's pain level C. Cover the wound with a moist, sterile gauze dressing D. Obtain a culture and sensitivity of the wound drainage

C. Cover the wound with a moist, sterile gauze dressing

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? A. Exposed bone B. Blood filled blisters C. Partial-thickness skin loss D. Necrotic subcutaneous tissue

D. Necrotic subcutaneous tissue

1. A nurse is assessing a client't wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous

D. Serosanguineous

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply) a. warm the enema solution prior to instillation b. position the client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle d. slowly insert the rectal tube about 5 cm e. hang the enema container 61 cm above the client's anus

a. warm the enema solution prior to instillation b. position the client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered, According to recognized staging system this pressure injury would be classified as: a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. Stage 2

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. have the client hold their breath briefly and bear down b. clamp the enema tubing c. remind the client that cramping is common at this time d. raise the level of the enema fluid container

b. clamp the enema tubing

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply) a. bradycardia b. hypotension c. elevated temperature d. poor skin turgor e. peripheral edema

b. hypotension c. elevated temperature d. poor skin turgor

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? a. macaroni and cheese b. one medium apple with skin c. one cup of plain yogurt d. roast chicken with white rice

b. one medium apple with skin

. A nurse is performing digital removal of stool on a patient with fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should the nurse's next action be? a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the PCP. c. Stop the procedure, assess vital signs, and notify the PCP. d. Stop the procedure, wait 5 minutes, and then resume the procedure.

c. Stop the procedure, assess vital signs, and notify the PCP.

A nurse is planning bowel-training program for a patient with frequent constipation. What is the recommended intervention? a. Using a diet that is low in bulk b. Decreasing fluid intake to 1,000ml c. Administering an enema once a day to stimulate peristalsis d. Monitoring bowel movements

d. Monitoring bowel movements

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? a. Keeping the head of bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

d. Using a mild cleansing agent when cleansing the skin

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following should be included when explaining the procedure to the client? a. eating more protein is optimal prior to testing b. one stool specimen is sufficient for testing c. a red color change indicates a positive test d. the specimen cannot be contaminated with urine

d. the specimen cannot be contaminated with urine

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9 % Sodium chloride saline irrigation before obtaining the specimen B. Irrigate the wound with an antiseptic prior to obtaining the specimen C. Include intact skin at the wound edges in the culture D. Swab an area of the skin away from the wound to identify the usual flora

A. Cleanse the wound with 0.9 % Sodium chloride saline irrigation before obtaining the specimen

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply) A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased fiber in the diet E. Increased activity

A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. Wet-to-dry gauze dressing C. Hydrogel dressing D. Alginate dressing

A. Transparent dressing

A nurse is implementing a bowl training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? A. When the client has the urge to defecate B. Every 2 hr. While the client is awake C. Immediately before the client has a meal D. After the client feels abdominal cramping

A. When the client has the urge to defecate

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. the nurse checks the surgical wound and finds it separated with viscera protruding. which of the following actions should the nurse take? (select all that apply) A. cover the are with saline soaked sterile dressings B. apply an abdominal binder snugly around the abdomen C. use sterile gauze to apply gentle pressure to the exposed tissue D. position the client supine with the hips and knees bent E. offer the client a warm beverage (herbal tea)

A. cover the are with saline soaked sterile dressings D. position the client supine with the hips and knees bent

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. which of the following findings should the nurse expect? (select all that apply) A. increase in incisional pain B. fever and chills C. reddened wound edges D. increased in serosanguineous drainage E. decrease in thirst

A. increase in incisional pain B. fever and chills C. reddened wound edges

A nurse is caring for a client who is at risk for developing a pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (select all that apply) A. keep the head of the bed elevated 30 degrees B. massage the clients bony prominences frequently C. apply cornstarch liberally to the skin after bathing D. have the client sit on a gel cushion when in a chair E. reposition the client at least every 3 hr while in bed

A. keep the head of the bed elevated 30 degrees D. have the client sit on a gel cushion when in a chair

A nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) A. stage 3 pressure ulcer B. sutured surgical incision C. casted bone fracture D. laceration sealed with adhesive E. open burn area

A. stage 3 pressure ulcer E. open burn area

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. their Hgb is 12 g/dl and BMI is 17.1. the incision is approximated and free of redness with scant serous drainage on the dressing. the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) A. extremes in age B. chronic illness C. low hemoglobin D. malnutrition E. poor wound service

B. chronic illness C. low hemoglobin D. malnutrition

. A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. Macaroni and cheese b. Fresh fruit and whole wheat toast c. Bread pudding and yogurt d. Roast chicken and white rice

b. Fresh fruit and whole wheat toast

A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema

b. Hypotension c. Elevated temperature d. Poor skin turgor

The nurse is performing pressure injury assessment for patients in hospital settings. Which patient would the nurse consider to be at greatest risk for developing a pressure injury? a. A newborn b. A patient with cardiovascular disease c. An older patient with arthritis d. A critical care patient

d. A critical care patient