exam 2: Prep U questions

____________ refers to the process by which oxygenated capillary blood passes through body tissues.

Perfusion

The nurse is assessing the wounds of clients 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 grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

crepitus

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

inspection, auscultation, percussion, palpation

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: ptosis. entropion. ectropion. miosis.

ptosis

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

stage II

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True False

true A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

A 1. ______________ disease is caused by food or environmental toxin. 2.___________, communicable disease, and 3. _____________ do not describe food poisoning.

1. Noncommunicable 2.Infectious disease 3. contagious disease

A Venturi mask delivers a maximum FiO2 of 1. ______ A nasal cannula delivers a maximum FiO2 of 2.______. A simple mask delivers a maximum FiO2 of 3.______

1. 55%. 2. 44% 3. 60%.

What percentage of weight change in 6 months is considered abnormal?

10%

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a. Assess the client's wound and vital signs. b. Administer the prescribed analgesic. c. Notify the health care provider of the pain. d. Document the pain and vital signs.

A.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? corticosteroids antihypertensive drugs potassium supplements laxatives

Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a: 1. reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. 2. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. 3. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter? a. Use an alcohol-based hand rub to decontaminate the hands. b. Remove all jewelry, including wedding bands, before hand washing. c. Keep hands lower than elbows to allow water to flow toward fingertips. d. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips.

c. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.

A nurse is performing physical assessments of residents in a long-term care facility. What common head and neck variations in the older adult does the nurse document as a normal finding? Select all that apply. a. Decreased color vision and peripheral vision b.Increased adaptation to light and dark c. A blue ring around the cornea d.Entropion and ectropion e. Impaired conductive hearing

e.,d,a entropion- is a condition in which the eyelid is rolled inward against the eyeball, typically caused by muscle spasm or by inflammation or scarring of the conjunctiva. Ectropion- is when the lower eyelid turns or sags outward, away from the eye, exposing the surface of the inner eyelid. This condition can cause eye dryness, excessive tearing, and irritation.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

hypoxia- Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia.

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

non-rebreather mask - only device that can deliver an FiO2 of 100% to a client without a controlled airway.

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is:

standard/ universal precautions relate to blood and certain body fluids to protect health care workers from clients possibly carrying HIV, hepatitis B virus, or other blood-borne pathogens.

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-After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

the nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? a."What brings you here today?" b. "Are you having any pain?" c."What medications do you normally use?" d. "Do you have any allergies?"

a.

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? a. Cough medicine with a high sugar content b. Cough medicine with iodine c. Cough medicine with an antihistamine d.Cough medicine with a decongestant

c.

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition? a. infectious disease b. communicable disease c. noncommunicable disease d.contagious disease

c.

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? Select all that apply. a. "What seems to make the pain worse?" b. "Why do you have the pain?" c."How long does the pain last?" d."Where is the pain located and does it move anywhere else?" e."Have you taken acetamiophen for the pain?" f. Intensity

a,c,d,f,

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? a. the client who is 48-hours postsurgical procedure b. the client admitted with a rash who reports recent exposure to measles c. the client admitted with diarrhea who tested positive for Escherichia coli (E. coli) d, the client placed in contact isolation who was admitted with a draining abdominal wound

a.

Which technique should the nurse use to assess the pupillary light reflex on a client? A. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. b. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. c. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. d. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.

a.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? a. Hold sterile objects above waist level to prevent inadvertent contamination. b. Consider the outside of the sterile package to be sterile. c. Consider the outer 3-in. (8-cm) edge of a sterile field to be contaminated.

a. Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. ******The outside of the sterile package and the outer 1 in. (2.5 cm) of a sterile field are contaminated.

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: A. adequate tissue perfusion. b. diminished stroke volume. c. high cardiac output. d.heart failure.

a. Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? a. The tympanic membrane is translucent, shiny, and gray. b.The ear canal is rough and pinkish. c. The tympanic membrane is reddish. d. The ear canal is smooth and white.

a. The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a. Snack on high-carbohydrate foods frequently. b. Eat smaller meals that are high in protein. c. Contact the physician for nutrition shake. d. Eat one large meal at noon

b. The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? a. Infection of the wound b.Herniation of the wound c. Dehiscence of the wound d. Evisceration of the viscera

d. Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way."