Infections
The nurse is caring for a patient who had knee replacement surgery 5 days go. The patient's knee appears red and warm to the touch and patient is requesting increased pain medication. What complication should the nurse be concerned about?
A. nothing, this is expected post operatively
B. patient is becoming dependent on pain medication
C. post operative wound dehiscence
D. post operative wound infection
D (p. 177 and 414)
The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on my face and feet but it doesn't have an odor. The nurse knows that this condition could be related to:
a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.
a. (p. 422)
You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury:
A. A 19-year-old female who is a quadriplegic.
B. A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.
C. A 55-year-old female who has controlled diabetes and is ambulating three times a day.
D. A 76-year-old male with an elevated ammonia level and is excessively sweaty. E. A 45-year-old with a Braden Scale score of 7
A, B, D, E (p. 440)
A nurse is assessing a patient's skin and notes a 3 cm shallow crater on the patient's buttocks. The patient winces when the area is palpated. How should the nurse stage this wound?
A. stage 1 pressure ulcer
B. stage 2 pressure ulcer
C. stage 3 pressure ulcer
D. stage 4 pressure ulcer
B (p. 440)
As a nurse working on a burn unit, which of your patients are at high risk for internal tissue damage?
A. Patient in room 2101 with a chemical burn to face.
B. Patient in room 2106 with a radiation burn on the abdomen.
C. Patient in room 2103 with a thermal burn to peritoneal area.
D. Patient in room 2101 with an electrical burn on torso.
D (p. 461-462)
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client?
A. Reverse isolation
B. Respiratory isolation
C. Standard precautions
D. Contact isolation
D (p. 408)
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
a. Contains mostly fat cells.
b. Consists mostly of keratin.
c. Is replaced every 4 weeks.
d. Contains sensory receptors.
d. (p. 421)
While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be?
A. Stage 1 pressure injury
B. Deep-tissue injury
C. Stage 4 pressure injury
D. Stage 2 pressure injury
B (p. 440)
When educating a patient about wound healing the nurse should include what in the teaching?
A. inadequate nutrition delays wound healing and increases risk of infection.
B. chronic wounds heal better in a dry, open environment so leave them open to air.
C. fat tissue heals more rapidly because there is less vascularization.
D. long term steroid use diminishes the inflammatory response and speeds up wound healing
A (p. 445)
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
A. Check skin turgor.
B. Monitor daily weight.
C. Assess mucous membranes.
D. Measure hourly urine output.
D (p. 464)
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?
A. A diagnosis of AIDS and cytomegalovirus
B. A positive PPD with an abnormal chest x-ray
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung
B (p. 408)
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat
d (p. 424)
You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury?
A. There is full loss of skin tissue that can extend to the muscle, bone, or tendon.
B. A hallmark of a stage 3 pressure injury is that the skin will be intact but not blanch.
C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue.
D. The wound edges will never roll away (epibole) as with a stage 2 pressure injury.
C (p. 440)
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
A. Alginate
B. Dry Gauze
C. Hydrocolloid
D. No dressing indicated.
C (p. 445)
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
A. Encourage the patient to cough and auscultate the lungs again.
B. Notify the health care provider and prepare for endotracheal intubation.
C. Document the results and continue to monitor the patient's respiratory rate.
D. Reposition the patient in high-Fowler's position and reassess breath sounds.
B (p. 465)
Your patient in droplet precautions has family visiting. A family member asks how far they should stand away from the patient while visiting. Your response is:
A. 2 feet or more
B. 3 feet or more
C. Stand at the doorway
D. 6 feet or more
B (p. 410, Table 21.4)
Risk factors that may lead to skin disease and breakdown include:
A. Loss of protective cushioning of the dermal skin layer
B. Decreased vascular fragility
C. A lifetime of environmental trauma
D. Increased thickness of the skin
C (p. 425)
You're developing a plan of care for a patient who is at risk for pressure injury development. The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. In addition, the patient has a urinary tract infection and is incontinent of urine. The patient is on aspiration precautions and is ordered a honey thick liquid diet with pureed foods. Select all the nursing intervention you will include in the patient's plan of care to prevent a pressure injury:
A. When feeding the patient keep the head of bed elevated at 45' degree and avoid elevating the foot of the bed.
B. Apply barrier cream as needed to the skin daily.
C. Turn the patient every 4 hours.
D. Keep linens and gowns dry and wrinkle free.
E. Use a wedge pillow for the right and left legs daily.
B, D, E (p. 439)
Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical debridement)? (Select all that apply)
A. 24-year-old with an open infected wound from a spider bite
B. 7-year-old with an abrasion on bilateral knees
C. 50-year-old with a post operative knee replacement incision
D. 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater type wound
A, D (p. 444)
A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient, he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm?
A) Superficial partial-thickness
B) Deep partial-thickness
C) Full partial-thickness
D) Full-thickness
D (p. 461)
A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse?
A. Taking the antibiotic before jogging 2 miles daily
B. Taking the antibiotic most days
C. Taking the antibiotic as prescribed
D. Taking the antibiotic with a full glass of water
B (p. 413)
To determine if a dark-skinned patient is pale, the nurse should assess the color of the:
A. mucous membranes
B. earlobes
C. palms of the hands
D. skin in the antecubital space
A (p. 433)
An 86-year-old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position?
A. Sacral
B. Patella
C. Ankle
D. Ear
E. Elbow
F. Hip
G. Heel
H. Shoulder
A, B, C, D, E, F, G, H (p. 440)
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur?
A. Tertiary intention
B. Secondary intention
C. Regeneration of cells
D. Remodeling of tissues
B (p. 457)
The nursing instructor is going over burn
injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?
A) Emergent
B) Immediate resuscitative
C) Acute
D) Rehabilitation
C (p. 464)