Exam 4 Fund.
What pressure injury stage? Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 1
What pressure injury stage? Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum- filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), includ- ing incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive- related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 2
What pressure injury stage? Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/ or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
Stage 3
What pressure injury stage? Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, liga- ment, cartilage, or bone in the ulcer. Slough and/ or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
Stage 4
Which patient is at risk for compartment syndrome due to a burn? 1.A 25 year old with circumferential burn of the anterior and posterior left arm. 2.A 7 year old with a burn of the left and right ear. 3.A 55 year old with an electrical burn on the neck. 4.A 15 year old with a chemical burn to the right foot.
Answer: 1 Circumferential burns of the extremities produce a tourniquet like effect and leads to vascular problems.
A patient is undergoing a escharotomy. Which of the following is correct about the procedure? 1.It is performed on circumferential burns and is usually performed at bedside without anesthesia. 2.It is performed on radiation burns and requires general anesthesia. 3.It is performed if tissue perfusion does NOT return after a fasciotomy. 4.None of the options are correct.
Answer: 1 Escharotomy are performed at the beside without anesthia because the nerves are already damaged. It is first performed when a patient has a circumferential burn and if tissue perfusion fails to return a fasciotomy is performed in the operating room.
A patient with 55% burns is groaning out in pain and rates pain 10 on 1-10 scale. You have PRN orders for the following medications. What is the best option for this patient? 1.IV Morphine 2.Oral Lortab liquid suspension 3.IM Demerol 4.Subcutaneous Demerol
Answer: 1 IV route is the best option when a patient has burns. If a medication is given IM or subq, hypovolemia may disrupt absorption. In addition, oral route should be avoid due to potential GI dysfunction.
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? 1.Check for kinks in the outflow tubing 2.Raise the drainage bag above the level of the abdomen 3.Place the patient in a reverse Trendelenburg position 4.Ask the patient to cough
Answer: 1 Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement.
What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.
Answer: 1, 3, 4. Maintaining regular bowel elimination prevents the rectum from filling with stool, which can irritate the bladder. Adequate hydration will ensure that the bladder is regularly flushed and will help prevent a UTI. Cotton undergarments are recommended. Pelvic muscle exercises promote pelvic health but do not necessarily prevent UTIs.
Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine
Answer: 1, 3, 5. A transfer device can pick up a patient and pre- vent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position causes patient to slide down, causing shear.
When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area
Answer: 1, 3. Warm compresses can improve circulation by dilat- ing blood vessels, and they reduce edema. The moisture of the compress conducts heat.
A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be imple- mented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.
Answer: 1, 4, 5. An IVP involves intravenous injection of an iodine-based contrast media. Patients who have had a previous hypersensitivity reaction to contrast media are at high risk for another reaction. Informed consent is required. The patient may experience facial flushing during injection of the contrast media. There is no need for a full bladder such as with a pelvic ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such as with a cystoscopy.
Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment
Answer: 1, 4, 5. Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protec- tive layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure injuries.
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the sur- gical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.
Answer: 1, 4. If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? 1.Fever 2.Intact skin 3.Inflammation 4.Lethargy
Answer: 2 Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.
For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? 1.Cover the mattress with a sheepskin. 2.Keep the linens wrinkle free. 3.Separate the skin folds with towels 4.Apply petrolatum barrier creams.
Answer: 2 Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence.
During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound? 1.Area is red and does not blanch 2.Full-thickness skin loss to dermis and subcutaneous tissues. 3.Partial thickness of dermis with shallow open ulcer. 4.Full thickness with bone and tendon visible.
Answer: 2 Stage 3 pressures are full-thickness skin loss to dermis and subcutaneous tissues.
Nurse Pete is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? 1.Specific gravity of 1.03 2.Urine pH of 3.0 3.Absence of protein 4.Absence of glucose
Answer: 2 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.
When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? 1.The client sets the drainage bag on the floor while sitting down. 2.The client keeps the drainage bag below the bladder at all times 3.The client clamps the catheter drainage tubing while visiting with the family 4.The client loops the drainage tubing below its point of entry into the drainage bag
Answer: 2 To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.
Nurse Mary is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: 1.initiate a stream of urine 2.breathe deeply 3.turn to the side 4.hold the labia or shaft of penis
Answer: 2 When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, anddoing so may contaminate the sterile field. Answer: 2
A postoperative patient with a three-way indwelling urinary cath- eter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.
Answer: 2, 3. An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irritant solution infused. If the system is not draining urine and irrigant, the irrigant should be stopped immediately; the catheter may be occluded and the bladder distended. Pain medication should not be administered until after assessment is completed.
Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal.
Answer: 2, 3. By allowing the balloon to drain by gravity, it is possible to avoid the development of creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dic- tated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters before removal.
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. Establish a toileting schedule. Recommend that she be evaluated for an indwelling catheter. Start a bladder-retraining program.
Answer: 2. The first nursing intervention for any patient with incontinence who is able to toilet is to help him or her with toilet access. This patient has dementia; therefore a bladder-retraining program is inappropriate for her. There is nothing in the assessment to indicate that she may have an overactive bladder. A catheter increases risk for infection and is never the best intervention for incontinence.
There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.
Answer: 2. The catheter may be in the vagina; leave the catheter in the vagina as a landmark indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for catheter-associated urinary tract infection (CAUTI).
Which nursing intervention decreases the risk for catheter-asso- ciated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3 Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water
Answer: 2. Evidence-based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.
A patient is being discharge after having autografting. What would you include in your discharge education? 1.Avoid using splints or any type of support garment. 2.Encourage for the site to be exposed to sunlight to promoted melanin production. 3.Keep the site free from pressure and keep the site lubricated. 4.Encourage weight-bearing exercise every 4 to 6 hours.
Answer: 3 The patient should avoid the sunlight due to increase risk of sunburn to delicate skin. In addition, the patient should avoid weight-bearing activities to prevent damage to the newly grafted skin. It is best to encourage splints and support garments to protect the skin during activity.
As a home care nurse, you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming? 1.Exercise the extremities actively and passively. 2.Turn and re-position the patient every 2 hours. 3.Keep the skin moist and layer the sacral area with extra sheet layers. 4.Use pillows to elevated bony prominences
Answer: 3 You will keep the pressure ulcer dry and clean and avoid extra sheets (this could increase the risk for moisture and form wrinkles and friction onto the skin
Which of the following causes the majority of UTI's in hospitalized patients? 1.Lack of fluid intake 2.Inadequate perineal care 3.Invasive procedures 4.Immunosuppression
Answer: 3 Invasive procedures such as catheterization can introduce bacteria into the urinary tract. A lack of fluid intake could cause concentration of urine, but wouldn't necessarily cause infection.
An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? 1.Renal calculi 2.Renal trauma 3.Recent sore throat 4.Family history of acute glomerulonephritis
Answer: 3 The most common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body.
Which patient is at greatest risk for developing a urinary tract infection (UTI)? 1.A 35 y.o. woman with a fractured wrist 2.A 20 y.o. woman with asthma 3.A 50 y.o. postmenopausal woman 4.A 28 y.o. with angina
Answer: 3 Women are more prone to UTI's after menopause due to reduced estrogen levels. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection. Angina, asthma and fractures don't increase the risk of UTI.
What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert 1/4 inch more.
Answer: 3. Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bedsheets increases the risk for accidental pulling or tension on the catheter. Advanc- ing the catheter until urine flows and then inserting it 1⁄4 inch more is not unique to the male patient.
Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discom- fort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.
Answer: 3. To adequately assess bladder function after a catheter is removed, voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a urinary tract infection.
A preceptor is observing a nursing student provide care to a patient with major burns to the face and head. What nursing intervention does the student perform correctly? 1.Assist the patient with eating food tray. 2.Uses gloves and face mask when providing care. 3.Places the patient in trendelenburg position. 4.Elevates the head of the bead at 30'.
Answer: 4 Due to edema and respiratory issues patient with facial burns should have the HOB at 30'. In addition, strict isolation protocol is implemented because they patient is at high risk for infection ( gloves and facial mask are not sufficient enough). In addition, the patient will not be eating but will be on tube feedings.
As a nurse working on a burn unit, which of your patients are at high risk for internal tissue damage? 1.1. Patient in room 2101 with a chemical burn to face. 2.Patient in room 2106 with a radiation burn on the abdomen. 3.Patient in room 2103 with a thermal burn to peritoneal area. 4.Patient in room 2101 with an electrical burn on torso.
Answer: 4 Electrical burns are caused by heat generated by electrical current which is transferred through the body. This current burns the skin but also affects internal tissue as well.
What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.
Answer: 4, 3, 2, 5, 1. Organized steps ensure a safe, effective irrigation of the wound.
Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wounds urface
Answer: 4. A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode
Answer: 4. When repositioning an immobile patient, it is import- ant to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pres- sure is applied, tissue damage is likely.
Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.
Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9.
You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers? 1.A 72 year old female weighing 82 lbs with stress incontinence and dementia. 2.A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities. 3.A 6 month old with the flu. 4.An ambulatory 88 year old with dementia who is admitted with shingles.
Answer: 1
You have a patient who has multiple burns on their body. Using the rule of nines, what is the estimate extent of burn injury to the following patient. The following areas are burned: Anterior trunk, anterior left arm, and posterior left leg. 1.31.5% 2.36% 3.28.5% 4.30%
Answer: 1 Using the rule of nines you would get 31.5%. The anterior trunk is: 18%, anterior left arm 4.5%, posterior left leg 9%....total equals 31.5.
What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization
Answer: 1. Debridement is the removal of nonliving tissue, clean- ing the wound to move toward healing.
The most common early sign of kidney disease is: 1.Sodium retention 2.Elevated BUN level 3.Development of metabolic acidosis 4.Inability to dilute or concentrate urine
Answer: 2 Increased BUN is usually an early indicator of decreased renal function.
You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than: 1.200ml 2.400 ml 3.800 ml 4.1000 ml
Answer: 2 Oliguria is defined as urine output of less than 400ml/24hours.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure
Answer: 2, 4. A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreas- ing stress from coughing and movement.
Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis? 1. Jaundice and flank pain 2. Costovertebral angle tenderness and chills 3. Burning sensation on urination 4. Polyuria and nocturia
Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice indicates gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection. Answer: 2