skills exam 3
Which client is a greatest risk of developing a pressure injury?
47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness
Which client would be at greatest risk for developing a pressure injury?
Adult client who is comatose
The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next?
Apply skin barrier to the tip and end of the nose
A nurse is gathering the necessary equipment to empty a client's Hemovac drain. Which personal protective equipment (PPE) would be most essential for the nurse to use at a minimum?
Clean gloves
The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure?
Clean the wound.
The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next?
Cleanse the wound with a nonantimicrobial cleanser.
A client has undergone surgery and has a Hemovac drain in place. When providing care to this client, the nurse would monitor the drain status at which frequency?
Every 4 hours
The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound?
From the upper end of the wound to the lower end
After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain?
Fully compress the bulb and reapply the cap.
Following the removal of a nasogastric NG tube, the nurse should monitor the client for which possible adverse reaction?
Gastric distention.
In what position would the nurse place the client prior to removing a nasogastric tube?
In an upright position with the bedrail nearest the nurse down
The nurse, removing a nasogastric (NG) tube from a client, flushes the NG tube prior to removing it. Which would be most appropriate for the nurse to do?
Instill 30 to 50 mL of air to clear the tube.
When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe?
Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound
The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next?
Proceed with nasogastric tube placement.
When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results?
Rolling motion
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?
Secure the drain to the client's gown with a safety pin below the level of the wound.
How often will the nurse empty a Jackson-Pratt drain? Select all that apply.
The nurse should empty the Jackson-Pratt drain when the drain is one-half to two-thirds full and at least every 4 hours.
The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container?
Use a gauze pad to clean the outlet.
The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound?
When the solution from the wound flows out clear
When repositioning a client, how should the nurse handle an arm cast that is not fully dry?
by using the palms of the hands and lifting gently
The nurse has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction?
fully compressed and the cap reapplied while compressed to re-establish suction
The nurse is caring for a client with a cast and notes both decreased sensation and capillary refill in the casted extremity. What complication should the nurse report?
impaired circulation
Which documentation does the nurse complete after inserting a client's nasogastric (NG) tube?
measurement of the exposed tube
After emptying a client's Hemovac drain, the nurse re-establishes suction and closes the cap. Which action would the nurse do next?
secure the drain to the client's gown below the level of the wound.
The nurse is caring for a client who has had a cast placed. What are the most common reasons that clients may need cast application? Select all that apply.
to stabilize weakened joints, to treat injuries, to correct a deformity, to promote healing after surgery
After putting on gloves, the nurse lubricates the nasogastric (NG) tube prior to insertion into the client's nares. Which lubricant is appropriate to use?
water-soluble lubricant
Which would be most appropriate for the nurse to do when removing a nasogastric (NG) tube?
Ask the client to take a deep breath and pull out the tube quickly and carefully.
A family member assisted the client with an arm cast to bathe. The client reports that the cast "got a little wet." What action should the nurse take?
Assess cast integrity and report any abnormalities.
The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change?
Assessing the need for analgesia
When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure?
Date and reuse leftover irrigation solution within 24 hours.
When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding?
Deep tissue injury
The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which would the nurse do first?
Discontinue the suction.
A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client?
History of facial fractures
Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply.
No bone, tendon, or muscle visible., Visible subcutaneous fat, Full-thickness tissue loss
The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first?
Obtain a sterile wound culture
The nurse is monitoring a client who had a nasogastric (NG) tube placed postoperatively after abdominal surgery. Which criterion would the nurse use to determine that the tube could be removed?
Passage of flatus.
A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.
Press and rotate the swab several times over the wound surfaces., Place the swab in the culture tube when done., Insert a swab into the wound.
The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next?
Remove gloves and perform hand hygiene.
Following insertion of a nasogastric tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take?
Secure the tubing with a safety pin to the client's gown at shoulder level.
The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding?
Stage 1 pressure injury
The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution?
Sterile basin
The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time?
Teach the client ways to relieve the pressure on the heel.
The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which has likely occurred?
The NG tube is in the client's airway.
The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing?
To promote moist wound healing and protect the wound from contamination and trauma.
The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development?
Turn and reposition the client every 2 hours.
How would the nurse secure a Jackson-Pratt drain after emptying it?
With a safety pin, secure the drain to the client's gown below the wound.
A client who has a plaster arm cast reports itching under the cast and asks the nurse what to do about it. What is the appropriate response by the nurse?
You can tap lightly on the outside of the cast or use a hair dryer on cool setting to blow cool air into the cast."
A client scheduled for the removal of a nasogastric tube asks the nurse, "Will taking out the tube hurt?" What is the nurse's best response?
You may experience minor discomfort as the tube is being removed."
The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:
has black brown eschar covering the top.
After measuring from the client's nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client?
to the xiphoid process