SKIN WOUND

A nurse is developing a plan of care for a client who has stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? A. Apply a heat lamp twice a day. B. Reposition the client at least every 2 hr. C. Clean the wound with hydrogen peroxide solution. D. Massage reddened areas with dressing changes.

Reposition the client at least every 2 hr. The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.

Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate? A. Droplet B. Contact C. Airborne D.Protective

Contact Contact precautions are a type of transmission-based precaution for clients who have an infection, such as VRE, which spreads either by direct or indirect contact.

A nurse is assessing a client who has had staples removed from an abdominal wound postop. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs. B. Assess the client's pain level. C. Cover the wound with a moist, sterile gauze dressing. D. Obtain a culture and sensitivity of the wound drainage.

Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of NS solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record?

415 STEP 1: What is the unit of measurement the nurse should calculate? mL STEP 2: What is the amount of drainage in the NG canister? Quantity = 475 mg STEP 3: What is the amount of irrigation used? Irrigation = 60 mL (30 x 2) STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Quantity - Irrigation = X 475 - 60 = X 415 = X

A nurse is assessing a client following the application of an aquathermis pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? Blistering Erythema Eschar Absence of pain

B Blistering Blistering is an indication of a superficial partial thickness burn, involving injury to the upper third of the dermis. These injuries also are pink and moist, blanch to pressure and are very painful. Erythema Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat. Eschar Eschar is seen in clients who have a full thickness wound involving the epidermis and dermis. This is dead tissue that must be removed for healing to occur Absence of pain A thermal injury that is not painful can be classified as a deep full-thickness burn which extends into muscle, bone, or tendons.

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? SATA A. Bradycardia B. An increase in neutrophils C. An increase in RBCs D. An increase in platelets E. Localized edema

Bradycardia is incorrect. Tachycardia, not bradycardia, is an indication of infection. An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms. An increase in RBCs is incorrect. An increase in the RBC count reflects polycythemia, not infection. An increase in platelets is incorrect. An increase in the platelet count can reflect malignancies, not infection. Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? Hypotension Numbness Shivering Reduced blood viscosity

C Hypotension Hypertension is a systemic response that can result from cold therapy because it causes vasoconstriction. Numbness Numbness is a localized response that results as a local anesthetic effect from cold therapy. Shivering Shivering is a systemic response to cold therapy as the body attempts to promote heat production. Reduced blood viscosity Cold application increases the blood's viscosity. Heat application reduces the blood's viscosity.

A nurse is assessing a client who is postop and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? A. Cover the wound with a sterile saline-soaked dressing. B. Place the client in high-Fowler's position. C. Auscultate all quadrants of the abdomen for bowel sounds. D. Gently reinsert the protruding tissue.

Cover the wound with a sterile saline-soaked dressing. The nurse should cover an eviscerated wound with sterile saline-soaked gauze to prevent damage and infection.

A nurse is caring for four clients. The nurse should identify which of the following clients as having a contraindication to receiving moist heat? A. A client who has osteoarthritis and has pain of lower extremity joints B. A client has a spinal cord injury and muscle spasms of the lower back C. A client who is 1 day postoperative and has deep vein thrombosis D. A client who broke his ankle 2 hr ago and has swelling of the lower extremity

D. A client who has osteoarthritis and has pain of lower extremity joints. Clients who have osteoarthritis can apply moist heat to stiff joints to decrease muscle tension and possibly reduce pain. A client has a spinal cord injury and muscle spasms of the lower back. A client who has a spinal cord injury and muscle spasms can use moist heat to relax muscles and increase contractility. A client who is 1 day postoperative and has deep vein thrombosis Clients who have deep vein thrombus can use moist heat to decrease inflammation by increasing blood flow to the area which brings nutrients to the area and carries waste away. This will also reduce pain. A client who broke his ankle 2 hr ago and has swelling of the lower extremity A client who had a traumatic injury should not receive heat application for the first 24 hr due to increased bleeding and swelling. The client's leg should be kept elevated and ice should be applied during the first 24 hr to decrease swelling.

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 3 pressure ulcer? Exposed bone Blood filled blisters Partial-thickness skin loss. Necrotic subcutaneous tissue

D. Exposed bone Manifestations of a stage 4 pressure ulcer can include full-thickness skin loss with exposed or palpable bone or muscle. Blood filled blisters Manifestations of a stage 1 pressure ulcer can include reddened intact skin and blood filled blisters. Partial-thickness skin loss. Manifestations of a stage 2 pressure ulcer can include partial-thickness skin loss and a superficial ulcer. Necrotic subcutaneous tissue Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue.

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? Kidney beans Grilled salmon Peanut butter Raw spinach

Grilled salmon Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing.

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding? A. Place the client in a lateral position. B. Provide an adaptive feeding device for the client. C. Initiate a liquid diet for the client. D. Arrange the food groups clockwise on the client's plate.

Provide an adaptive feeding device for the client. Adaptive devices, such as utensils with bent or angled handles, wide handles, or foam handles, are helpful for clients whose hand mobility is limited because these devices promote independence.

A nurse is providing teaching for a client who is postop following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for wound healing? Vitamin B1 Vitamin C Folate Vitamin E

Vitamin C Vitamin C promotes collagen synthesis, which is essential for wound healing.

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires interventions? A. "Does your skin condition keep you awake at night?" B. "Have you had any changes in your diet?" C. "How do you handle stress?" D. "How does your skin condition make you feel?"

"How do you handle stress?" Although stress can play a role in creating or exacerbating a skin condition, this question does not obtain specific information that relates to the skin condition.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following lab findings will affect wound healing? Serum albumin 3.2 g/dL Hemoglobin 16 g/dL WBC count 8,000/mm3 PTT 1.8

A. Serum albumin 3.2 g/dL A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection. Hemoglobin 16 g/dL A level below the expected reference range indicates poor delivery of oxygen to the tissues and decreases wound healing. However, this finding is within the expected reference range. WBC count 8,000/mm3 A level below the expected reference range can increase the risk of infection and delay wound healing. However, this finding is within the expected reference range. PTT 1.8 Prolonged coagulation studies can promote intravascular clotting and decreased blood supply to the wound area, affecting wound healing. However, this finding is within the expected reference range.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

C Reposition the client every 3 hr. Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough. The nurse should reposition the client at least every 2 hr. Massage bony prominences to promote circulation. Massaging the skin over bony prominences can traumatize deep tissues. Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown. Apply cornstarch to keep the skin dry. Cornstarch can create gritty particles that can abrade sensitive skin.

A client who is having burn debridement states, "You are the worst nurse I have ever seen. all you do is hurt me." Which of the following responses should the nurse make? A. "That's a hurtful thing to say." B. "Tell me more about that." C. "Why would you say such a thing?" D. "Well, that's your opinion."

"Tell me more about that." This statement asks the client to talk about the problem. The nurse is not threatened and is open to hearing more about the problem. Whether the client's statement is true or false, the client will be able to talk about the feelings that caused the outburst. The nurse will be able to adapt care based upon better input and insight into the client's problem.

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incision. Which of the following factors should the nurse include in the teaching? SATA Poor nutritional state Altered mental status Obesity Pain medication administration Wound infection

A, C, E Poor nutritional state is correct. A client who is in a poor nutritional state is at risk for dehiscence due to impaired healing. Altered mental status is incorrect. Altered mental status is not a risk factor for dehiscence. Obesity is correct. A client who is obese is at risk for dehiscence due to poor healing abilities of adipose tissue and the constant strain placed on the incision. Pain medication administration is incorrect. A client who is taking pain medication is not at risk for dehiscence. Wound infection is correct. A client who has a wound infection is at risk for dehiscence due to delayed healing.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify the usual flora.

A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results. Irrigate the wound with an antiseptic prior to obtaining the specimen. Irrigating with an antiseptic prior to obtaining the specimen can destroy the bacteria and result in false-negative results. Include intact skin at the wound edges in the culture. Intact skin at the wound edges can result in the inclusion of superficial skin organisms in the culture and cause misleading results. Swab an area of skin away from the wound to identify the usual flora. The nurse should sample the wound itself, not skin in other areas.

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area? A. Montgomery straps B. Enzymes C. Alcohol swabs D. A transparent dressing

A. Montgomery straps Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips. Enzymes The nurse should use enzymes to debride a wound that contains eschar. Alcohol swabs The nurse should recognize that alcohol has a drying effect on the skin. A transparent dressing The nurse should use a transparent dressing to protect a client from shearing forces. The transparent dressing should be used on intact skin. This type of dressing would cause damage each time it is removed, as the entire surface contains adhesive.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? Protein Calcium Vitamin B1 Vitamin D

A. Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing. Calcium Calcium is a nutrient that functions in the formation and maintenance of bone and teeth. It does not promote wound healing. Vitamin B1 Vitamin B1 is a nutrient that functions to promote normal appetite and nervous system functioning. It does not promote wound healing. Vitamin D Vitamin D is a nutrient that helps to maintain serum calcium levels. It does not promote wound healing.

A nurse is caring for a client who has a JP drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? A. To prevent fluid from accumulating in the wound B. To limit the amount of bleeding from the surgical site C. To provide a means for medication administration D. To eliminate the need for wound irrigations

A. To prevent fluid from accumulating in the wound The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures. To limit the amount of bleeding from the surgical site A JP drain does not limit the amount of bleeding. To provide a means for medication administration A JP drain does not provide a means for medication administration. To eliminate the need for wound irrigations A JP drain is not used as a substitute for wound irrigation.

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply? Transparent dressing Wet-to-dry gauze dressing Hydrogel dressing Alginate dressing

A. Transparent dressing stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area. Wet-to-dry gauze dressing A wet-to-dry dressing is used to remove necrotic tissue from a wound. A stage I pressure ulcer has no necrotic tissue. Hydrogel dressing A hydrogel dressing rehydrates the bed of a wound and promotes autolytic debridement. It is used for stage II through stage IV pressure ulcers. Alginate dressing Alginate dressings are used for stage II through stage IV pressure ulcers that have moderate to heavy drainage.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter.

Apply a moisture barrier ointment to the client's skin. Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

A nurse in an ED is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? Apply a tourniquet just below the elbow. Apply direct pressure over the wound. Clean the wound. Elevate the limb and apply ice.

Apply direct pressure over the wound.

A nurse is caring for a client who is postop following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? A. Place the head of the client's bed in the flat position. B. Gently reinsert the bowel back into the client's wound. C. Apply moistened sterile gauze to the site. D. Position the client on his left side.

Apply moistened sterile gauze to the site. The nurse should apply moistened sterile gauze to the site to reduce the risk for further injury and infection.

A nurse in an ED is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? A. Apply a tourniquet just above the wound. B. Apply pressure directly to the wound. C. Start two large-bore IV catheters. D. Place the client in a modified Trendelenburg position.

Apply pressure directly to the wound. The greatest risk to the client is hypovolemic shock. Therefore, the initial action to control bleeding is to apply pressure directly to the area or to the artery proximal to the wound.

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. Inspecting the site for reduced swelling B. Monitoring the client's pulse rate C. Asking the client to rate the pain D. Having the client perform range-of-motion of the affected arm

Asking the client to rate the pain Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness.

A nurse is preparing to remove staples from a client's surgical incision. Which of the following actions should the nurse take? SATA A. Assure the client there will be no discomfort during the procedure. B. Clean the surgical site. C. Lift the staple remover when squeezing the handle. D. Examine the incision. E. Verify the prescription for staple removal.

B, D, E

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? SATA A. A client who is ambulatory following a cardiac catheterization 4 hr ago B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has protein calorie malnutrition D. A client who has right-sided heart failure and 4+ edema to the lower extremities E. A client who has postoperative delirium

C, D, E A client who is ambulatory following a cardiac catheterization 4 hr ago is incorrect. Because this client is ambulatory, there is no identified risk for the development of a pressure ulcer. A client who has type1 diabetes mellitus and is hyperglycemic is incorrect. The nurse should identify the client who has hyperglycemia as being at risk for long-term complications such as renal failure. However, this client has no identified risk for the development of a pressure ulcer. A client who has protein calorie malnutrition is correct. A client who has poor nutritional status is at risk for the development of pressure ulcers. A client who has right-sided heart failure and 4+ edema to the lower extremities is correct. A client who has poor skin perfusion resulting from a condition such as peripheral edema is at risk for the development of pressure ulcers. A client who has postoperative delirium is correct. A client who has a decreased level of consciousness, such as delirium, is at risk for the development of pressure ulcers.

A nurse working in an ER is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? Abrasion Contusion Laceration Puncture

C. Abrasion An abrasion is an open wound that occurs when the skin is scraped or rubbed off, such as an injury resulting from a fall in which the knees are scraped. Contusion A contusion is a closed wound; the result of a blunt force impact. The wound appears ecchymotic (bruised) as a result of trauma to the vascular system. Laceration Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound. Puncture A puncture is an open wound usually caused by a sharp object that penetrates the skin leaving a small surface opening.

A nurse is caring for a client who is postop following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's JP drain? A. Measure the drainage every hour for the first 8 hr postoperative. B. Secure the drain to the client's bed sheet. C. Expel the air from the JP bulb after emptying to re-establish suction. D. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.

C. Measure the drainage every hour for the first 8 hr postoperative. It is not necessary to empty, measure, and record the drainage hourly. The nurse should monitor the color and measure the amount of drainage every 8 hr and when the JP container becomes full. Secure the drain to the client's bed sheet. The drain should be secured to the client's gown to avoid tension on the drain site from the weight of the drain bulb when the client is ambulatory and to from accidental dislodgment of the drain when the client is in bed. Expel the air from the JP bulb after emptying to re-establish suction. With the drainage and the air removed and the bulb tightly closed, the system works to exert gentle negative pressure, facilitating the removal of accumulated fluid from the surgical area. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze. A surgeon removes a JP drain, usually on the second postoperative day. If the tube is displaced accidentally, the nurse should cover the site with sterile gauze.

A nurse is caring for a client who is 2 days postop following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first? A. Raise the head of the client's bed 15° to 20°. B. Place the client supine with knees bent. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation. According to evidence-based practice, the nurse should first cover the area with a sterile dressing moistened with normal saline to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.

A nurse is reviewing the lab results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following lab values as an indication that the client has developed an infection? BUN Potassium RBC count WBC count

D BUN An elevation in BUN indicates an impairment in renal function. Potassium An elevation in potassium indicates an impairment in renal function. RBC count An elevation in the RBC count indicates polycythemia. WBC count An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear. D. Determine if the client uses hearing aids.

Determine if the client uses hearing aids. The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? A. Discard the dressing in the bedside trash receptacle. B. Dispose of the dressing in a biohazardous waste container. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. D. Double-bag the dressing in clear bags and label it "biohazard".

Dispose of the dressing in a biohazardous waste container. The nurse should discard potentially infective material, such as a dressing that contains blood and pus, in a biohazardous materials container separate from the regular trash.

A nurse is caring for a client who has a closed suction drain. Which of the following actions should the nurse take? SATA A. Connect the drainage tube to wall suction. B. Keep the drain insertion site open to air. C. Expect a moderate amount of drainage on the drain dressing. D. Report serosanguineous drainage to the charge nurse. E. Empty the collection chamber using sterile technique.

E. Connect the drainage tube to wall suction is incorrect. A closed suction drain is used to remove blood and other drainage from a wound following surgery. The collection chamber of a closed suction drain should remain compressed to provide continuous low-pressure suction. Keep the drain insertion site open to air is incorrect. The nurse should place a drain sponge or a piece of folded gauze dressing at the insertion site of the drainage device to absorb drainage. Expect a moderate amount of drainage on the drain dressing is incorrect. Drainage that appears on the dressing around a closed suction drain is an indication of a blockage of the drain itself. The nurse should notify the provider if this occurs. Report serosanguineous drainage to the charge nurse is incorrect. A drainage device is inserted during surgery when a significant amount of drainage is anticipated. Following surgery, the nurse should expect sanguineous (blood) or serosanguineous (serum and blood) drainage in the drain reservoir. Because this is an expected finding, it is not necessary to report this finding to the charge nurse. Empty the collection chamber using sterile technique is correct. The collection chamber of a closed suction drain should be emptied every shift and as needed. The nurse should use sterile technique to avoid introducing organisms into the drainage system. The nurse should document the amount of drainage in the client's I&O record, as well as describe the appearance of the drainage.

A nurse is about to explain a therapeutic procedure to a client who doesn't speak the same language as the nurse. Which of the following actions should the nurse take? A. Ask a family member to translate. B. Have a medical interpreter present during the teaching. C. Tell the client that he will receive written information in his language after the procedure. D. Use nonverbal gestures to assure the client that the procedure is safe and will help him.

Have a medical interpreter present during the teaching. Federal law requires specific procedures for accommodating language barriers. The nurse should use a medical interpreter to give the client instructions he can understand.

A nurse identifies a 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? A. Document what the nurse believes was the cause of ulcer development. B. Include any relevant statements the client made about the ulcer. C. Document in the client's medical record that she completed an incident report. D. Question the charge nurse about care deficits that might have contributed to the ulcer's development.

Include any relevant statements the client made about the ulcer. The nurse should document any relevant statements the client makes about the ulcer and use quotation marks to indicate that they are the client's words and not the nurse's.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? SATA A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep the client's skin dry with powder. E. Minimize skin exposure to moisture.

Massage over erythematous bony prominences is incorrect. The nurse should avoid massaging bony prominences, since it may cause further skin break down. Implement turning schedule every 4 hr is incorrect. The nurse should implement a 2 hr turning schedule to prevent skin breakdown. Use pillows to keep heels off the bed surface is correct. The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels. Keep the client's skin dry with powder is incorrect. The nurse should apply lotion and avoid applying powder to the skin, which may cause skin breakdown. Minimize skin exposure to moisture is correct. The nurse should minimize skin exposure to moisture to prevent skin breakdown.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postop following a partial bowel resection, requires a dressing change, TPN administration and reports a pain level of 6 on a scale from 0-10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? A. Weigh the second client. B. Obtain vital signs for both clients. C. Administer pain medication to the first client. D. Change the dressings of both clients.

Obtain vital signs for both clients. Using the nursing process as an organizing framework, the nurse should obtain vital signs on the two clients to determine if there are any emergent problems.

An AP reports to the nurse that a client who is 3 days postop following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? A. Change the abdominal dressing. B. Obtain vital signs. C. Palpate for possible bladder distention. D. Observe the incision site.

Obtain vital signs. Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?

Perform hand hygiene Remove the bottle cap Place the bottle cap face-up on a clean surface Pick up the bottle with the label facing toward the palm Pour 1-2 mL into a receptacle Pour the solution onto the gauze

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad under the client's leg, apply clean gloves to remove dressing, clean site using circular motion, open sterile kit, irrigate wound The nurse should first place a waterproof pad on the bed under the client's leg to prevent soiling the bed linen. The nurse should then apply clean gloves to remove and discard the old dressing. Next, the nurse should clean the puncture site using a circular motion, moving from the cleanest area in the center of the wound outward. After cleaning the wound, the nurse should prepare the equipment necessary for irrigation by opening a sterile dressing set and supplies. Finally, the nurse should irrigate the wound until the solution becomes clear to ensure that exudate is no longer present.

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? A. Massage the client's red bony prominences. B. Assess the client's skin for increased coolness. C. Reposition the client every 2 hr. D. Keep the client's skin moist.

Reposition the client every 2 hr. The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? A. Instruct the client about home disposal of contaminated dressings. B. Schedule a follow-up visit by a home health nurse for dressing changes. C. Provide a dietary list of foods which promote wound healing. D. Establish a follow-up appointment with the client's provider.

Schedule a follow-up visit by a home health nurse for dressing changes. The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serous Purulent Sanguineous Serosanguineous

Serosanguineous Watery red drainage should be documented as serosanguineous. Serous Watery red drainage should not be documented as serous which is yellowish. Purulent Watery red drainage should not be documented as purulent which is thick and odorous. Sanguineous Watery red drainage should not be documented as sanguineous which is bloody.

A nurse is changing the dressing of a client who is 1 week postop following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances? A. Serosanguineous drainage at this time is expected after abdominal surgery. B. Serosanguineous drainage at this time is a manifestation of possible dehiscence. C. Serosanguineous drainage at this time is a manifestation of hemorrhage. D. Serosanguineous drainage at this time is a manifestation of infection.

Serosanguineous drainage at this time is a manifestation of possible dehiscence. Serosanguineous drainage beyond the fifth postoperative day is a manifestation of possible dehiscence and the provider should be notified.

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? A. Set the pad's temperature to 42.2° C (108° F). B. Stop the treatment if the client's skin becomes red. C. Leave the pad in place for at least 40 min. D. Use safety pins to keep the pad in place.

Stop the treatment if the client's skin becomes red. Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider.

A nurse is preparing a teaching plan for a client who speaks limited English and is scheduled for a surgical procedure. Which of the following guidelines should the nurse plan to use when selecting written educational materials for the client? SATA A. Use culturally diverse materials. B. Use pictures. C. Use materials written at an eighth-grade level. D. Use materials written in the client's spoken language. E. Provide a variety of educational materials.

Use culturally diverse materials is correct. The nurse needs to have knowledge of the client's cultural background and beliefs to show respect to the client and promote understanding. Using culturally diverse materials facilitates learning and adherence. Use pictures is correct. Visual aids, such as pictures, can facilitate understanding and reinforce communication. Use materials written at the eighth-grade level is incorrect. Generally, for an adult learner, written materials should be written at a sixth-grade reading level or lower. Teaching materials should include short words and sentences, large type, and a simple format. Use materials written in the client's spoken language is correct. The nurse should provide materials to the client in her spoken language so that she can review and understand the information. Provide a variety of educational materials is correct. Using a variety of written materials and teaching techniques increases the client's attention to the information, reinforces learning, and offers a mixture of learning opportunities.

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? A. Hold gauze packages 7.6 cm (3 in) above the sterile field. B. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field. C. Use sterile forceps to move the sterile items on the sterile field. D. Position the wrapped package on the bedside table so the outer flap opens towards her.

Use sterile forceps to move the sterile items on the sterile field. A sterile object remains sterile only if the nurse touches it with another sterile object. This principle guides the nurse in placement of sterile objects and how she should handle them such as using sterile forceps or wearing sterile gloves to handle objects on a sterile field.