NURS 200 Exam 3
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?
"That is necrotic tissue, which must be removed to promote healing."
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?
"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form."
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 mL/day
A nurse is performing a physical assessment of a patient experiencing fluid volume excess. The patients lower extremity on assessment have a 6mm deep pit. This represents
3+ pitting edema
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3,000 mL
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
How does infant skin and mucous membranes differ from adults?
An infant's skin and mucous membranes are easily injured and at risk for infection.
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?
Anti-A antibodies
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?
Apply saline solution-moistened gauze over the protruding area.
When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?
Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation.
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?
Assess the client's wound and vital signs
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy?
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
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?
Dehiscence of the wound (partial or total separation of previously approximated wound edges, due to a failure of proper wound healing)
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another site.
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?
Discontinue the therapy and assess the client.
The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?
Document the color, odor, amount, and type of wound drainage
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution the expected clearness and consistency.
A client with stage III breast cancer has been prescribed 10 weeks of chemotherapy. Which intravenous (IV) access does the nurse anticipate will be needed?
Groshong catheter tunneled into the subclavian vein
A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing interventions would the nurse perform based on this patient reaction?
Lower the solution container then check the temperature and flow rate
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?
Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.
A nurse is administering a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the area is edematous and cool to touch. What would be the nurse's next action related to these findings?
Put on gloves and remove the catheter.
The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply. - Sensory perception - Nutritional status - Mental status - Skin moisture - Stages of pressure injuries
Sensory perception Nutritional status Mental status Skin moisture
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 2
The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?
Stage 2
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?
The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.
A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?
The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.
A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?
The status of the client's tetanus immunization
The nurse is preparing to access an implanted port when administering intravenous fluids and medications. What best practice should be used when accessing this port?
The system is accessed with a noncoring needle and patency is maintained by periodic flushing.
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
To splint the area when engaging in activity
Which complication is the primary cause of transfusion-related client death in the United States?
Transfusion-related acute lung injury
The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?
Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL).
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a newly admitted 88-year-old with a 2-day history of vomiting and loose stools a 47-year-old who had a colon resection yesterday and is reporting pain
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
The nurse would recognize which client as being particularly susceptible to impaired wound healing? - an obese woman with a history of type 1 diabetes - a man with a sedentary lifestyle and a long history of cigarette smoking - a client whose breast reconstruction surgery required numerous incisions - A client who is NPO (nothing by mouth) following bowel surgery
an obese woman with a history of type 1 diabetes
Which nursing care task is acceptable for a registered nurse to delegate to the unlicensed assistive personnel (UAP)? A. Performing initial and ongoing assessments. B. Assisting a client with ambulation. C. Evaluating nursing care delivered to a client. D. Developing a client teaching plan.
assisting with ambulation
Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply. client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa client who has full-thickness (third-degree) burns over 40% of the body client with peptic ulcer disease client who has cholelithiasis
client who has full-thickness (third-degree) burns over 40% of the body client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? - contusion - avulsion - puncture - incision
contusion
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? - potassium supplements - corticosteroids - antihypertensive drugs - laxatives
corticosteroids
What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
decreased potassium
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?
dessication
Signs and symptoms of hyperkalemia
diarrhea, nausea, muscle weakness, paresthesias, cardiac dysrhythmias. Causes unique changes in ECG- prolonged PR interval, widened QRS, ST segment depression & tall/peaked T wave.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?
elevate and support the stump
What independent nursing intervention can be implemented to stimulate appetite? A. Assess manifestations of malnutrition. B. Recommend dietary supplements. C. Encourage or provide oral care. D. Administer prescribed medications.
encourage or provide oral care
The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?
evisceration
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? - Pasta salad - Fish - Banana - Green beans
fish
A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? - small amount of drainage that appears to be mostly fresh blood - copious drainage that is blood-tinged - foul-smelling drainage that is grayish in color - large amounts of drainage that is clear and watery and has no smell
foul-smelling drainage that is grayish in color
The process of filtration begins at the:
glomerulus
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?
hypokalemia
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
hyrdocolloid
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:
low calcium
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? A. exposed bone with eschar B. visible subcutaneous fat C. nonblanchable redness D. a shallow open injury
nonblanchable redness
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least iportant for the evaluation process? A. Medication being taken B. The incontinence pattern C. Age of the patient D. State of physical immobility
patient's age
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking the client to pump their fist several times asking if the client is right or left handed placing the tourniquet on the upper arm for 2 minutes palpating the veins on the nondominant hand
placing the tourniquet on the upper arm for 2 minutes. should not be more than 1 min
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
potassium
The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? - pulling the sheets to reposition the client every 2 hours - pulling the client up from under the arms - preventing the client from sliding in bed - improving the client's hydration
preventing client from sliding in bed
A decrease in arterial blood pressure will result in the release of:
renin
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? - Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. - Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. - Rotate the swab several times over the wound surface to obtain an adequate specimen. - Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain.
rotate swab several times to obtain adequate sample
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?
secondary intention
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? - purulent - sanguineous - serosanguineous - serous
serosanguineous
The 3 primary extracellular electrolytes are:
sodium, chloride, and bicarbonate
A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?
stop removing the staples and notify the surgeon
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?
tertiary intention
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm to facilitate rehydration. What type of dressing will the nurse apply over the client's venous access site?
transparent film
A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?
use clean technique instead of sterile if the wound is closed
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?
use pillows to maintain a side-lying position as needed
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:
winged infusion needle
The nurse is preparing to measure the depth of a client's tunneled wound. What is the correct way of doing so?
with a sterile, flexible applicator moistened with saline