Test 2
A client with a hip fracture has a sacral pressure ulcer. Which of the following would indicate the best response to treatment?
The client's skin status, including length, width, depth, condition of the wound margins, and stage of the ulcer as well as the integrity of the surrounding skin.
The wound care nurse documented a client's pressure ulcers on admission as 3.3 cm x 4.0 cm stage II on the coccyx. Which information would alert the nurse that the client's pressure ulcer is getting worse?
The coccyx wound extends to the subcutaneous layer and there is drainage.
A client has a stage 2 sacral pressure ulcer that's receiving a transparent film dressing. Which of the following statements is correct for this type of dressing?
The dressing will maintain a moist environment for the wound.
When assessing the skin around the stoma of an elderly client, the nurse realizes the client is most at risk for skin breakdown due to
The epithelial and subcutaneous fat layer are thinner in the elderly
Which of the following occurs in the gastrointestinal system of the child with Hirschsprung disease?
There is a partial or complete mechanical obstruction in the intestine.
A client with an ileostomy is receiving medication in a slow-release capsule form. The nurse would be alert for which of the following?
Undissolved capsules
Which of the following assessments would suggest that a child's postoperative feeding schedule following pyloric stenosis surgery should be slowed?
Vomiting
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?
Hirschsprung disease
The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap?
Away from the nurse.
Which intervention should a nurse perform after administering an injection of penicillin to a patient with an infection?
Make the patient wait at least 30 minutes before leaving the health care facility.
The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressings is best?
Moisture-vapor permeable dressing
A client in skeletal traction slides down in the bed so that the feet touch the foot of the bed. What should the nurse do to ensure that the pull of traction remains uninterrupted?
Move client up in bed without releasing pull of traction on the extremity.
A client with a colostomy is asking the nurse about what he should and shouldn't eat and drink. Which of the following responses would be appropriate?
"Be sure to drink at least 2L of water a day"
A client comes to the emergency department complaining of a sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?
Azithromycin (Zithromax)
A patient has been prescribed a PO antibiotic to be taken at home for ten days to treat an upper respiratory infections. The patient asks you if he can stop taking the drug after a few days if he is feeling better. As the nurse, which statement is the best response for this patient?
Take the antibiotics for the full 10 days even if you are feeling better.
Which instruction should the nurse give a 21-year old female patient being treated with ampicillin?
The ampicillin may decrease the effectiveness of your oral contraceptive
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which of the following foods would be permitted in the diet of the child with celiac syndrome? (Select all that apply)
Bananas Skim milk applesauce
Which of the following instructions should the nurse include in the teaching plan of a client who has undergone a colostomy?
Chew food well
The client with a new colostomy is being discharged. Which statement made by the client indicated the need for further teaching?
"I should drink only liquids until the colostomy starts to work"
A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
"I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus."
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac syndrome?
"She loves hotdogs, and we always cut hers up into small pieces."
A client with syphilis is to receive penicillin G benazathine 1.2 million units IM as a single dose. The pharmacy supplies the medication, which is labeled as 2.4 million units/4mL. How many milliliters would the nurse administer? Enter the number ONLY. ______ mL
2
Which of the following dietary recommendations should the nurse give a client after ostomy surgery to prevent irritation and slow transit time?
A low-fiber diet
A client with a total hip replacement is concerned about dislocation of the prosthesis. The nurse should include which information in a response?
Activities that involve hip adduction may cause hip dislocation
The nurse is changing the dressings of a client with full thickness burns who is being treated with Sulfamylon (mafenide acetate). When changing the dressing, the nurse's actions should include:
Administering pain medication.
The nurse is reviewing the results of a client's diagnostic testing indicating a positive strep culture. Which prescription medication does the nurse anticipate?
Amoxicillin
Due to changes that occur postoperatively in absorption of bile acids, a client who has undergone a ileostomy is at risk for
Cholelithiasis
A nursing assistant will be changing the soiled bed linens of a client with a draining pressure ulcer. Which of the following protective equipment should the nursing assistant wear?
Clean gloves
A client with an ostomy is receiving instruction about peristomal skin care. Which of the following would be most important to include?
Cleaning the area with warm water and soap
A client is scheduled to undergo surgery for an ileostomy. The nurse instructs the client to stop taking which of the following for at least one (1) week before surgery?
Aspirin
Black wounds are treated with debridement. Which type of debridement is most selective and least damaging?
Autolytic Debridement
The nurse is preparing a teaching plan for a client who is being discharged following a total hip replacement. The nurse would include which of the following content as part of the teaching plan? Select all that apply.
Avoid low, cushioned chairs. Use a device that raises the toilet seat. Avoid bending greater than 90 degrees. Do not cross the legs.
The nurse cares for a client with a wound in the maturation phase of tissue repair. The wound may be protected by applying a:
Hydrocolloid dressing.
The nurse understands teaching was effective if the client states the following related to their ileal reservoir? (Choose all that apply)
NO "I will not have to wear an external appliance" "I will empty from reservoir twice a day, when I wake up and before I go to bed" "I will enter a catheter through the nipple valve to drain the reservoir" NO no empty twice No no wear app no app "The reservoir will contain GI effluent"
A client has a diabetic stasis ulcer on the lower leg. The nurse uses a Duoderm dressing to cover it. Which of the following are included in the procedure for application? Select all that apply.
NO Remove the old dressing and document that a thick exudate formed over the wound. Clean the skin and wound with normal saline. Choose a bandage no more than ¼ inch larger than the wound size. Hold the dressing in place for one minute to allow it to adhere. NO all but no more then 1/4 NO no hold no hold no 1/4
A client with an ileostomy calls the nurse to report that she is experiencing abdominal cramps, vomiting, and watery discharge from her ileostomy. The nurse should:
Notify the physician immediately
A client with a recently applied plaster leg cast reports unrelieved pain and paresthesia in the affected extremity. The assessment by the nurse reveals diminished pulse, pallor, and increased pain on passive motion. What should the nurse do first?
Notify the primary care provider immediately
The nurse is providing discharge instructions to a client who had a hip replacement. The nurse should teach the client to avoid what activity to prevent dislocation of the hip?
Crossing the legs at the knees
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would document the stool's appearance most likely as which of the following?
Currant jelly-like
An adult has developed a stage II pressure ulcer. He is scheduled to receive wet to dry dressings every shift. What will the nurse state is the purpose of applying this type of dressing?
Debride slough and eschar
To prevent pulmonary complications following abdominal surgery with colostomy placement, the nurse would including the following in the client's plan of care: (Choose all that apply)
Deep breathing and coughing Frequent activity/turning and repositioning every two hours while in bed Incentive spirometry
When providing diaper care to an infant after pyloric stenosis surgery, which approach is indicated?
Diapers should be folded so that the incision line does not become contaminated.
A patient prescribed ampicillin ask you about the possible adverse effects. Which of the following are the most common side effects of ampicillin?
Diarrhea and rash
A preschooler has celiac disease. Her mother is preparing a gluten-free diet. By preparing which breakfast foods would you believe she understands the diet?
Eggs and orange juice
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
Empty the pouch when it is one-third to one-half full
Which of the following techniques is correct for obtaining a wound culture from a surgical site?
Gently run a sterile swab over clean areas of granulation tissue.
The nurse is examining the stoma site twelve (12) hours after surgery. Which of the following findings would require a further assessment of the client?
Heart rate of 120
The nurse should complete which intervention before initiating IV antibiotic therapy?
Obtain a specimen for culture and sensitivity
The nurse is performing a wound irrigation and dressing change. Which action, if taken by the nurse, would be a break in technique?
Opening the marked bottle of irrigating solution and pouring directly into a container on the sterile field.
A patient with infective endocarditis (IE) and a fever is admitted to the intensive care unit (ICU). Which of these physician orders should the nurse implement first?
Order blood cultures drawn from two sites.
The nurse is caring for a client who had open reduction and internal fixation (ORIF) of the right femur. The client reports intense pain, swelling, tenderness and warmth at the site; chills; malaise; and has a temperature of 102.2 F and leukocytosis. The nurse concludes that this data is consistent with which complications?
Osteomyelitis
The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse had documented that he client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area?
Partial-thickness skin loss of the dermis.
The nurse is caring for a patient admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the patient will be ordered which of the following medications?
Penicillin
The physician's orders for an adult include warm compresses to the left leg three times a day for treatment of an open wound. What action will the nurse perform?
Place both a dry covering and waterproof material over the compress.
In caring for an infant diagnosed with pyloric stenosis, the nurse would anticipate doing which of the following?
Preparing the infant for surgery
The nurse is caring for a child admitted with pyloric stenosis. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis?
Projectile vomiting
The nurse is assessing the stool pattern of a client who has had a colostomy for 3 years now. The client states the constancy to be formed stool. The nurse suspects the client has a
Sigmoid Colostomy
The nurse should contact the physician immediately if which of the following conditions arise while their patient is receiving IV vancomyicin?
dizziness ringing in the ears hearing loss
