Wounds
Your client has a Braden scale score of 17. Which is the most appropriate nursing action?
1. Assess the client again in 24h; the score is within normal limits.
2. Implement a turning schedule; the client is at increased risk for skin breakdown.
3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown.
4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.
2
Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.
The nurse is teaching an older female patient how to manage stress incontinence at home. She instructs her to contract her pelvic floor muscles for at least 10 seconds followed by a brief period of relaxation. What is this intervention called?
1) Prompted voiding
2) Crede technique
3) Valsalva maneuver
4) Kegel exercises
4) Kegel
During the nursing assessment the client revels that he has diarrhea and cramping every time he eats ice cream. He attributes this to the cold termperature of the food. However, the nurse begins to suspect the these symptoms might be associated with.
A. Food allergy
B. Irritable bowel
C. Lactose intolerance
D. Increased peristalsis
Lactose intorlerance
Which blood level is commonly tested to help assess kidney function?
1) Hemoglobin
2) Potassium
3) Sodium
4) Creatinine
4) Creatinine
A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? (Select all the apply.)
1. Establish a schedule of voiding prior to meal times.
2. Have the client record voiding times.
3. Gradually increase the voiding intervals.
4. Remind client to hold urine until next scheduled voiding time.
5. Provide a sterile container for voiding.
1, 3, 4
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed
1, 3, & 4
Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.
A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.)
1) palpating the bladder height.
2) obtaining a clean-catch urine specimen.
3) performing a bladder scan.
4) asking the patient about his recent voiding history.
5) encouraging the patient to consume cranberry juice daily.
6) inserting a straight catheter to measure residual urine.
1) Palpating the bladder height.
3) Performing a bladder scan.
4) Asking the patient about his recent voiding history.
In assessing a 55 year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to proved a stool specimen for guaiac fecal occult blood testing:
A. If the client notices rectal bleeding
B. If there is a family history of intestinal polyps
C. As part of a routine screening for colon cancer
D. If a palpable mass is detected on digital exam
As part of a routine screening for colon cancer
What is the range for normal specific gravity?
Normal urine specific gravity ranges from 1.005 to 1.030.
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (select all that apply)
a. cover the area with saline-soaked sterile dressings
b. apply an abdominal binder snugly around the abdomen
c.use sterile gauze to apply gentle pressure to the exposed tissues.
d. position the client supine with his hips and knees bent
e. offer the client a warm beverage, such as herbal tea
a. cover the area with saline-soaked sterile dressings
d. position the client supine with his hips and knees bent
Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that:
1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation)
2. It will be acceptable to leave the pad in place for another thirty minutes
1
Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation); The heating pads need to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction.
A patient is experiencing oliguria. Which action should the nurse perform first?
a. Increase the patient's intravenous fluid rate.
b. Encourage the patient to drink caffeinated beverages.
c. Assess for bladder distention.
d. Request an order for diuretics.
c. Assess for bladder distention.
Diarrhea that occurs with a fecal impaction is the result of:
A. A clear liquid diet
B. Irritation of the intestinal mucosa
C. Inability of the client to form a stool
D. Seepage of stool around the impaction
Seepage of stool around the impaction
What is BUN, and what is the range?
Blood urea nitrogen (BUN) 7-20 mg/dL
A client who has an indwelling catheter reports a need to urinate. Which of the following interventions should the nurse perform?
1. Check to see whether the catheter is patent.
2. Reassure the client that it is not possible for her to urinate.
3. Recatherize the bladder with a larger-gauge catheter.
4. Collect a urine specimen for analysis.
1
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is:
1. Risk for Impaired Skin Integrity
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection
2
Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.
A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse.
The nurse understands the patient's inability to void because
a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void.
b. The patient does not recognize the physiological signals that indicate a need to
void.
c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention.
d. The patient is not drinking enough fluids to produce adequate urine output.
a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough
to void.
Soon after the client's abdominal surgery, the nurse includes in the plan of care which of the following interventions, which is essential for promoting peristalsis?
A. Consumption of a high-fiber diet
B. Early ambulation
C. Restriction of fluid intake
D. Administration of large doses of opioids
Early ambulation
Hemoglobin and Hematocrit
14-18 (m); 12-16 (f)
45-52% (m); 37-48% (f)
A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (select all that apply)
a. increase in incisional pain
b. fever and chills
c. reddened wound edges
d. increase in serosanguineous drainage
e. decrease in thirst
a. increase in incisional pain
b. fever and chills
c. reddened wound edges
Which statement, if made by the client or family member, would indicate the need for further teaching?
1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse.
2. Putting foam pads under the heels or other bony areas can help decrease pressure.
3. If a person cannot turn himself in bed, someone should help them change position q4h.
4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.
3
If a person cannot turn himself in bed, someone should help them change position q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires additional teaching.
Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.
An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care?
a. Urinary retention
b. Hesitancy
c. Urgency
d. Urinary incontinence
d. Urinary incontinence
To prevent the client from performing Vlsalva maneuver, the nurse might request a stool softener for a client with which of the following conditions? (Select all that apply.)
A. Glaucoma
B. Hypotension
C. Cardiovasular disease
D. Risk for increased intracranial pressure
Glaucoma
Cardiovasular disease
Risk for increased intracranial pressure
If your patient had a UTI what lab test would you expect to see done on your patient. What are they looking for?
Urinalysis; evidence of infection (bacteria and WBC)
While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action?
a. Positioning the patient in the dorsal recumbent position with a bed pan
b. Assisting the patient to the bedside commode
c. Stopping the enema cleansing and rolling the patient into right-lying Sims' position
d. Inserting a rectal plug to contain the enema solution
A
Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in the dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to the toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is
inappropriate