nurs 120 quiz 3
When to take pictures of pressure ulcers
Admission, weekly, transfer or change, discharge
Age is most at risk for fat embolism
Adults age 70 to 80 and meals between 20 and 40 years old
Identify the pressure ulcer after a client had a long extensive recovery following a surgical procedure when completing an incident report about the pressure ulcer the nurse should take which of the following actions
And any relevant statements the client made about the ulcer
A nurse is assessing a client who has a pressure ulcer the nurse should recognize which of the following findings is a manifestation of a stage three pressure ulcer?
necrotic subcutaneous tissue
Client was in skeletal traction fine femur fracture and she notices he slid down towards the front of the bed and the way it is on the floor will action shut the nurse take?
Add the client use a trapeze to pull himself up while ensuring the way he hangs freely
Which activities can the nurse working in the outpatient clinic delegate to a license vocational nurse
Administer patch testing to a patient with allergic dermatitis Apply a sterile dressing after the healthcare provider exercises the mall
On the first postoperative day a patient with a below the knee amputation complains of pain in the amputated limb which action is best for the nurse to take?
Administer prescribe analgesics to relieve the pain
Pelvic fractures
Assess abdomen, if pelvic bone has fracture to the stomach it can cause distended stomach which can cause absent bowel sounds,
Displaced fracture
Bone fragments
Skin traction
Bucks traction, used for hip fractures There's a weight to pull the leg down to mobilize is it Don't let weights touch the floor or move risk for skin breakdown
plaster casts
Cheaper, heavier, slow drying 24 to 48 hours, can't get them wet
A dark skinned patient has been admitted to the hospital with chronic heart failure Howard the nurse assess the patient for cyanosis
Check the lips and oral mucous membranes
A patient is admitted to the emergency department with possible left lower leg fractures which of the following should be the initial action by the nurse?
Check the pump pedal dorsalis pedis and posterior tibial pulses
Jackson-Pratt drain
Close drain, placed during surgery by MD, measured drain and observed type of drain in document, squeeze bulb to create negative suction, if less than 30 mL you can remove the drainage
Carpal tunnel syndrome
Compression of the median nerve in wrist, Paresthesia of fingers, assembly line workers are most at risk, DX with Tinel sign: 90° palm and tap to feel numbness, phalens sign: inverted prayer
compartments syndrome SS and interventions
DO NOT want to ice or elevate, Paresthesia (numb and tingle), Paralysis, pulselessness, pain, pressure, Pallor (cool/loss of color)
Client with a fractured developed compartment syndrome which of the following signs should alert the nurse to impending Penny
Dark reddish brown urine
Halo fixation
Deep cervical spine in place and stable
Fibroblast cast
Drive very fast, can get wet
Moisture related wounds
Due to sweat and found under skin folds, breasts, armpits, groin area I need to further skin breakdown, keep skin dry and clean and protect the skin, monitor for incontinence
A nurse is assessing a client who is 24 hour postoperative following an open reduction and internal fixation to repair a fracture of the femur which of the following assessment findings as an early manifestation of fat embolism syndrome?
Dyspnea
Went first applying cast what do you do in the beginning
Elevate extremity for 24 hours to reduce swelling and edema which would reduce risks of compartment syndrome
A nurse is developing a plan of care for a client who has cellulitis of the leg which of the following intervention should the nurse include in the plan
Elevate the affected leg on two pillows
Jena rides in the emergency department with a swollen ankle after his soccer injury which action by the nurse is appropriate?
Elevate the ankle above the heart level
A nurse is caring for a client who is in the queue ankle sprain which of the following actions should the nurse take?
Encourage rest Place a compression bandage on the ankle elevate ankle
How often to inspect cast
Every 8 to 12 hours
How often to check underneath Boot for irritation during bucks traction
Every eight hours checking for irritation and swelling and skin breakdown
How long to perform neurovascular status on affected body part
Every on ehour for 24 hours and every four hours after that
Complication of fracture
Fat embolism syndrome, compartment syndrome, necrotic tissue, DVT
Venous stasis
Fragile skin cellulitis
Complete fracture
Goes through entire bone dividing into distinct parts
Nurse is caring for a client who is one day postoperative following a total hip arthroplasty it is 830 and the client is scheduled for physical therapy at zero 900 which of the following intervention should the nurse take
Identify the clients pain level and medicate if needed
Highest risk for pressure injury
Immobility
Cellulitis
Inflammation of deep connective tissue due to infection, and venous stasis Elevate extremity, can lead to weeping Edema which is fluid moving out of the cells with increase with white blood cells and is red and swollen and painful
Nurse working in an emergency room is assessing a client who had a leg wound. the nurse notes a full thickness wound with jagged edges and muscle tissue visible the nurse should document as which type of wound
Laceration
Diabetic wounds
Microvascular complications due to neuropathy
Halo fixation interventions
Monitor the clients vital signs every four hours, monitor the clients pin sites for loosening, check the client skin to ensure jacket is not applying pressure
A patient who has had an open reduction and internal fixation ORIF of left lower leg fractures complains of constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable in the foot is cool which action should the nurse take next?
Notify the healthcare provider
open reduction internal fixation
ORIF, surgical alignment of fractured bones using screws, pins, wires, or nails to maintain bone alignment. more for compound fractures rather than distal fractures
A nurse is preparing to care for a client who is in balance skeletal traction to stabilize the femur fracture. Which of the following actions should the nurse include in the clients plan of care?
Offering the client a diet and high fluid and fiber, to promote gastrointestinal function
Simple fracture has what
One fracture line while I communicated fracture has multiple fractures lines splitting the bone
A nurse is caring for a client immediately following a plaster cast what should the nurse monitor for report as a finding of compartment syndrome?
Paresthesias of the extremity,
Compartment syndrome findings
Paresthesias, numbness, tingling, weakness, pain that doesn't respond to medication
Cast care and patient teaching
Perform neurovascular assessment (6 ps), elevated 24 hrs after notify provider of purulent drainage or smell teach patient to use blow dryer with cold air for itching, teach them to keep moving and do ROM exercises to promote blood return
A nurse in the clinic is caring for an older adult client who reports dry flaky skin on her upper back which of the following is an intervention the nurse should complete?
Pinch a fold of skin to check for turgor
What does bucks extension traction do
Reduces pain, decreases muscle spasm, and stabilizes
Nurse is teaching in assistive personnel about the purpose of a foot plate on the bed for a client whose leg is in bucks traction which of the following statements indicates the AP understands the teaching?
Play helps to prevent foot drop
What are the four pulses to check for neurovascular assessment bilaterally on the legs
Poplietal, femoral, dorsal pedis, tibial
Braden scale
Pressure ulcers lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers
Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the healthcare provider?
Prolong capillary refill of the left foot
DVT
Pulling of blood, diagnosed with Doppler ultrasound, edema, redness, weak pulses, sense of doom
suspected deep tissue injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
A patient is seen in the clinic complaining of knee pain following a arthroscopic procedure seven days ago and the healthcare provider performs arthrocentesis. Which finding will be of most concern to the nurse?
Purulent appearing fluid
A nurse is assessing a client who is 24 hour postoperative following in above the elbow amputation which of the following findings should the nurse identify as a priority?
Report of muscle spasms
Young male patient with paraplegia has a stage to sacral pressure injury and is being cared for at home by his family to prevent further tissue damage with instructions are most important for the nurse to teach patient and the family?
Reposition every 1 to 2 hours
Pressure ulcer interventions
Reposition every two hours, assessed frequently, when transferring patient don't slide patient on bed because the sheets can irritate the skin. lift patient of bed don't slide
Planning care for a patient who has had hip replacement surgery which nursing action camera nurse delegate to experience nursing assistant personnel
Reposition patient every 1 to 2 hours
Fracture or sprain or strain nursing interventions
Rest Ice, within the first 24 to 48 hours intermittently for vaso constriction 15 to 20 minutes then takeoff Compress, venous return Elevate
Types of wound drainage
Serous- clear, watery Sanguineous- active bleeding - bright red (active process) Serosanguineous- pale, red, watery: mixture of clear red fluid (pink)-thin Purulent- yellow, green, tan or brown & odor
A nurse is discussing the differences between skeleton skin traction with a newly licensed nurse which of the following statements by the newly licensed nurse indicates understanding?
Skeletal traction is more appropriate than skin traction for reducing a fracture
Hip fracture interventions
Splint leg and rice Post hip fracture surgery keep them abductor pillow to immobilize hip joint give anticoagulants prophylactic for DVT, provide compression stockings, raise higher to prevent flexing of hips (>90 degrees), educate not to bear weight and to rest it
Delegation that cannot be given to uap
T teaching A assesment P planning E evaluating
Skeletal traction
The most effective means of traction, applying to a bone with wire pins which can become loose and cause infection Notify provider if redness inflammation present
The nurse could delegate care of which patient to a license vocational nurse
The patient who requires a hydrocolloid dressing change for a stage three sacral ulcer
athroplasty
The surgical replacement of a joint splint to keep in place, asses skin breakdown, compression stockings, anticoagulants, pain/edema
A nurse is providing teaching for a client who is postoperative following below the knee amputation the nurse should instruct the client to which of the following nutrients is necessary for wound healing?
Vitamin C
The nurse is caring for a patient who is on bed rest after having a complex pelvic fracture which assessment finding is most important to report to the healthcare provider?
abdominal distention is present and bowel tones are absent
uap things can do
ambulate, turn, bathe, I and O (no IV), mouth care, toileting, linen, feeding (no aspiration), stable pts, do not give meds,
Fat embolism syndrome
blocking of small blood vessels by fat globules subsequent to a fracture, especially one of long bones or pelvis Petechiae is usually found on eyes, treat with anticoagulants heparin, DO NOT elevate or ice, O2 sat will be lower because the fat particles so you can give up to 2 L O2 nasal cannula without doctor prescription
open (compound) fracture
broken bone penetrates through the skin Grade 1 minimal skin damage grade 2 damage includes skin and muscle contusions but without extensive soft tissue injury Grade 3 damages excessive to skin muscles nerves and blood vessels
Unstageable
covered with necrosis
Closed simple fracture
does not break the skin
compartment syndrome signs and symptoms
early signs: hypoxia dyspnea, necrotic tissue late sigsn: headaches and agitation
heel wound interventions
heel protectant to prevent skin breakdown, don't let the heel touch the edge a better sheets
Moderate ankle injury grade 2, actions?
ice
compartment syndrome
involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles Requires fasciotomy, common with casts, pain not relieved by pain meds,
Delegation of wound care
necrotic tissue: wound care nurse or physician LVN can perform wound care but cannot teach about it, can do dressing after everything has been established including medication and first wound dressing change CNA cannot perform dressing changes only reposition and ambulation
Closed reduction
nonsurgical realignment of broken bone ends and splinting of bone ss: erythema, discoloration, edema, pain and limited rom
Is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia which of the following is the priority action for the nurse to take
perform neurovascular assessment
Arthrocentesis
remove fluid from joint
5 rights of delegation
right task right circumstance right person right direction/communication right supervision/evaluation
lvp can do
same as uap + stable pt with chronic predictable dx, no new admission, no education, can gather data like vitals, cannot interpret data, give vaccines, cannot do IV/blood products, can give po meds
Braden scale factors
sensory perception, moisture, activity, mobility, nutrition, friction and shear
Russell traction
skin traction, a sling is positioned under the knee which suspends the distal thigh above the bed, risk for skin breakdown
open reduction
surgical realignment of broken under anasthesia More for compound fractures location ss: erythema, discoloration, edema, pain and limited rom
arthroplasty
surgical repair or replacement of a joint Splint to keep in place put surgically Abductor pillow or wedge pillow immobile precautions: Assess skin breakdown give, compression stockings etc.