medication and nutrition + skin integrity and wound care: practice questions (exam 1)

A nurse working in a hospital includes an abdominal assessment as part of the patient assessment. In which patient would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. A. A patient diagnosed with peritonitis B. A patient who has diarrhea C. A patient who has gastroenteritis D. A patient who has an early bowel obstruction E. A patient who has paralytic ileus caused by surgery

A. A patient diagnosed with peritonitis E. A patient who has paralytic ileus caused by surgery Rationale: A and E, a patient with peritonitis (an inflammation of the inner wall of the abdomen) and paralytic ileus can cause diminished or absent bowel sounds. All of the other options would cause hyperactive bowel sounds. A late obstruction would cause absent bowel sounds, not an early one.

A nurse is assessing a patient's diet for carbohydrates, protein, and fat. What is a function of fat in the diet? A. Absorbs fat-soluble vitamins B. Slows gastric emptying time C. Spares protein for other functions D. Prevents ketosis

A. Absorbs fat-soluble vitamins Rationale: Fat is necessary for the absorption of fat-soluble vitamins (ADEK).

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. A. Administer a prescribed analgesic 30-40 minutes before changing the dressing, if necessary B. Change the dressing midway between meals C. Apply a protective ointment or paste, if appropriate to cleansed skin surrounding the wound D. Apply another layer of protective ointment or paste on top of the previous layer when changing dressings E. Apply an absorbent dressing material as the first layer of the dressing F. Apply a non-absorbent material over the first layer of absorbent material

A. Administer a prescribed analgesic 30-40 minutes before changing the dressing, if necessary B. Change the dressing midway between meals C. Apply a protective ointment or paste, if appropriate to cleansed skin surrounding the wound (to avoid skin breakdown)

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contours of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? A. Auscultate the abdomen in all four quadrants B. Percuss the abdomen in a clockwise, systematic pattern C. Lightly palpate over the abdomen to check for any areas of pain, guarding or discomfort D. Deeply palpate over all four abdominal quadrants, noting muscular resistance, tenderness, organ enlargement or masses

A. Auscultate the abdomen in all four quadrants Rationale: A, unlike other assessments the nurse does, the abdomen is first inspected, then AUSCULTATED, then palpated and percussed, as not to disturb normal peristalsis or create bowel sounds when there are none.

When a client is being treated for a wound infection, it is most important for the nurse to routinely perform which action? A. Check and record the client's temperature B. Send samples of wound drainage for culture C. Assess the perfusion in the area D. Evaluate the results of the blood culture

A. Check and record the client's temperature Rationale: A, a client with a wound infection is at risk for bacteremia or other complications from their infection. B is not the priority though a culture will be drawn. C is incorrect because the nurse would assess for inflammation, not perfusion in the area. D is outside of the nursing scope and would be the role of the provider.

A nurse administering mediations to older patients must consider what age-related alteration that may affect the drug action? A. Decreased gastric motility B. Increased lean body mass C. Decreased adipose tissue D. Increased lipid content in skin

A. Decreased gastric motility

The nurse plans to administer a 3-mL intramuscular injection. The nurse understands that the least desirable muscle for the administration of this medication is the: A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis

A. Deltoid Rationale: A. The deltoid, on the lateral aspect of the upper arm, is a small muscle that is incapable of absorbing a large medication volume. This site is more appropriate for 1 mL of solution. The dorsogluteal site uses the gluteus maximus muscles in the buttocks, which can absorb larger medication volumes. The ventrogluteal site uses the gluteus medius and minimus muscles in the area of the hip, which can absorb larger medication volumes. The vastus lateralis muscle is located on the anterolateral aspect of the thigh, which can absorb larger medication volumes.

The nurse assesses a client with a long arm cast. The client reports the presence of severe pain in the casted arm. Which finding indicates to the nurse the possibility of an impending pressure injury in the casted arm? A. Pain over a bony prominence B. Numbness or tingling C. Swelling or discoloration D. Cool skin distal to the injury

A. Pain over a bony prominence Rationale: A, pain over bony prominence. B is called Paresthesia, and is associated with neurological deficits. Swelling, discoloration and cool skin distal to the injury are associated with vascular complications.

Is the following statement true or false? A nasogastric tube may be used to decompress or drain unwanted fluid and air from the stomach. A. True B. False

A. True

Given this order, would you give the med? Date: 9/7/2020 06:45am Rx: John Doe DOB: 5/20/1992 800mg Ibuprofen PO PRN for pain, not to exceed 3200mg/day A. Yes B. No

A. Yes Rationale: Yes, all parts of an order are present. Patient name, DOB, Date, Time, Drug name, Dose, Route, Frequency, Provider signature

Which outcome does the nurse recognize as an indication of normal wound healing after surgery? A. A tender, localized point beneath the wound B. A wound is reddened and warm C. A hematoma has begun to form D. A hypertrophic scar begins to form

B. A wound is reddened and warm Rationale: B is correct because the incision has caused some localized inflammation to the area and is expected for 2-3 days post-surgery. A is incorrect, tender points may be associated with bacterial infections or abscesses forming in the wound. C is incorrect because a hematoma (bleeding beneath the skin) is abnormal and will delay healing.

An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the client has no teeth and has difficulty eating. The client has no signs of dysphasia. Which diet should the nurse encourage the HCP to prescribe to this client? A. Liquid supplementation B. Dental soft C. Pureed D. Mechanical soft

B. Dental soft Rationale: B. dental soft is modified only in texture. It includes moist foods that require minimal chewing, eliminates raw fruits and veggies, nuts and dried fruit that can be hard to chew. FIBER AND FATS are still okay! In dental soft, BREAD is okay! In Mechanical, there is no bread allowed. Only the texture and consistency of foods are changed.

A nurse is caring for clients with a variety of nutrition-related problems. Which problem should the nurse anticipate eventually may require a client to have a feeding tube inserted? A. Malabsorption syndrome B. Difficulty swallowing C. Stomatitis D. Vomiting

B. Difficulty swallowing Rationale: Because a patient who has dysphagia may not respond well to a mechanical soft, soft, or pureed diet and may eventually need a gastronomy tube ("g-tube," synonymous to PEG tube). These can minimize the risk of aspiration (remember, its going into the stomach or jejunum, not down the esophagus, where the patient could aspirate). If a client has malabsorption syndrome, they may not respond well to enteric feedings. Stomatitis does not indicate a need for a feeding tube and is often transient. NG and PEG tubes are contraindicated with vomiting and can cause aspiration.

Is the following statement true or false? The deposit of medication administered intravenously creates a depot at the site of injection, designed to deliver slow, sustained release over hours, days, or weeks. A. True B. False

B. False Rationale: Drugs given by IV push are used for intermittent dosing or to treat emergencies. The drug is administered very slowly over at least 1 minute. The deposit of medication via an intramuscular injection creates a depot at the site of injection, designed to deliver slow, sustained release over hours, days, or weeks

Is the following statement true or false? A Penrose drain is sutured into place to prevent the drain from slipping back into the incised area. A. True B. False

B. False (a Penrose drain is not sutured)

The nurse identifies which diet best meets the needs of a client with multiple wounds? A. High protein, low fat, high iron diet B. High vitamin C, high protein, high carbohydrate diet C. High vitamin A, high calcium, high fat diet D. High vitamin B, high protein, low carbohydrate

B. High vitamin C, high protein, high carbohydrate diet Rationale: B, because increasing vitamin C is essential to wound healing, as is increasing protein for improved tissue growth and increased CHO for increased energy to support this growth. A. is incorrect because iron is not indicated for wound healing unless there was a lot of blood-loss or anemia involved. Vitamin A is not essential for wound healing, and B is wrong b/c a high CHO is essential for wound healing.

The nurse must reconstitute a powdered medication. The nurse should: A. Keep the needle below the initial fluid as the rest of the fluid is injected B. Instill the solvent that is consistent with the manufacturer's directions C. Score the neck of the ampule before breaking it D. Shake the vial to dissolve the powder

B. Instill the solvent that is consistent with the manufacturer's directions Rationale: A. This will create excessive bubbles that can interfere with complete reconstitution or result in bubbles being drawn into the syringe. Both occurrences can result in an inaccurate dose. B. Compatibility is necessary so that a compound or precipitate that is harmful to a patient does not result. C. Reconstitution occurs in a vial (a closed system), not an ampule (an open system). D. Shaking the vial will create excessive bubbles. The vial should be rotated between the hands to facilitate reconstitution.

Can you give this med? Insulin 20U SQ A. Yes B. No

B. No Rationale: No, should write out units and subcut/subcutaneously and no frequency

A nurse is positioning an elderly client in bed. Which factor is most important for the nurse to consider? A. Allow for skeletal deformities such as kyphosis B. Prevent pressure on bony prominences C. Provide for adequate hydration prior to entering the bed D. Avoid stretching or neuromuscular tissue

B. Prevent pressure on bony prominences Rationale: While it is important to allow for bodily differences in A and avoiding stretching muscular tissues, B is the priority to prevent pressure sores. C can be contraindicated in older patients with mobility issues, as it may cause functional incontinence if the patient cannot get back to the bathroom.

During which phase of healing by primary intention does the nurse normally expect to see a purplish, irregular wound with a raised scar? A. Defensive stage B. Reconstructive stage C. Maturation stage D. Granulation stage

B. Reconstructive stage Rationale: B is the correct answer because this is the stage that includes collagen formation, as the wound undergoes growth of fibrous tissue and begins to heal. The defensive stage is when blood vessels constrict and a clot forms. The maturation stage is after the reconstructive phase, as the scar lessens or fades. The granulation stage is when the tissue is fragile, bleeds easily, may protrude above wound margins.

A nurse assesses a patient's pressure injury that contains partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, moist and has an intact serum-filled blister. What stage does this describe? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B. Stage 2

How often should "Colace 100 mg b.i.d." be given? A. Three times a day B. Two times a day C. Every other day D. At bed time (HS)

B. Two times a day Rationale: A. The abbreviation for three times a day is t.i.d. B. The abbreviation b.i.d. represents twice a day. C. Every other day must be written out; an abbreviation should not be used. D. The abbreviation for hour of sleep is h.s.

Patient has a diagnosis of hepatitis B and has been hospitalized. What is the isolation the nursing staff should observe for this patient (Asepsis and Infection Control page 616) A. Would you observe droplet precautions B. Would you observe standard precautions C. Would you observe contact precautions D. Would you observe airborne precautions

B. Would you observe standard precautions

Patient who is on bedrest needs to be repositioned on their left side. What is the nurses priority? (Activity page 1182) A. Would you ensure a friction pad is in place B. Would you seek assistance from another health care worker C. Would you raise the siderails before moving the client. D. Would you stand opposite the client's center.

B. Would you seek assistance from another health care worker

The nurse is administering medications to patients on a medical-surgical ward. What is the second check the nurse would make to ensure the correct medication is given? A. The nurse reads the eMAR and selects the proper medication from the unit stock. B. The nurse rechecks the labels with the eMAR before taking the medication to the patient. C. After retrieving the medication from the drawer, the nurse compares the label with the eMAR. D. At the bedside, the nurse rechecks the label with the eMAR.

C. After retrieving the medication from the drawer, the nurse compares the label with the eMAR.

The nurse must administer a medication that is supplied in an ampule. What should the nurse do first to access the ampule? A. Inject the same amount of air as the fluid to be removed B. Wipe the constricted neck with an alcohol swab C. Break the constricted neck using a barrier D. Insert the needle into the rubber seal

C. Break the constricted neck using a barrier Rationale: A. This is done with a vial, not an ampule. B. The rubber seal of a vial, not the neck of an ampule, should be wiped with alcohol. C. A barrier, such as a commercially manufactured ampule opener, sterile gauze, or an alcohol swab, should be used to protect the hands from broken glass. D. This is done with a vial, not an ampule.

A nurse is caring for a client who is confused and disoriented. Which type of food containing chicken is most appropriate for this client? A. Chicken Soup B. Chicken Salad C. Chicken fingers D. Chicken casserole

C. Chicken fingers Rationale: C. chicken fingers are a single food item that is familiar to most people and is easy to manipulate without a utensil. Food that can be held with the fingers promotes more independence for a confused and disoriented client. Soup, while soft/liquid, may be hard to manipulate a spoon with, and the other options also require the use of a utensil.

The nurse provides care for a client diagnosed with a pressure injury on the sacrum that is 3cm deep and 2cm wide with an irregular border. The muscular tissue is sloughing. Which stage does the nurse classify this pressure injury? A. Grade I B. Grade II C. Grade III D. Grade IV

C. Grade III Rationale: C, because Stage 3 pressure injuries involve the muscular tissue, includes localized necrotic tissue. A stage I pressure injury is limited to superficial epidermal and dermal layers. A stage II goes down to the subcutaneous adipose, and a Stage IV includes the muscle, bone and joint tissues.

A nurse is assisting a patient to empty a change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? A. Reassure the patient that this is a normal finding with a new ostomy B. Notify the primary provider that the stoma has prolapsed C. Have the patient rest supine or low-fowlers for 30 minutes to see if it resolves D. Remove the appliance and redo the procedure using a larger appliance.

C. Have the patient rest supine or low-fowlers for 30 minutes to see if it resolves Rationale: C. The nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the provider. This can be a stoma prolapse, which is when the stoma "telescopes" through because of weakened abdominal muscles. Increased abdominal pressure can also be a factor.

The same client who has undergone abdominal surgery remains in the unit for a few days after their surgery. On the fourth day, while being transferred from their bed to a chair, the client reports that "My incision feels strange all of the sudden". Which should the nurse do first? A. Take vital signs B. Apply abdominal binder immediately C. Place the client in a low-fowler's position D. Encourage slow, deep breathing

C. Place the client in a low-fowler's position (least aggressive intervention) Rationale: C is the correct answer. A low-fowler's position (or supine/on the back) permits the nurse to inspect the wound and promotes retention of abdominal viscera in the case of dehiscence. A is not the priority, B is a preventative measure but will not treat dehiscence, and D is contraindicated, as deep breathing may increase the intra-abdominal pressure which can cause evisceration.

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

C. Stop the procedure, assess vital signs, and notify the primary care provider Rationale: C. when a patient reports dizziness or lightheadedness and has N/V during a stool removal, you should stop and assess vitals b/c the vagus nerve may have been stimulated, causing hypotension.

The nurse is preparing to administer a subcutaneous injection of insulin. The nurse knows that the best site to use to promote its absorption is the patient's: A. Upper lateral arms B. Anterior thighs C. Upper chest D. Abdomen

D. Abdomen Rationale: A. Although insulin can be administered at the deltoid site, it is a small area that is not conducive to injection rotation within the site. The rate of absorption at this site is slower than at the preferred site for insulin administration. B. Although insulin can be administered in this site, the tissue of the thighs and buttocks have the slowest absorption rate. C. This site is not acceptable for the administration of insulin because of the lack of adequate subcutaneous tissue. D. The abdomen is the preferred site for administration of insulin because it is a large area that promotes a systematic rotation of injections and it has the fastest rate of absorption.

A client has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative paralytic ileus in this client after surgery? A. Identify the time of the first bowel movement B. Monitor the tolerance of a clear liquid diet C. Palpate for abdominal distention D. Auscultate for bowel sounds

D. Auscultate for bowel sounds Rationale: D is the correct answer because bowel sounds indicate the propulsion of intestinal contents through the lower GI tract, and signify that intestinal motility is returning. An ileus is when the bowels stop moving after too much manipulation, like after surgery. A is incorrect because it may take a while for bowel movements to return and is not the first sign of bowel function. B is contraindicated, as administering fluids before intestinal motility has returned can be dangerous. C is done, but is not the best assessment for paralytic ileus, and distention can be caused by numerous other issues, such as a hemorrhage, peritonitis (inflammation of the peritoneum) and urinary retention.

A nurse is caring for a client receiving bolus enteral feedings several times daily. Which nursing intervention is most important to prevent diarrhea? A. Flush the tube after every feeding B. Check the residual before feeding C. Elevate the head of the bed 30 degrees continuously D. Discard refrigerated open cans after 24 hours

D. Discard refrigerated open cans after 24 hours Rationale: Contaminated formula can cause diarrhea; open cans can promote bacterial growth even when refrigerated. Discard after 24 hours. Flushing the tube is important to move the formula into the stomach and maintain tube patency, but it does not reduce the risk of diarrhea. Residuals are also important to know to prevent aspiration and titrate levels of absorption so the patient does not get more than they can handle, but does not cause diarrhea. Elevating HOB is important for aspiration precautions, not diarrhea.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? A. Determine the extent of wound undermining B. Measure length, width, and depth of the wound C. Massage the healthy tissue surrounding the wound D. Document the color, odor, amount, and type of wound drainage

D. Document the color, odor, amount, and type of wound drainage

A nurse is assessing a patient's wound that is healing by secondary intention. What is a characteristic of this type of wound? A. Approximated edges B. Minimal loss of tissue C. Left open for edema or exudate to resolve D. Healing occurs by formation of granulation tissue

D. Healing occurs by formation of granulation tissue

The nurse is inserting a NG tube to a stroke client. The nurse knows the best position for insertion is? A. Supine B. Sims C. Trendelenburg D. High fowlers

D. High fowlers Rationale: High fowlers is used to prevent aspiration.

Patient had decreased mobility and diabetes and need foot care. (Hygiene page 1011) A. Would you soak patients' feet in hot water B. Would you remove any corns and calluses C. Would you not use any commercial soap or cleaners D. Would you use athlete feet powder

D. Would you use athlete feet powder