Practice 2
A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client's legs?
1. Defer the assessment because the stockings are in place.
2. Remove the stockings for this assessment.
3. Review the morning assessment, but don't repeat it unless a problem occurs.
4. Assess the skin when the client removes the stockings at bedtime.
Answer: 2
Explanation: The stockings should be removed to do this assessment.
Page Ref: 837
A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do?
1. Keep the problem on the care plan, in case the symptoms return.
2. Document that the problem has been resolved and discontinue the care for the problem.
3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met.
4. Document that the potential problem is being prevented because the symptoms have stopped.
Answer: 2
Explanation: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.
Page Ref: 212
The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate?
1. Administering parenteral medications
2. Changing a dressing
3. Performing a urinary catheterization
4. Using personal protective equipment
Answer: 4
Explanation: 4. Using personal protective equipment demonstrates medical asepsis.
Page Ref: 636
The nurse notes that a client has the outcome goal "Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic." Which client statement should the nurse use to evaluate this goal?
1. "I'm getting really sleepy from that medication. I think I'll take a nap."
2. "My pain is a 4."
3. "I still have some pain."
4. "Will the pain ever go away?"
Answer: 2
Explanation: 2. The nurse collects data so that conclusions can be drawn about whether goals have been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the nurse to evaluate it.
Page Ref: 211
The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out?
1. Delegating to the appropriate staff
2. Delegating the appropriate task
3. Selecting the appropriate client
4. Appropriately supervising care
Answer: 4
Explanation: 4. The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (that is, giving people duties within their scope of practice) and (2) adequate supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave an unlicensed person a duty that was appropriate. Unlicensed assistive personnel completed the duty and documented the findings. The nurse is still responsible for analyzing data, planning care, and evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was performed and analyze the findings.
Page Ref: 210
A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." What statement demonstrates that the nurse appropriately evaluated this goal?
1. Goal not met, client able to state one positive aspect by the end of the week.
2. Goal met, client able to state one positive aspect by the end of the week.
3. Goal met, client able to state two positive aspects of therapy by week's end.
4. Goal incomplete, client not able to positively state anything about rehab.
Answer: 3
Explanation: 3. An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week, and the evaluation statement should reveal that.
Page Ref: 211
A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client?
1. Edema, rubor, heat, and pain
2. Fever, malaise, anorexia, nausea, and vomiting
3. Palpitations, irritability, and heat intolerance
4. Tingling, numbness, and cramping of the extremities
Answer: 2
Explanation: 2. Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection.
Page Ref: 610
On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take?
1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.
2. Read the policy and procedure manual before the teaching session.
3. Do the best the nurse can by remembering what was taught in nursing school.
4. Ask for a different assignment until the nurse feels comfortable with this one.
Answer: 1
Explanation: When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching).
Page Ref: 210
A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements? Select all that apply.
1. Minimal tissue loss.
2. Closure of the wound will occur within 5 days.
3. Healing time will be longer.
4. Potential for scarring is greater.
5. Susceptibility to infection is greater.
Answer: 3, 4, 5
Explanation: 3. In secondary intention healing, the repair time is longer.
4. In secondary intention healing, the scarring is greater.
5. In secondary intention healing, the susceptibility to infection is greater.
Page Ref: 834
A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase?
1. Inflammatory
2. Proliferative
3. Maturation
4. Remodeling
Answer: 1
Explanation: The inflammatory phase is initiated immediately after injury, and lasts 3—6 days.
Page Ref: 835
The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care for this client?
1. Clean-contaminated
2. Contaminated
3. Dirty
4. Infected
Answer: 2
Explanation: A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound.
Page Ref: 829
The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process?
1. Assessment is done at the beginning of the process.
2. Evaluation is completed at the end of the process.
3. They are the same and there is no need to differentiate.
4. The difference is in how the data are used.
Answer: 4
Explanation: 4. Although the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care.
Page Ref: 211
The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound?
1. Adjust the diet so it contains more fruits and vegetables.
2. Apply lubricating lotion to the edges of the wound.
3. Notify the physician of any edema, heat, or tenderness at the wound site.
4. Thoroughly irrigate the wound with hydrogen peroxide.
Answer: 3
Explanation: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection.
Page Ref: 607
The nurse is assessing a client's pressure ulcer. To determine the depth of the ulcer, the nurse should take which action?
1. Measure the width.
2. Measure the length.
3. Insert a sterile swab into the deepest part of the wound.
4. Identify where on the face of a clock the ulcer is located.
Answer: 3
Explanation: To measure the depth of a wound, the nurse should insert a sterile swab into the deepest part of the wound and then measure the length of the swab that was inserted.
Page Ref: 838
While changing a client's dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wound's drainage?
1. Purulent
2. Serous
3. Sanguineous
4. Serosanguinous
Answer: 1
Explanation: Purulent exudate is thick, and can vary in color, including green and yellow.
Page Ref: 836
A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing?
1. Exudative
2. Proliferative
3. Inflammatory
4. Maturation
Answer: 4
Explanation: Dark, thick scars, or keloids, are caused by an abnormal amount of collagen during the maturation phase of healing.
Page Ref: 835
The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale, the nurse
1. should receive specific training.
2. must be certified.
3. is required to ask the client's permission.
4. has to obtain special assessment equipment.
Answer: 1
Explanation: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate.
Page Ref: 833
A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate?
1. Impaired Skin Integrity
2. Risk for Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection
Answer: 2
Explanation: Because the client is experiencing episodes of incontinence without any current changes in skin integrity, the client is at Risk for Impaired Skin Integrity.
Page Ref: 842
Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take?
1. Place a tourniquet above the wound.
2. Remove the dressing and place direct pressure on the wound.
3. Add an additional dressing to the wound without removing the original.
4. Remove the dressing and replace it with a new sterile dressing.
Answer: 3
Explanation: In this scenario, where there are multiple clients in need of care and because this client is stable, the correct nursing action is to add an additional dressing to the wound without removing the original.
Page Ref: 847
A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client? Select all that apply.
1. The application of cold dilates blood vessels.
2. The application of cold constricts blood vessels.
3. The application of cold decreases inflammation.
4. The application of cold reduces localized pain.
5. The application of cold provides a calming, sedative effect.
Answer: 2, 3, 4
Explanation: 2. The application of cold does constrict blood vessels.
3. The application of cold does decrease inflammation.
4. The application of cold does reduce localized pain.
Page Ref: 856
The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? Select all that apply.
1. Poor skin turgor
2. Elevated body temperature
3. Diminished pain sensation
4. Thin epidermis
5. Dry skin
1, 3, 4, 5
Explanation: 1. The older person is more prone to impaired skin integrity because of decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis.
3. The older person is more prone to impaired skin integrity because of diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch.
4. The older person is more prone to impaired skin integrity because of generalized thinning of the epidermis.
5. The older person is more prone to impaired skin integrity because of increased dryness due to a decrease in the amount of oil produced by the sebaceous glands.
Page Ref: 837
The nurse is preparing to irrigate a client's abdominal wound. In which order should the nurse perform this irrigation?
1. Dry the area around the wound.
2. Insert the catheter into the wound until resistance is met.
3. Remove and discard clean gloves.
4. Apply clean gloves.
5. Irrigate until the solution flows clear.
6. Select a syringe with a catheter attached or with an irrigating tip.
Answer: 4, 6, 2, 5, 1, 3
Explanation: 1. After irrigating, the nurse should dry the area around the wound.
2. The nurse should then insert the catheter into the wound until resistance is met.
3. The nurse should then remove and discard the clean gloves.
4. The nurse first should apply clean gloves.
5. The nurse should then irrigate the wound until the solution flows clear.
6. The nurse should then select a syringe with a catheter attached or with an irrigating tip.
Page Ref: 850
A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause
1. decreased oxygen supply to tissues.
2. suppression of the inflammatory process necessary for healing.
3. a decrease in the amount of nutrients such as glucose in the blood.
4. blood vessel constriction, which impairs waste product removal.
Answer: 2
Explanation: Steroids suppress the inflammatory process, which is a normal part of the healing process.
Page Ref: 835
A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client's wound? Select all that apply.
1. Cover it with transparent film.
2. Apply a damp-to-damp normal saline dressing.
3. Cover it with a dry dressing.
4. Irrigate the wound.
5. Apply impregnated hydrogel.
Answer: 2, 4, 5
Explanation: 2. A damp-to-damp normal saline dressing will remove nonviable tissue from the wound, and is appropriate for a yellow wound.
4. Irrigating the wound is appropriate for a yellow wound.
5. Applying impregnated hydrogel is appropriate for a yellow wound.
Page Ref: 846
During morning care, unlicensed assistive personnel observe a client's abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel do?
1. Reinforce the wound with supplies on the client's bedside table.
2. Document that the bath was completed, and the condition of the dressing.
3. Complete the bath, then report the change to the nurse.
4. Report the dressing changes to the nurse immediately.
Answer: 4
Explanation: When delegating the care of the client to the UAP, the nurse should have provided direction to the UAP to report any changes to the nurse. UAP should report the dressing changes to the nurse immediately.
Page Ref: 854