Infection Wounds
Which client information collected by the nurse reflects a systemic response to a wound infection?
1. Hyperthermia
2. Exudate
3. Edema
4. Pain
1. Hyperthermia; Hyperthermia is a common systemic response to infection. With hyperthermia, microorganisms or endotoxins stimulate phagocytotic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center, resulting in fever.
Exudate, edema, and pain are all signs of infection but are considered local responses to infection or injury.
The nurse is caring for a 60-year-old female patient who is confined to bed and most closely monitors for signs of which complication?
A. Hypertension
B. Orthostatic hypotension
C. Deep vein thrombosis
D. Pressure ulcer
C. Deep vein thrombosis
The nurse caring for an older adult suspects elder abuse. Which action is appropriate?
1- collect proof of abuse before notifying authorities
2- confront the caretakers about suspicion of abuse
3- notify the authorities of suspected abuse
4- report abuse if the older adult giver permission
3- notify the authorities of suspected abuse
A patient with a history of heart failure is receiving diuretic therapy. At the end of a 12-hour shift, the nurse calculates the total intake as 1000 mL and the total output as 1500 mL. What is the net balance, and how should it be interpreted?
A. -500 mL indicating the patient is at risk for hypovolemic shock
B. -500 mL indicating a desired therapeutic outcome for the patient
C. A zero balance indicating the patient has achieved euvolemia
D. +500 mL indicating the patient is becoming fluid overload
B. -500 mL indicating a desired therapeutic outcome for the patient
1000ml (intake)- 1500 mL (output)= -500 mL net balance. For a patient with heart failure on diuretics, this negative balance shows that more fluid is being removed than taken in which is the intended goal of the therapy.
A patient is scheduled for surgery and asks why they cannot take their morning blood pressure medication. The best response by the nurse is:
A) “All medications must be skipped before surgery.”
B) “Some medications are held because they can affect anesthesia; your provider will guide you.”
C) “It doesn’t matter; just take it after surgery.”
D) “You can take it, but drink a full glass of juice.”
Answer: B – Some medications, especially antihypertensives, anticoagulants, or diabetes meds, interact with anesthesia or perioperative management.
You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
2. Stage II;
Stage I pressure ulcer involves a nonblanchable erythema of intact skin, while a stage II involves a partial-thickness skin loss involving epidermis, dermis, or both, with the ulcer being superficial and presenting as an abrasion, blister, or shallow crater.
A patient needs to go up the stairs while using crutches. What finding by the nurse demonstrates the patient understands how to ambulate upstairs with crutches?
A. The patient moves the crutches forward up the step, then the injured and non-injured leg.
B. The patient moves the non-injured leg forward onto the step and then the moves the injured leg and crutches up.
C. The patient moves the injured leg forward onto the steps, then moves the crutches, and then moves the non-injured leg
D. The patient moves the crutches and non-injured leg forward to the step together, and then the non-injured leg.
B. The patient moves the non-injured leg forward onto the step and then the moves the injured leg and crutches up.
The patient will move the non-injured leg forward onto the step and then will move the injured leg and crutches up.
An 80-year-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to (select all that apply)
A) Improve her quality of life.
B) Assess her coping ability with disease.
C) Have time to teach patient and family about disease.
D) Focus on reducing the severity of disease symptoms.
E) Provide care that the family is unwilling or unable to give.
A,D
A male patient has an enlarged prostate, making urethral catheterization difficult. Which type of catheter would be most appropriate for the healthcare provider to use in this situation?
A. Straight catheter
B. Coude catheter
C. 3 way foley catheter
D. Suprapubic catheter
B. Coude catheter
It is designed with a firm, angled tip specifically to help maneuver around obstructions such as an enlarged prostate gland during insertion.
A physician orders Vancomycin 750 mg IV for a patient. The pharmacy sends a vial containing 1 g of Vancomycin powder. The vial must be reconstituted with 10 mL of sterile water to make a solution. How many mL should the nurse administer?
7.5 mL
or the main question:
Ordered dose: 750 mg
Vial concentration after reconstitution: 1000 mg ÷ 10 mL = 100 mg/mL
Volume to administer: 750 mg ÷ 100 mg/mL = 7.5 mL
Which of the following actions is an example of maintaining medical asepsis in a healthcare setting? SATA
A. Using sterile technique during a central line insertion
B. Disinfecting the blood pressure cuff between patients
C. Wearing a mask during a surgical procedure
D. applying gloves before administering an injection
E. Turning your back to a sterile field
F. washing hands for 20 seconds
G. Using sterile gloves to remove a foley catheter
B,D,F
question is asking about medical asepsis also known as "clean technique" not sterile
A patient who has been immobile for 2 weeks develops flank pain and cloudy urine. Which complication is the nurse most concerned about?
A. Urinary tract infection
B. Renal calculi
C. Acute kidney injury
D. Bladder cancer
B. Renal calculi
A caregiver of a patient with dementia reports exhaustion, insomnia, and feelings of hopelessness but denies thoughts of harm. Which interdisciplinary team member should the nurse involve NEXT?
A. Psychiatrist
B. Social worker
C. Chaplain
D. Case manager
B. Social worker
A patient reports severe diarrhea and muscle weakness after taking a magnesium-based laxative daily for a week. What is the nurse’s priority action?
A) Encourage increased fluid intake.
B) Notify the healthcare provider and assess electrolytes.
C) Administer an anti-diarrheal.
D) Stop the laxative and recommend a high-fiber diet.
B – Magnesium-based laxatives can cause hypermagnesemia or electrolyte imbalances. Lab assessment and provider notification are essential.
When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about?
1. Post surgical hemorrhage and anemia
2. Wound dehiscence and evisceration
3. Impaired skin integrity and decubitus ulcers
4. Loss of motility and paralytic illeus
2. Wound dehiscence and evisceration
Wound dehiscence is most likely to occur 4 to 5 days postoperatively, and risk factors include obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration.
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; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever.
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 patient has been on bed rest for 10 days after multiple fractures. Which findings indicate late complications of prolonged immobility?
(Select all that apply.)
A. Decreased plasma volume
B. Muscle atrophy
C. Renal calculi formation
D. Orthostatic hypotension
E. Joint contractures
F. Atelectasis
B, C,E
Which outcomes indicate improvement in caregiver role strain?
(Select all that apply.)
A. Caregiver schedules regular time off
B. Caregiver reports sleeping 6–8 hours
C. Caregiver refuses outside help
D. Caregiver verbalizes realistic expectations
E. Caregiver neglects personal health needs
A,B ,D
A patient experiencing severe diarrhea due to an inflammatory bowel disorder is at risk for which complication?
A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis and fluid volume deficit
D. fecal impaction due to intestinal slowdown
D.
A. Metabolic acidosis
The loss of bicarbonate rich intestinal fluid leads to metabolic acidosis
A 68-year-old patient with heart failure is admitted with shortness of breath, edema, and fatigue. Labs reveal:
Sodium (Na⁺) = 128 mEq/L
Potassium (K⁺) = 3.0 mEq/L
Chloride (Cl⁻) = 92 mEq/L
BUN = 28 mg/dL
Creatinine = 1.2 mg/dL
The patient is on furosemide (Lasix) daily.
Which interventions should the nurse prioritize? (Select all that apply)
A) Administer potassium chloride as ordered.
B) Restrict fluid intake.
C) Encourage high-sodium foods.
D) Assess for muscle weakness and cardiac dysrhythmias.
E) Hold all diuretics until electrolytes normalize.
✅ A) Administer potassium chloride as ordered – Low K⁺ (3.0) puts patient at risk for dysrhythmias, especially with loop diuretic therapy.
✅ B) Restrict fluid intake – Patient has fluid overload due to heart failure (edema, SOB).
✅ D) Assess for muscle weakness and cardiac dysrhythmias – Hypokalemia and hyponatremia increase risk of muscle and heart complications.
❌ C) Encourage high-sodium foods – Incorrect; patient has hyponatremia and fluid overload.
❌ E) Hold all diuretics until electrolytes normalize – Not appropriate; diuretics are needed to manage fluid overload, but potassium replacement may be needed concurrently.
The nurse is supervising the care of a patient with a wound infected with methicillin-resistant staphylococcus aureus (MRSA). Which action by the student nurse would prompt the nurse to intervene?
A. Dons a gown before entering the patient’s room
B. Washes hands and dons a pair of clean gloves prior to removing the dressing
C. Removes and discards the dirty dressing, removes the dirty gloves, and dons a pair of sterile gloves
D. Cleans and redresses the wound, discards the pair of sterile gloves, and washes her hands
C. Removes and discards the dirty dressing, removes the dirty gloves, and dons a pair of sterile gloves
Proper sterile technique is critical to avoid infection/reinfection of a chronic wound. In the third step, the student nurse removed the dirty gloves and put on a pair of sterile gloves without washing her hands in between. The nurse would intervene and remind the student nurse to wash her hands prior to donning sterile gloves. The student nurse correctly donned a gown before entering the patient’s room due to contact precautions for the MRSA infection. The student nurse correctly washed the hands and donned clean gloves before starting the dressing change. And in the last step, the student nurse correctly redressed the wound, discarded the gloves and washed the hands.
Which findings are characteristic of Rheumatoid Arthritis (RA) rather than Osteoarthritis (OA)?
(Select all that apply.)
A. Autoimmune-mediated synovial inflammation
B. Cartilage degeneration from mechanical wear and tear
C. Symmetric joint involvement
D. Presence of rheumatoid factor
E. Pain that worsens with joint use
F. Systemic manifestations (fatigue, fever)
A, C, D, F
(RA = autoimmune, symmetric, systemic)
Which findings are most consistent with DELIRIUM rather than DEMENTIA?
(Select all that apply.)
A. Acute onset over hours to days
B. Progressive cognitive decline over years
C. Fluctuating level of consciousness
D. Inattention and inability to focus
E. Memory loss as the first symptom
F. Symptoms worse at night (“sundowning”)
1. A, C, D
(Delirium = acute, fluctuating, poor attention)
During assessment, a patient reports passing pale, clay-colored stool with foul odor. The nurse suspects a problem with which body system?
A) Gastrointestinal motility
B) Liver or biliary system
C) Pancreas
D) Kidneys
B – Pale, clay-colored stool often indicates bile obstruction or liver dysfunction.
A patient is admitted to the medical-surgical unit at 0700. The nurse must calculate the total intake and output from 0700–1900.
Intake
0.9% NS IV running at 83 mL/hr from 0700–1330
D5½NS IV running at 62 mL/hr from 1400–1900
Tube feeding at 45 mL/hr from 0830–1230
Patient drinks:
6 oz apple juice at 0900
180 mL water at 1200
½ cup coffee at 1600
Output
Urine:
325 mL at 0930
410 mL at 1430
275 mL at 1830
Emesis: 145 mL at 1015
Liquid stool: 215 mL at 1715
NG tube drainage: 35 mL/hr from 1100–1500
Total Intake: 1,610 mL
Total Output: 1,510 mL