Ch 29, 25 PrepU HW
A client is receiving oxygen therapy via a nasal cannula at 3 L/min. The nurse estimates that the client is receiving which concentration of oxygen?
30% Explanation: Using the 'rule of four", for each L/min, the oxygen concentration increases by 4%. Therefore, 1 L/min provides 22% oxygen and 2 L/min provides 26%. The nurse would estimate that 3 L/min would provide 30% oxygen. A flow rate of 4 L/min would provide an oxygen concentration of 34%
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm by 6.4 cm. Which of the following actions should the nurse use during wound care?
Cleanse with a new gauze for each stroke. Explanation: When cleansing a wound the nurse should use a new gauze or swab on each downward stroke using the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least one inch beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles beginning in the center and working toward the outside.
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia?
Confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
A nurse is assisting a client with a partial airway obstruction and who is coughing. What resuscitation efforts should the nurse perform to provide relief to a client with a partial airway obstruction of the throat?
Encourage and provide physical support to the client. Explanation: Other than encouraging and supporting the client, a partial obstruction requires no additional resuscitation efforts. The Heimlich maneuver is performed on clients with complete, not partial, obstructions. It involves the use of subdiaphragmatic thrusts or chest thrusts. Nurses avoid sweeping the finger inside a client's throat to remove an obstruction unless the obstruction is clearly visible. Activating the emergency medical system is appropriate if the client's independent efforts to relieve a partial obstruction are unsuccessful.
A nurse is caring for a client with a sinus infection at a health care facility. The physician has prescribed aerosol therapy to keep the mucous membranes moist and the mucus thin. Which of the following is a benefit of using aerosol therapy?
Encourages spontaneous coughing Explanation: Aerosol therapy encourages spontaneous coughing. It also improves breathing and helps to raise sputum for diagnostic purposes by loosening secretions. Postural drainage is a positioning technique that promotes gravity drainage of secretions from various lobes or segments of the lungs. Aerosol therapy does not prevent lung infections. Aerosol therapy also does not produce mucus; the body continuously produces mucus.
A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing to the client that has a highly absorbent nature. Which of the following types of dressing should the nurse use for this client?
Gauze Explanation: Gauze dressing is ideal for covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage. The nurse uses a hydrocolloid dressing when caring for a client with superficial burn wounds as hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist. Transparent dressing allows the nurse to assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.
A nurse is giving chest thrusts with two fingers to an infant with a partial obstruction. Which of the following places is most suitable for giving chest thrusts to an infant?
Middle of the sternum Explanation: Nurses turn the infant supine and use two fingers to give five chest thrusts at approximately one per second to the middle of the breastbone just below the nipple line, not above the nipple line. They do not give thrusts below the rib cage or close to the heart. They should repeatedly alternate five back blows and chest thrusts until the object is dislodged or the infant fails to respond.
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
Notify the physician and prepare for surgery. Explanation: Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.
A client at a health care facility who underwent an appendectomy describes to the nurse that he feels like something has "given way." On inspecting the surgical wound, the nurse notes a pinkish drainage on the dressing. What intervention should the nurse perform in this case?
Position the client to put the least strain on the operated area. Explanation: If wound disruption is suspected, the nurse should position the client to put the least strain on the operated area. The nurse should inform the physician immediately rather than informing the head nurse first. If evisceration occurs, the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues. The nurse must be alert for signs and symptoms of impaired blood flow such as swelling, localized pallor or a mottled appearance, and coolness of the tissue in the area around the wound. Inspecting the wound to determine the extent of the secretion may not be an appropriate action in this case.
Which of the following is an indication for the use of negative pressure wound therapy?
Pressure ulcers Explanation: Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin
A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client?
Prevents the aspiration of oral fluids Explanation: A tracheostomy tube may have a balloon cuff; when inflated, the cuff seals the upper airway to prevent aspiration of oral fluids and provide more efficient ventilation. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. During insertion of a tracheostomy tube, an obturator, a curved guide, is used. Most clients with tracheostomy tubes require frequent suctioning.
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?
Proliferation phase Explanation: The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.
The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?
Removing secretions from the throat through an orally inserted catheter Explanation: Oropharyngeal suctioning is the removal of secretions from the lung through an orally inserted catheter. Nasotracheal suctioning is the removal of the secretion from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretion from the throat through a nasally inserted catheter.
A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound?
Secondary intention Explanation: The patient with a wound dehiscence will undergo wound repair by secondary intention. In these wounds, the wound edges are not well approximated and will require more tissue replacement. Primary intention involves wound edges that are well approximated or close together. Tertiary intention involves wounds that are left open for a period of time and then closed. Desiccation is a process where cells are dehydrated. This leads to cell death and delays healing.
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 Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.
The nurse is applying a heating pad to a patient experiencing neck pain. Which nursing action is performed correctly?
The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. Explanation: The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.
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. Explanation: A postoperative wound has well approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
True
A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon.
True Explanation: Antimicrobial dressings are appropriate for chronic wounds at risk for infection.
A client is confined to bed due to a spinal cord injury. The client's plan of care identifies a nursing diagnosis of risk for impaired skin integrity related to immobility. Which of the following would be most appropriate for the nurse to do when providing skin care to this client?
Use light dusting of powder in skin folds Explanation: The nurse should use light dusting of powder to prevent the moisture in the skin folds of the client. Areas where skin lies in folds, such as under the breasts and in the gluteal areas, can collect moisture and require special attention. The use of lotions or creams helps to maintain skin hydration. Alcohol should be avoided as it is a drying agent. Clients with dry skin should bathe only once or twice a week
A nurse is caring for a client with influenza who requires an external source of oxygen in order to breathe efficiently. In which of the following situations is oxygen humidified?
When more than 4 L/min of oxygen is administered for an extended period Explanation: When administering oxygen to a client using an external source of oxygen, the nurse should remember that oxygen is humidified when more than 4 L/min of oxygen is administered for an extended period. Oxygen need not be humidified if less than 4 L/min of oxygen has been administered to the client. Oxygen administered over an extended period of time, not intermittently, is humidified.
Atelectasis
a complete or partial collapse of a lung or lobe of a lung
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's ...
hemoglobin level Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
"It is inserted into the space between the lining of the lungs and the ribs." Explanation: A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted into the pleural space, thus allowing compressed lung tissue to re-expand.
