NU 311 Exam 3

Which statement made by the student nurse regarding moist-to-dry dressings will make Dr. Lynch happy?

"I know that the purpose of moist-to-dry dressings is to mechanically debride the wound."

Which statement/s regarding the application of ice, or cryotherapy is/are true?

-Cold therapy is one of the most widely used therapeutic modalities in the management of acute musculoskeletal injuries. -Cold applications must be removed from areas that have turned red or blue during therapy related to the possibility of worsening ischemia.

The RN is caring for a client recovering from major abdominal surgery 2 days ago. The RN realizes factors affecting surgical wound healing include:

-Nutritional status -Diabetes -Advanced age -Wound Infection

When repositioning an immobile client, the student nurse notices a deep red-maroon color over a bony prominence. When the area is further assessed, it does not blanch indicating:

a deep tissue pressure injury.

The student nurse is changing a dressing and is preparing to cleanse the intact suture line. The proper technique for cleaning an intact suture line includes:

cleaning the wound from an area of least contamination to an area of most contamination.

The RN is documenting on the electronic health record (EHR) at the client bedside. Which action/s by the RN requires intervention by the nurse manager?

-The RN gives the personal password to the charge nurse and asks the charge nurse to complete documentation since he/she is taking care of a dying client. -The RN leaves the computer monitor on in the ICU since valuable time is lost when logging in. -The RN deletes the nurse's notes from the previous day since errors in spelling were noted. The RN re-wrote the notes today with correct spelling.

Which statement/s is/are TRUE regarding wound irrigations?

-Wound irrigations are useful for decreasing bacterial counts. -Protective equipment such as a gown and eye wear should be used by the nurse.

A 63-year old woman is admitted for lung surgery related to a tumor in her left lower lobe. You receive her into the OR to begin a series of procedures. Which of the following must be completed before setting up the sterile field?

-asses the patient for allergies -make sure all equipment needed is in the room -positioning the patient and covering with warm blankets

The patient falls on the unit. Which actions will the nurse perform?

-assess extent of any injury to the patient -identify the patient using at least two identifiers - document your clinical assessment in the EHR

Pressure injuries occur:

-because of tissue ischemia. -from poorly positioned medical devices. -on any area of skin subjected to pressure.

During a hand-off report, the nurse will:

-provide background information about the patient -recommend the priority of care for the next shift -include in the assessment the patient's response to pain medications

The postoperative client with a closed abdominal wound reports a sudden "pop" after coughing. The student nurse examines the surgical site and sees separation of the wound layers and internal organs protruding through the wound. The priority nursing action is to:

cover the wound with a moist sterile saline dressing, notify the surgeon immediately, prepare for emergent surgery.

What is an advanced directive? What are the types?

A document that details patient's decision about future medical care or designates another person or persons to make medical decisions if the in the individual loses decision making capacity. It can be a living well, power of attorney, or a notaried handwritten document.

HIPPA

A federal law protecting the privacy of patient-specific health care information and providing the patient with control over how this information is used and distributed.

Which of the following examples illustrates the benefit of collecting data using computerized system?

A hospital found that the highest readmission rate was seen in patients with congestive heart failure.

What is Against Medical Advice (AMA)? What are the patient implications?

AMA is against medical advice and the patient implications are that he or she understands the risk involved in leaving and that the health insurance provider may not pay for hospitalization.

As the RN, you administer Tylenol instead of Motrin. You understand when a medication error occurs:

The RN must assess the effects of the drug on the client.

The health care provider is planning to insert a chest tube. You obtained the necessary equipment and prepare to open the sterile field. While doing this, you noticed that the item touched the edge of the drape. What would you do next?

The equipment is considered contaminated and new sterile equipment would need to be obtained

ANA Code of Ethics Provision 9

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

What is the purpose of the hand-off report?

To permit the new nurse an opportunity to ask questions about the patient.

A sterile dressing with no absorbent capacity that is impermeable to fluids and bacteria and is used as prophylaxis for high-risk intact skin (high risk friction areas), superficial wounds with minimal or no exudate best describes:

Transparent film

Be familiar with the Centers for Medicare and Medicade Services

CMS requires all patients receive information regarding their rights related to health care services at admission; otherwise the hospital will not receive reimbursement for services. Notice of rights, exercise of rights, privacy and safety, confidentiality of patient record, restraint or seclusion.

Select the most appropriate statement to be included in the electronic health record (EHR):

Client states, "I am dreading my surgery tomorrow because the last time I had surgery I got an infection in my wound." Client crying.

Key concepts of HIPAA [2003]

Consent and authorization of use, security of information, transfer info, standard for electronic interchange, standard for code sets for date, unique health identifiers, e-signatures, notify patient of breach.

The nurse has opened the sterile supplies and donned a pair of sterile gloves to complete to a sterile dressing change, that requires surgical asepsis. The nurse must:

Consider the 1 inch border on the sterile field as contaminated.

The RN is performing a pressure injury risk assessment using the Braden Scale. The Braden Scale predicts client risk for pressure injury by evaluating:

Friction and Shear, Nutrition, Mobility, Activity, Moisture, and Sensory Perception.

A surgical wound is expected to drain approximately 500 mL or more/24 hours. Which type of treatment does the RN anticipate?

Hemovac drain

The RN finds the post cardiac catheterization client with a large amount of bright red blood soaking the femoral dressing. What is the priority action of the nurse?

Look underneath the dressing and then apply pressure to the bleeding site.

Rights Condition of Participation Act of 1999

Medicaid and Medicare hospitals have standards that ensure minimum protection of each patient's physical and emotional health and safety.

When aseptic procedures are performed, the nurse must have a sterile work area or sterile field. Which statement regarding maintenance of sterile fields is true?

Once a sterile field is outside of the vision of the nurse, the sterile field is considered contaminated.

Dr. Swanzy is at the bedside with a clinical student preparing to perform a sterile procedure. The student makes an A in clinical for the day when he/she:

Opens the outermost flap of the sterile field away from the body, keeping arm outstretched and avoiding crossing the sterile field.

What part if discharge process may be delegated?

Packing patient's belongings, walking/rolling them out.

The RN caring for a client following recent abdominal surgery finds the wound edges of the incision well approximated. The RN knows the wound is healing by:

Primary intention

The RN is caring for a client with a transparent film dressing (Tegaderm) over a wound that is showing a large amount of drainage. How should the nurse proceed?

Recommend another type of dressing for the wound.

Which intervention is most beneficial in preventing pressure injury in the immobile client?

Reposition the client every 1-2 hours

When would the RN consider obtaining a wound culture?

When the surrounding area is red and the wound has yellow drainage and foul odor.

The nurse assesses a Stage I pressure injury as:

intact skin with nonblanchable redness.

Serosanguineous drainage from a wound may be described as:

pale red, watery drainage.

The client has an order for the application of an elastic bandage for compression. Which action by the nurse indicates proper understanding of the procedure?

wrapping the bandage from distal point to proximal point.