Exam 2 - Questions Flashcards

Question

# ATI Skills - Enteral Tube Feeding A 16-year-old client is being considered for major oral surgery following a motor-vehicle crash that resulted in extensive damage to her lower jaw. Her recovery from the surgery will interfere with her oral intake for approximately 3 weeks. With the client's parents present, you prepare to educate the client about the proposed alternative form of feeding involving intermittent enteral tube feedings. You explain to the client that the provider has prescribed a small-bore nasogastric tube for which of the following reasons? a. It does not cause discomfort upon insertion b. It is best suited for short-term enteral feeding therapy c. Tube placement can be verified by injecting air through the tube and auscultating for gurgling sound

Answer 1

It is best suited for short-term enteral feeding therapy ## Footnote small-bore NG tube is appropriate for therapy lasting LESS THAN 4 WEEKS

Answer 2

Identifying a displaced tube by obtaining a gastrointestinal aspirate for pH measurement

Answer 3

Fill the bag with enough formula to last over a 4- to 8-hr period ## Footnote filling the bag with only enough formula for 4 hr will DECREASE THE RISK OF BACTERIAL CONTAMINATION

Answer 4

Flushing the tube with 30 mL of water every 4 hr to prevent clogging

Answer 5

Evaluate the patency of the client's nares

Answer 6

Instruct the client to swallow during tube insertion

Answer 7

Wear clean gloves during the procedure

Answer 8

Measure the distance from the client's naris to his ear lobe to the tip of his xiphoid process.

Answer 9

Testing the pH of an aspirated fluid sample from the NG tube **The only true, reliable method of confirmation is an X-RAY! Many policies require using secondary methods of verification, one of which is typically the pH of NG aspirate** ## Footnote a. Assessing for normal bowel sounds [normal bowel sounds do NOT assist in determining NG placement] b. Auscultating while flushing 30 mL of air through the tube to hear swooshing sounds [unreliable - esp. If someone has a small-bore tube inserted]

Answer 10

Fold the tube onto itself while quickly pulling back on it ## Footnote folding the tube prevents tube contents from draining into the client’s oropharynx + quick removal minimizes discomfort

Answer 11

Ensuring proper NG tube placement according to facility policy

Answer 12

Elevate the head of the client's bed to a minimum of 30 degrees

Answer 13

Cleanse the top of the canned formula with an alcohol swab before opening it

Answer 14

Adjust the syringe height to adjust the rate of feeding flow

Answer 15

Flushing the NG tube with 30 to 60 mL of water

Answer 16

Keeping the head of the client's bed elevated at 30 to 45 degrees

Answer 17

Flush the tubing with at least 15 mL of water before the first c medication, between each medication, and after the last medication

Answer 18

"It appears that you are uncomfortable with administering yourself an enema."

Answer 19

"I will try to retain the solution for 5 to 10 minutes."

Answer 20

0.9% sodium chloride

Answer 21

a. Preheat the normal saline solution to lukewarm prior to administration. b. Lubricate the tip of the rectal tube before inserting it into the client's anus. c. Point the tip of the enema tube toward the client's umbilicus while inserting it.

Answer 22

Large amount of slightly discolored solution with no solid fecal matter

Answer 23

On the left side turned toward the abdomen with the right leg drawn up

Answer 24

Lower the height of the solution bag to slow the instillation rate

Answer 25

Elevated white blood cell count Urine with a pungent odor Increased sediment in the urine Confusion or alteration in mental status Change in urination pattern Fever

Answer 26

Always use sterile technique when placing Foley catheter Give appropriate & thorough perineal care Assess equipment carefully to ensure a closed system Intervene to prevent prolonged catheter use

Answer 27

Inability to void because of retention The need for close hemodynamic monitoring Post-surgical recovery Standards of practice encourage the removal of a catheterization ASAP

Answer 28

Ask an assistive personnel to help and then apply sterile gloves; re-cleanse the meatus with sterile antiseptic

Answer 29

Slowly advance the catheter tip while gently rotating the tubing

Answer 30

Collect 5 to 10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode

Answer 31

Examine the catheter and the drainage tube along their entire path ## Footnote ALWAYS EXAMINE / ASSESS / INSPECT BEFORE ANY FURTHER INTERVENTIONS LEAST INVASIVE FIRST

Answer 32

Stop the procedure and evaluate for an occlusion

Answer 33

The client newly admitted to the unit after kidney surgery with bloody urine output

Answer 34

Auscultate and palpate the abdomen **The client reports severe abdominal pain and may be hemorrhaging. For this client, the hemorrhage is most likely in the abdominal cavity where the surgery took place, so auscultate the abdomen immediately for decreased bowel sounds and palpate it for increased firmness and discomfort. You might not find other objective signs of hemorrhage, such as tachycardia, hypotension, decreased urine output, agitation, and pale or diaphoretic skin until the client's hemoglobin is well below 10.0 gm/dL.** ## Footnote a. Obtain orthostatic blood pressures - obtaining orthostatics is appropriate when you suspect dehydration or to assess fluid status b. Palpate bilateral pedal pulses - palpating pedal pulses helps you detect ischemia of the lower extremities

Answer 35

The client that is reporting pressure around their bladder

Answer 36

The client with dementia who pulled off his condom catheter **This is the client you should see first. When a condom catheter is removed traumatically, tissue damage can result. Also, a condom catheter can impair circulation to the penis if it is applied incorrectly, and that might be why the client removed it. Since the client has dementia and might not be able to answer your questions reliably, your immediate nursing assessment is imperative. When deciding which client to see first, you can use the nursing process as a guide. It is usually best to see clients who require a nursing assessment before clients who need routine interventions. Base your assessment priorities on immediate potential or actual immediate threats to airway, breathing, and circulation. Or, use Maslow's hierarchy to plan care by meeting physiological and safety needs prior to higher-level needs.** ## Footnote a. The client who is 1 day postoperative and needs their indwelling catheter removed - Although this client might be eager to have their catheter removed, it is not the highest priority among these four clinical scenarios b. The client with a condom catheter who reports pain each time he urinates - Dysuria, or painful urination, is most likely due to infection or presence of renal calculi (stones). You'll have to collect a urine specimen to help determine the cause, but this is not the highest priority among these four clinical scenarios

Answer 37

Provide perineal care with soap and water

Answer 38

The client with a condom catheter who reports pain each time they urinate

Answer 39

The client with an indwelling urinary catheter who has green exudate seeping from their urethra

Answer 40

* Selecting the correct type of dressing can help * In general, keeping some moisture within a wound reduces pain * Choose dressings that have enough adhesive to stay in place but will not be too difficult to remove * Absorptive dressings can help decrease excessive moisture, which can otherwise lead to maceration and additional pain * Packing wounds too tightly or wrapping a bandage too tightly can also increase pain * Change dressings infrequently (unless otherwise prescribed) to reduce pain * When a client is still experiencing considerable pain with dressing changes, consider offering premedication and providing a relaxing environment prior to dressing changes * Complete pain assessment prior to dressing changes to help plan alternative methods of delivering wound care

Answer 41

**One important component of fluid hydration is increasing the number of times you offer clients fluids (not just with meals)** Alternatives to water are: * popsicles * flavored gelatin * soup * sorbet * ice cream * milk * ice chips

Answer 42

**ALWAYS CONTINUE TO ASSESS HYDRATION STATUS WHEN CARING FOR CLIENTS WHO HAVE WOUNDS** **DEHYDRATION CAN LEAD TO: ** * WEIGHT LOSS * DRY SKIN * RAPID PULSE * HYPOVOLEMIA * LOW-GRADE FEVER * ORTHOSTATIC BP ALTERATIONS [LOW] - CAUSES POOR PERFUSION TO THE WOUND ## Footnote Hypovolemia can impair tissue oxygenation and can therefore hinder wound healing. By keeping the client adequately hydrated, you can also decrease risk for pressure injury formation.

Answer 43

* Include the wound's location, age, size, stage or depth, presence of tunneling or undermining, manifestations that impair healing (necrosis, erythema), manifestations that aid in healing (wound edges, granulation), exudate characteristics, pain, and temperature * Assess size using a ruler or other device to measure the exact dimensions of the wound, including its depth * Describe the wound's age in days, weeks, or months * Location should reflect anatomic references * Document the amount, color, and odor of any exudate * Every additional component you report when assessing a wound can help contribute to the correct diagnosis, treatment, management, and — ultimately — healing of the wound

Answer 44

Color: Black / Brown Moisture content: Can be hard OR soft/soggy Adherence: Firmly attached to wound % of wound involved: 50-100% WOUND PRESENCE: "FULL-THICKNESS" STAGE 3 STAGE 4 UNSTAGEABLE

Answer 45

Color: Yellow / White / Milkyish Moisture content: Soft, Soggy, Stringy Adherence: Firmly attached OR in clumps % of wound involved: 25-100% WOUND PRESENCE: "FULL-THICKNESS" Stage 3 Stage 4 Unstageable

Answer 46

CLEAR & THIN Composed of PLASMA Yellow-ish or pale pink-ish tint due to presence of RBC **NORMAL FINDING FOR WOUND HEALING PROCESS** ## Footnote Released from damaged / inflammed tissue

Answer 47

THICK & OPAQUE Composed of WBC/NEUTROPHILS Yellow/Green/Tan **INDICATION OF AN INFECTION** ## Footnote Produced in response to infection and/or inflammation

Answer 48

THIN Composed of RBC BRIGHT RED **NORMAL FINDING FOR WOUND HEALING PROCESS AS LONG AS IT IS NOT PROLONGED/EXCESSIVE**

Answer 49

Thin Composed of SEROUS + SANGUINEOUS Fluid Light red / Pink-ish **NORMAL PART OF EARLY WOUND HEALING PROCESS**

Answer 50

Empty the reservior **The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half-full, the suction pressure is diminished. This it is appropriate to empty it and record the amount of drainage you discard**

Answer 51

Collapse the drainage bulb fully and secure the seal

Answer 52

Client's gown

Answer 53

Mark the edges of the area of drainage with tape **ensures rest of care team can see and monitor client for increasing drainage/signs of hemorrhage**

Answer 54

SEROSANGUINEOUS **Serosanguineous drainage is plasma mixed with blood. It is thinner and more watery than blood, often yellowish in color, and blood-tinged, rather than bright red and bloody seen in sanguineous drainage**

Answer 55

Client has a stage 1 pressure injury **A stage 1 pressure injury is an observable alteration seen in intact skin over an area of pressure as compared with the surrounding or adjacent skin. These changes may include alterations in skin color or temperature or tissue consistency or sensation. Your description of intact skin with a well-defined area of redness that is boggy and nonblanchable meets the criteria for a stage 1 pressure injury** ## Footnote Stage 2: A stage 2 pressure injury is a visible area of damage, which may look like an abrasion, a blister, or a shallow crater. The area is typically edematous and there may be drainage from the non-intact skin This client's skin is intact. There is no evidence of skin loss at this time.

Answer 56

**a. Incontinence** - Both fecal and urinary incontinence increase the risk for pressure injury formation. Skin exposed continually to moisture leads to maceration, and fecal bacteria can cause infection, irritation, and breakdown **b. Previous hx of pressure injuries healed by scar formation** - Areas of skin that have previously had to heal by scar formation are typically not as strong and cannot tolerate pressure as well as areas of undamaged skin **c. Impaired cognitive ability** - Clients who have cognitively impairment cannot always sense when they need to change position and often cannot change position independently. This also applies to clients who are heavily sedated **f. Braden score less than 16** - The Braden Scale determines pressure-injury risk via six subscales: sensory perception, moisture, activity, mobility, friction, and shear. Scores range from 6 to 23; the lower the score, the greater the risk for pressure injury formation. For adults, a score less than 18 indicates increased risk ## Footnote A prealbumin level of less than 19.5 mg/dL would indicate inadequate nutrition, which is a potential risk factor for pressure injury development. While serum protein levels are influenced by other factors, a level of 19.6 mg/dL in itself does not indicate pressure injury risk due to malnutrition Sometimes, darkly pigmented skin requires a different assessment technique for pressure injury formation. However, it is not a risk factor for skin breakdown

Answer 57

Apply a moisture-barrier cream to the sacral area

Answer 58

Transparent - able to easily see / assess wound

Answer 59

It does not allow visualization of the wound

Answer 60

Side-lying

Answer 61

Granulation **Granulation tissue - INDICATES HEALTHY, HEALING WOUND**

Answer 62

Reduce the force you are using to flush the wound

Answer 63

a. Clip the hair along the wound borders c. Use strips of transparent film to patch any leaks. d. Use adhesive remover to help remove the transparent dressing. e. Avoid wrinkling the transparent film while applying it to the foam

Answer 64

Increased exudate in the drainage chamber

Answer 65

Loose, liquid stools after 1-2 days

Answer 66

Suture line **After checking for signs of abdominal bleeding, assess the suture line — also called the mucocutaneous junction - for signs of frank bleeding due to injury of the mesenteric artery. The presence of frank bleeding is a medical emergency requiring the surgeon's immediate intervention.**

Answer 67

Stoma **ASSESS STOMA FOR BLEEDING - trauma to the stoma mucosa can also cause bleeding **

Answer 68

Fresh tomatoes and celery **High-fiber foods, such as fresh tomatoes and celery, may cause food blockage. Other high-fiber foods to avoid are mushrooms, coconut, popcorn, and some shellfish, such as shrimp and lobster.**

Answer 69

High-volume effluent

Answer 70

"A well-fitted pouching system with a filter helps prevent odor."

Answer 71

Anger and feelings of loss

Answer 72

Request client participate in their ostomy care as they are physically able

Answer 73

The pouch should be frequently checked for signs of leakage

Answer 74

"I should measure the stoma, then cut the appropriate size before removing the adhesive backing. My stoma will shrink over the next several weeks, so I'll need to measure it regularly."

Answer 75

Resumption of normal activities, includng travel and sex

Answer 76

Inspect the circumference of the stoma

Answer 77

Diabetes mellitus

Answer 78

Stagnated healing

Answer 79

Carbohydrates

Answer 80

**a. Older adults are more prone to dehydration than younger adults** - When taking action, the nurse should include that sensations of thirst diminish with age, leaving older adults more prone to dehydration **b. The recommended intake of daily fiber decreases in older adults** - The recommended amount of daily fiber intake decreases in the older adult due to their lower caloric intake **c. Many older adults need calcium supplements** - Many older adults need an increased intake of calcium, whether through their diet or through calcium supplements to help prevent bone demineralization (osteoporosis) ## Footnote d. Older adults have a slower metabolic rate, so they require less energy (unless they are very active) and, therefore, need fewer calories e. Older adults should consume a healthy diet with an appropriate intake of calories through a balanced diet while limiting intake of fat, salt, refined sugars, and alcohol

Answer 81

Instructing the client to tuck their chin when swallowing

Answer 82

Ensure the specimen does not include urine

Answer 83

1. Warm the enema solution 2. Lubricate the end of the rectal tube 3. Slowly insert the rectal tube into the client's rectum 4. Hang the enema container 30-45 cm (12-18 in) above client’s anus 5. Ask the client to retain the solution

Answer 84

Hypotension Elevated temperature Poor skin turgor **ASSESS FOR SIGNS OF DEHYDRATION SECONDARY TO DIARRHEA Patient will present as: Tachycardic (fast heart rate) Elevated BP (not hypotension)**

Answer 85

b. Eat yogurt when diarrhea has stopped c. Increase fluid intake e. Avoid caffeinated beverages

Answer 86

a. Urinate after sexual intercourse c. Clean perineum from FRONT to BACK e. Avoid bubble baths

Answer 87

Random urinalysis - **Obtain a non-sterile urine specimen**

Answer 88

Clean - catch midstream for culture and sensitivity (C & S) - **Clean the urethral meatus prior to obtaining the urine specimen**

Answer 89

Timed urine specimen - **Collect urine for a 24 hr period**

Answer 90

Catheter urine specimen for C&S - **Obtain a sterile urine specimen from an indwelling urinary catheter**

Answer 91

b. Keep the urinary drainage bag below the level of the client’s bladder c. Assess the client’s need for the indwelling urinary catheter daily e. Maintain a closed system of the client’s urinary catheter

Answer 92

a. Maintain adequate fluid intake b. Empty bladder completely with each void c. Avoid bladder irritants [caffeine + alcohol] d. Perform pelvic muscle exercises 3-4 x day **ALL OF THE ABOVE!!!**

Answer 93

b. Have the client record urination times c. Gradually increase the time of the client’s urination intervals d. Remind client to try to hold urine until the next scheduled urination time

Answer 94

a. Stage 3 pressure injury e. Open burn area **OPEN PRESSURE INJURIES HEAL BY SECONDARY INTENTION = Process for wounds that have tissue loss and widely separated edges** ## Footnote b. Sutured sx incision - primary = process for wounds that have little to no tissue loss / well-approximated edges c. Casted bone fx - injury to underlying structure and does not require healing of skin d. Laceration sealed w/ adhesive - primary

Answer 95

a. Cover the area with saline-soaked sterile dressings **cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene ** d. Position the client supine with hips and knees bent **this position minimizes pressure on the abdominal area ** ## Footnote b. Apply an abdominal binder snugly around the abdomen [abdominal binder can help PREVENT..not treat…a wound evisceration] c. Use sterile gauze to apply gentle pressure to the exposed tissues [avoid handling or applying pressure to ANY exposed organs/tissue → these actions increase the risk of trauma / perforation] e. Offer client a warm beverage [herbal tea] [client should be NPO in anticipation for sx]

Answer 96

a. Increase in incisional pain b. Fever and chills c. Reddened wound edges ## Footnote d. Increase in serosanguineous drainage - nurse should expect the client to have **purulent drainage** with an incisional infection

Answer 97

b. Chronic illness **DM = chronic illness that places additional stress on body's healing mechanisms** c. Low hemoglobin **Hgb is ESSENTIAL for oxygen delivery to healing tissues** d. Malnutrition **underweight = malnourished = deficiences in essential nutrients delay wound healing** ## Footnote a. Age - age itself does not place them at an increased risk for impaired wound healing e. Poor wound care - no indications there have been any breaches in aseptic technique during wound care

Answer 98

a. Keep HOB elevated at 30 degrees **slightly elevating the HOB helps to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels** d. Have client sit on a gel cushion when in a chair **sitting on gel, air, or a foam cushion redistributes weight away from ischial areas** ## Footnote cornstarch and powder can abrade the sensitive skin

Answer 99

a. Auscultate the lungs

Answer 100

c. Elevate the head of the bed 45 to 90 degrees

Answer 101

c. The client should be weighed on the same scale at the same time each day

Answer 102

b. Swallowing examination

Answer 103

a. Identify the food location as though the plate were a clock

Answer 104

a. Albumin level is a poor short-term indicator of protein status

Answer 105

d. To assess the pattern of intake and compare it with daily reference intakes

Answer 106

a. Plain yogurt b. Custard c. Ice cream f. Gelatin

Answer 107

c. A 40-year-old client who has a postoperative bowel obstruction

Answer 108

b. Aspirate stomach contents and check pH

Answer 109

d. Increased abdominal distention

Answer 110

a. Obtain an x-ray

Answer 111

b. Provide frequent mouth care

Answer 112

c. Salem sump tube

Answer 113

a. Inspect the oropharynx with a penlight and a tongue blade

Answer 114

c. A client who has dysphagia

Answer 115

b. Persistent coughing

Answer 116

c. Obtain an x-ray

Answer 117

d. Place the client in a Fowler’s position

Answer 118

a. Limit the time the formula hangs to 8 hr

Answer 119

d. Xiphoid process plus 20 - 30 cm more

Answer 120

a. Closing off the glottis

Answer 121

b. Nasointestinal tube

Answer 122

a. Encourage the client to go to the dining room at meals times to talk with other clients

Answer 123

c. Lower the enema fluid container

Answer 124

d. Left lateral with the right leg flexed

Answer 125

a. Place the client in the dorsal recumbent position on a bedpan

Answer 126

c. Leave a space between the penis and sheath portion tip. **[The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.]**

Answer 127

1. Wipe the port with an alcohol swab or agency specified antiseptic 2. Attach a syringe to the collection port of the indwelling catheter 3. Withdraw 3 - 30 mL of urine 4. Transfer the urine to a sterile specimen container 5. Transport the specimen to the lab

Answer 128

b. Deflate the balloon completely before removal

Answer 129

d. Anus **[The nurse should identify that the basic aseptic principle applicable to perineal care is to cleanse from the area that is least contaminated to the area that is the most contaminated. The anal area is typically contaminated with coliform bacteria and should therefore be cleansed last.]**

Answer 130

a. Bear down **[The nurse should instruct the client to bear down as if to void because this relaxes the external sphincter and aids in the insertion procedure.]**

Answer 131

d. Check the catheter for kinks **[The nurse should identify that output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client's urine flow is not obstructed.] **

Answer 132

c. A client who is in the ICU for a gastrointestinal bleed **[The nurse should expect a prescription for urinary catheterization for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill.]** ## Footnote a. Urinary tract infection - Urinary tract infections are treated with antimicrobial agents, increased fluid intake, and pain management. Therefore, the nurse should not expect a prescription for urinary catheterization for a client who has a persistent urinary tract infection. b. Urge Incontinence - Treatment options for urge incontinence typically include pelvic floor exercises, medications, and bladder retraining. Therefore, the nurse should not expect a prescription for urinary catheterization for a client who has urge incontinence. d. Incontinence - Incontinence due to cognitive decline is a type of functional incontinence that is typically treated with scheduled toileting and absorbent adult briefs. Urinary catheterization might be necessary as a last resort for a client who has incontinence due to cognitive decline. However, as this client is newly admitted, the nurse should not expect a prescription for urinary catheterization.

Answer 133

b. Lift the penis perpendicular to the body ## Footnote Lifting the penis to a position perpendicular to the body, or at a 90° angle, while applying light traction straightens the urethral canal to facilitate catheter insertion.

Answer 134

d. Apply oxygen at 2 L/min via nasal cannula **Following an acute injury, the body responds best by increasing oxygen to improve perfusion, which is essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in clients who have a lack of oxygen or poor perfusion**

Answer 135

d. Stage 3 **The nurse should identify that this client has a stage 3 pressure injury indicated by full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. Stage 3 pressures can have slough, but it is not necessary** ## Footnote a. Unstageable - Unstageable refers to pressure injuries whose stage cannot be determined because eschar or slough obscures the wound. This wound has no eschar or slough b. A suspected deep tissue injury - A suspected deep tissue injury refers to tissue that is discolored due to underlying tissue damage, boggy, and warm to the touch. If the skin is intact the injury appears as a blood-filled blister. If the skin is nonintact the wound bed will appear very dark in color. c. Stage 4 - A stage 4 pressure injury has full-thickness tissue loss with destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, and some eschar and slough

Answer 136

a. Barrier creams **Barrier creams and ointments are used for clients that are prone to skin breakdown from pressure, shear, or incontinence. Therefore, the nurse should plan to apply barrier creams for a client who has a stage 1 pressure injury**

Answer 137

b. Corticosteroids **Corticosteroids suppress the immune system and can therefore delay wound healing**

Answer 138

b. Slough **Slough is stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed** ## Footnote a. Keloid - Keloids are hypertrophic scar tissue resulting from excessive collagen formation following a wound injury c. Granulation - Granulation has a granular, moist, shiny, beefy, red appearance within the wound bed. This does not correlate with the nurse’s assessment findings d. Eschar - Eschar is hard or soft necrotic tissue that is tan, black, or brown in color and is firmly attached to the wound bed

Answer 139

d. Hydrogel **The nurse should select hydrogel for this client because hydrogel does not adhere to the wound bed and maintains moisture, which results in decreased pain** ## Footnote a. Wet-to-dry dressings are usually painful to remove because, as the dressing dries, exudate, necrotic tissue, and healthy tissue adhere to the dressing and are pulled out when it is removed b. ABD dressings are used over other dressings to absorb excess drainage and should not be place directly over a wound. This type of dressing can cause increased pain on removal when it is placed directly over an open wound c. Gauze fibers can shed and adhere to the wound bed, causing painful removal

Answer 140

c. Pulsating lavage **Pulsating lavage or irrigations provides mechanical debridement by dislodging exudate, debris, and necrotic tissue in the wound bed** ## Footnote a. Transparent dressing - A transparent film dressing protects a healing stage 1 pressure injury b.Hydrocolloid - Hydrocolloids are an autolytic debridement using occlusive dressings d. Topical enzyme solution is a form of chemical enzymatic debridement

Answer 141

a. Serosanguineous **This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color** ## Footnote b. Sanguineous - Sanguineous exudate is thin in consistency but bright red in color c. Serous - Serous exudate is thin in consistency but clear in color d. Purulent - Purulent exudate can be thin or thick in consistency, but it is tan to yellow in color

Answer 142

c. Alginate **Alginate dressings help establish hemostasis while providing a moist environment for healing and absorption of exudate. They do not adhere to the wound, so removal is unlikely to cause further bleeding.** ## Footnote a. Transparent - Transparent film dressings are used for clients who have a stage 1 pressure injury with minimal drainage b. Hydrogel - Hydrogel dressings are used for clients who have a dry wound and minimal exudate d. Dry gauze - Dry gauze can disrupt angiogenesis, the development of the vascular bed in the wound, thereby causing further bleeding of the wound when removed

Answer 143

b. Empty the pouch when it is LESS than 1/2 full **The nurse should instruct the client to empty the pouch when it is between 1/3 to 1/2 full because waiting to empty the pouch until it is more than 1/2 full increases the risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin** ## Footnote a. The nurse should instruct the client to only use ostomy care products, such as skin sealants and ostomy skin creams, when changing the appliance c. Clients should avoid the use of soap, especially oil- or lotion-based soaps, because they leave a residue that can interfere with pouch adhesion, thereby increasing the risk of leakage. The nurse should instruct the client to cleanse the skin with warm tap water only. In situations where soap is essential, and if the provider allows it, the client should only use a mild, pH-balanced soap d. The nurse should instruct the client to change the pouch before a meal, when active bowel evacuation is less likely

Answer 144

a. Consume foods that are low in fiber content **The nurse should recommend that the client consume foods low in fiber to help thicken the stool. Examples of low-fiber foods include rice, noodles, white bread, and cheese**

Answer 145

d. Press gently around the barrier for 30 seconds to 1 min **The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence**

Answer 146

d. Cleanse the stoma and the peristomal skin **The first action the nurse should take is to remove any effluent adhering to the stoma and the peristomal skin to facilitate the assessment of the area**

Answer 147

c. Ileostomy **After removing the entire large intestine and the rectum, the provider will create an ileostomy to divert feces from the small intestine to the abdominal surface and into an ostomy pouch** ## Footnote a. A cecostomy is a surgical opening created in the cecum, the first section of the large intestine, with an opening to the abdominal wall for diversion of feces. This is not possible if the entire large intestine is removed b. A loop colostomy involves a large and usually temporary stoma that is created by pulling a loop of intestine onto the abdominal wall and creating two openings in the loop. This is not possible if the entire large intestine is removed d. A descending colostomy is created by removing a portion of the descending colon and using the remaining section to create a stoma on the outer surface of the abdomen. This is not possible if the entire large intestine is removed.

Answer 148

b. Use irrigation to help establish a regular bowel pattern **Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance** ## Footnote a. With a sigmoid colostomy, the effluent is solid and formed. An ileostomy produces effluent that is loose and continuous c. Ostomy appliances can remain in place for up to 7 days. d. A client with a newly created colostomy should expect effluent to begin draining within 2 to 5 days after surgery. Clients who have had an ileostomy created can have drainage within 1 to 2 days

Answer 149

Nausea and/or vomiting Bowel sounds 20/min Absence of diarrhea and constipation ## Footnote Criteria to consider when evaluating patient feeding tolerance include absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits

Answer 150

a. Stroke the underside of the patient’s chin to promote swallowing. ## Footnote To feed a patient with dementia, the nurse should stroke the underside of the patient’s chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

Answer 151

c. Provide a 30-minute rest period prior to mealtime ## Footnote The nurse should provide a 30-minute rest period prior to mealtime to promote better swallowing. The nurse alternates solids and liquids when feeding the patient; sits the patient upright or, if on bedrest, elevates the head of the bed at a 90-degree angle; and initiates a nutrition consult for diet modification and food size and/or consistency. Straws are avoided in patients with dysphagia. Assessing breath sounds will help detect aspiration but not prevent it

Answer 152

a. Patient with irritable bowel syndrome and intractable diarrhea b. Patient with celiac disease not absorbing nutrients from the GI tract f. Patient with burns who has not been able to eat adequately for 5 days

Answer 153

a. Remove the tray from the room. ## Footnote The first action of the nurse when a patient has nausea is to remove the tray, which may have noxious odor, from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect

Answer 154

a. B vitamins ## Footnote The need for B vitamins is increased in alcoholism because these nutrients are used to metabolize alcohol, thus depleting their supply. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI trac

Answer 155

a. Using a cotton-tipped applicator dipped into sterile saline solution and gently cleaning around the insertion site

Answer 156

d. The patient reports fullness and diarrhea after breakfast.

Answer 157

d. Ensuring validation of tube placement by x-ray ## Footnote Radiographic examination is the most accurate method to validate tube placement in the stomach. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual volume amount does not confirm placement.

Answer 158

b. Tooth loss and periodontal disease may make chewing more difficult. c. Decreased peristalsis can result in constipation, requiring additional fiber and fluid. d. Loss of taste between sweet and salty occurs with a preference for sweets. f. Caloric needs decrease, and the need for nutrients increases, especially protein.

Answer 159

c. 43-year-old patient who takes ginkgo biloba and an aspirin daily

Answer 160

c. Mechanically altered ## Footnote Mechanically altered diets provide adequate in calories and nutrients and contain chopped, ground, or soft foods. Liquid diets are generally used as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Clear-liquid diets are inadequate in calories, protein, and most nutrients; progression to more nutritious alternatives is recommended as soon as possible. Full-liquid diets include clear liquids plus milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. A high-calorie, high-protein supplement is recommended if a full-liquid diet is used for more than 3 days

Answer 161

a. Catheterizing a patient to collect a sterile urine sample for routine urinalysis b. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up c. Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter ## Footnote **A sterile specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collection drainage bag may not be fresh urine and could result in inaccurate analysis. **

Answer 162

a. Patient who is diagnosed with an enlarged prostate c. Patient who is diagnosed with vaginal prolapse e. Patient who is taking antihistamines to treat allergies ## Footnote Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for** urinary incontinence.**

Answer 163

a. Wear underwear with a cotton crotch. c. Drink of six to eight 8-oz glasses of liquid per day. d. Urinate before and after intercourse. e. After defecation, dry the perineal area from the front to the back.

Answer 164

a. Decreased amount and highly concentrated ## Footnote Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

Answer 165

a. The male urethra is more vulnerable to injury during insertion.

Answer 166

c. Blood clots that could block the catheter ## Footnote Post procedure continuous bladder irrigation, in the presence of hematuria, prevents stasis of blood and clot formation potentially obstructing urine output. In the absence of hematuria, clots or debris, natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction

Answer 167

a. Measuring the patient’s fluid intake and output c. Emptying the appliance frequently f. Monitoring the return of intestinal function and peristalsis

Answer 168

d. Stoma is a purple-black color. ## Footnote The stoma should appear pink to red, shiny, and moist; a dark brown or purple-blue stoma may reflect compromised circulation. The nurse contacts the health care provider immediately. A urostomy is incontinent; urine leakage is expected.

Answer 169

b. Assessing bladder residual using the bladder scanner ## Footnote Factors associated with urinary retention include medications, an enlarged prostate, and vaginal prolapse. Assist the patient to void when the patient first feels the urge. Assessing for residual urine will not promote voiding; rather, it will determine the volume of urine in the bladder. Cold water would cause the patient to tighten their muscles.

Answer 170

c. Teaching the patient how to perform PFMT exercises at regular intervals ## Footnote Pelvic floor exercises (Kegel exercises) may help a patient regain control of the micturition. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. Due to risk for infection, an indwelling catheter is the last choice of treatment.

Answer 171

a. Preventing the tubing from kinking to maintain free urinary drainage e. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis f. Ensuring the device does not restrict blood flow.

Answer 172

b. Selecting the smallest appropriate size indwelling urinary catheter ## Footnote The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient. The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16Fr gauge commonly used. A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise.

Answer 173

a. Wash your hands with soap and water. c. Separate your labia and wipe with the antiseptic towelettes in the kit. d. Without letting go of the labia, void a small amount into the toilet or collection hat. ## Footnote The nurse gives these instructions to collect the midstream/clean-catch urine specimen: Wash your hands with soap and water. Open the collection cup, and place the lid face up; do not touch the inside. Separate the labia and cleanse the urinary opening with soap and water or towelettes included in the kit. Void about 1 oz. (30 mL) into the toilet, then move the collection cup close to the urinary opening and void about 1 oz (no less than 2 teaspoons) into the container. Pass the remainder of the urine into the toilet. Without touching the inside of the lid, close the cup and return it to the nurse.

Answer 174

b. Assessing for kidney damage ## Footnote Nephrotoxic medications are those capable of causing kidney damage. The nurse can assess I&O, quality of the urine, and renal function blood tests to detect this problem. Urinary frequency, incontinence, and getting up at night to void (nocturia) are not effects of nephrotoxic medications

Answer 175

a. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants ## Footnote The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.

Answer 176

a. Peritonitis b. Prolonged bedrest f. Postoperative paralytic ileus ## Footnote Decreased or absent bowel sounds—documented only after listening for in the epigastric and umbilical area of the abdomen for 2 minutes or longer (Bickley et al., 2021)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction

Answer 177

b. Patient taking metformin for type 2 diabetes e. Patient taking amoxicillin clavulanate for infection f. Patient taking magnesium-containing antacids ## Footnote Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or antacids containing magnesium. Opioids, diuretics, and dehydration may lead to constipation

Answer 178

d. “The stool from an ileostomy is normally liquid.” e. “Eat dark-green vegetables to control the odor of the stool.” f. “You may have a tendency to develop food blockages.” ## Footnote *Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage intake of dark-green vegetables for their chlorophyll content, which helps to deodorize the feces. Explain that patients with ileostomies may tend to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.*

Answer 179

a. Irrigating the tube with 30-mL normal saline solution b. Confirming tube placement via pH testing of gastric secretions d. Instilling irrigation via the blue air vent e. Monitoring the patient’s abdomen for distention f. Documenting the nasogastric irrigation and drainage with I & O ## Footnote *Care of a patient with an NG tube connected to suction includes verifying placement before administration of any fluids or medications to avoid aspiration. Radiographic evidence of the tip of the tube in the stomach, measurement of tube length, measurement of tube marking, measurement of aspirate pH, and carbon dioxide monitoring may be used. The nurse irrigates the tube with 30 mL of saline solution (or as prescribed/ per policy) with an irrigating syringe. The nurse separates the tube from the suction device, clamps the NG tube to prevent gastric secretions from leaking, and places the tip of the syringe in the tube to gently insert the saline solution. The nurse should not place irrigant in the blue air vent of a Salem sump or double-lumen tube; rather, the nurse should instill air through the vent. The air vent decreases any pressure that has built up in the stomach during suction; instilling air promotes drainage. The air vent should be placed above the stomach. Abdominal distention may indicate lack of proper drainage or delayed return of GI function. The nurse documents all irrigation and NG tube output with the I & O. If the nurse allows the irrigant to drain out, that is excluded from intake.*

Answer 180

**d. Assessing the patient’s bowel patterns** ## Footnote *The nurse follows the steps of the nursing process to plan care. First the nurse assesses the patient’s bowel movements including frequency, consistency, shape, volume, and color. Based on the assessment findings, the nurse may recommend 3 of fluid daily or administer an enema, as appropriate. The nurse also monitors bowel sounds, teaches about specific foods that promote bowel regularity, ensures privacy, and encourages adequate fluid intake.*

Answer 181

a. Blood in the stool d. Unintentional weight loss

Answer 182

b. Left-sided end colostomy in the sigmoid colon ## Footnote *Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn disease*

Answer 183

c. Having the patient rest for 30 minutes to see if the prolapse resolves ## Footnote *If the stoma protrudes into the bag after changing the ostomy appliance, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.*

Answer 184

c. “The screening assesses for blood in your stool.” ## Footnote *The guaiac fecal occult blood testing (FOBT) is used to detect occult blood in the stool. It is used for initial/early screening for disorders such as cancer and for GI bleeding in conditions such as ulcer disease, inflammatory bowel disorders, and intestinal polyps. A positive FOBT result indicates that abnormal bleeding is occurring somewhere in the digestive tract.*

Answer 185

a. Documenting the findings and continuing to monitor the patient

Answer 186

b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.

Answer 187

1. C - Place the patient in the low Fowler position. 2. B - Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. 3. A - Notify the health care provider of the situation. 4. E - Maintain NPO status for return to the OR for repair. 5. D - Document the findings and outcome of interventions.

Answer 188

a. Applying sterile dressing supplies b. Discussing zinc supplementation with the health care provider d. Performing careful hand hygiene e. Teaching the patient to increase protein in the diet f. Suggesting the patient consume vitamin C–containing foods

Answer 189

b. The patient is an older adult with a poor appetite. c. The patient reports inability to control their urine. d. The patient’s albumin level is <3.2 mg/dL (normal, 3.4 to 5.4 g/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.

Answer 190

c. “Redness and swelling should decrease after cold treatment.” ## Footnote [The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.]

Answer 191

c. “Suction stimulates blood flow to the wound, removes excess fluid, and promotes a moist environment for healing.”

Answer 192

b. Stage 2 with 1-cm blister noted ## Footnote **BLISTER = STAGE 2**

Answer 193

b. Gently cleansing the wound and applying a moist dressing

Answer 194

d. Using a mild cleansing agent when cleansing the skin

Answer 195

**VERY HIGH RISK** **The patient is at very high risk for pressure injury. This patient responds only to painful stimulate (1); is occasionally moist (3); is bedridden (1); has not eaten (1), and requires maximum assistance for moving (1) for a total of 7 points. The Braden scale scoring is: a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk (Braden & Maklebust, 2005). In addition, nurses use clinical judgment to incorporate risk factors and/or other health problems into preventative interventions. **

Answer 196

a. Cigar smoker

Answer 197

b. A decrease in stool quantity and amount **X-RAY SHOWS COLON WITH BACKED UP FECES = CONSTIPATED**

Answer 198

b. Pain in the abdomen c. Distension d. Hypoactive bowel sounds

Answer 199

**IT IS EASIER TO PREVENT THAN TO TREAT** PREVENTION: * Increase fiber * Increase fluids * Increase activity * Medications - stool softeners vs laxatives * Warm prune juice if normal regimen starts to get off track

Answer 200

d. Mechanical soft

Answer 201

b. Follow recommendations from SLT about fluid/food consitencies c. Have client seated in high-Fowler's during and at least 30 min after meal d. Provide small bites of foot for patient as tolerated e. Inspect the client's oral cavity after each bite for pocketing

Answer 202

c. Get warm water and gently apply pressure by pushing and pulling back with a syringe

Answer 203

d. Abdominal x-ray

Answer 204

c. The client reports fullness and watery stool

Answer 205

d. Offer small, more frequent meals

Answer 206

a. Water and saliva dribbling from corner of mouth c. The client begins to cough after swallowing d. The client continuously ‘throat clears’ during their conversation after e. The clients voice sounds ‘wet’

Answer 207

c. Gently stroke underside if chin to promote swallowing

Answer 208

Open area on heel Foul odor

Answer 209

**BOTH** PRESSURE INJURY + VENOUS STASIS ULCER

Answer 210

**VENOUS STASIS ULCER**

Answer 211

**PRESSURE INJURY**

Answer 212

**VENOUS STASIS ULCER**

Answer 213

**BOTH** PRESSURE INJURY + VENOUS STASIS ULCER

Answer 214

**PRESSURE INJURY**

Answer 215

**CONTRAINDICATED**

Answer 216

**CONTRAINDICATED**

Answer 217

**INDICATED**

Answer 218

**INDICATED**

Answer 219

**CONTRAINDICATED**

Answer 220

1. Wash hands prior to dressing change 2. Monitor for signs of infection 3. Elevate heels when in bed

Answer 221

Pressure injury

Answer 222

ELEVATE HEELS PERFORM WOUND CARE

Answer 223

SIGNS OF INFECTION DEPTH OF WOUND

Answer 224

COUGHING ALOT DURING THE MEAL AND AFTER CHANGE IN VOICE SHORTNESS OF BREATH CYANOSIS DROOLING

Answer 225

DARK URINE LOW BLOOD PRESSURE [HYPOTENSION] FATIGUE DRY MUCOUS MEMBRANES ## Footnote **PATIENT COULD ALSO PRESENT WITH TACHYCARDIA = FAST HR**

Answer 226

BMI WAIST CIRCUMFERENCE

Answer 227

INCREASING FIBER INTAKE INCREASING FLUID INTAKE ONLY TAKING PAIN RX/MEDS PRN

Answer 228

UTILIZE A BARRIER CREAM AFTER ALL PERI CARE

Answer 229

"I WILL PLAN TO STORE THE COLLECTED SPECIMENS IN THE FRIDGE UNLESS OTHERWISE INDICATED"

Answer 230

CONNECT THE CATH TUBING TO WALL SUCTION

Answer 231

MEASURE THE LENGTH OF THE TUBE TO BE INSERTED

Answer 232

"I AM REALLY NOT LOOKING FORWARD TO HAVE THIS TUBE IN MY BODY ALL OF THE TIME. I AM AFRAID IT WILL GET CAUGHT ON SOMETHING AS I WALK AROUND"

Answer 233

"I WILL APPLY A PERFORATED DRY GAUZE AROUND THE DRAIN"

Answer 234

UNSTAGEABLE

Answer 235

DEEP TISSUE INJURY

Answer 236

ENSURE THE HOB IS AT LEAST 30 DEGREES CHECK GRV BEFORE FEED FLUSH TUBING BEFORE AND AFTER ADMINISTERING ENTERAL FEED

Answer 237

CLEANSE THE WOUND FROM LEAST CONTAMINATED AREA TO THE MOST CONTAMINATED AREA ## Footnote **CLEANEST --> DIRTIEST**

Answer 238

PROMOTING FLUID INTAKE STRENGTHEN PELVIC AND ABDOMINAL MUSCLE TONE MAINTAING A VOIDING SCHEDULE ASSIST CLIENT TO VOID IN USUAL VOIDING POSITION [ie sitting, standing...]

Answer 239

A PATIENT WHO IS CONFUSED AND HAS FALLEN TWICE TRYING TO GET OUT OF BED TO VOID

Answer 240

REMOVE THE TRAY

Answer 241

KEEP SKIN CLEAN AND DRY PERFORM FREQUENT SKIN ASSESSMENTS AND BRADEN SCALE SCORING OPTIMIZE NUTRITION PLAN TO ENSURE ADEQUATE NUTRIENT INTAKE UTILIZE SUPPORTIVE TOOLS TO OFF-LOAD PRESSURE SUCH AS WEDGES, PILLOWS, HEEL PROTECTOR BOOTS, ETC...