NSG 100 Exam 3 Flashcards

Question

The nurse is trying to give a liquid medication to a 2 1 2 -year-old child and notes that the medication has a strong taste. Which technique is the best way for the nurse to give the medication to this child? a. Give the medication with a spoonful of ice cream. b. Add the medication to the child’s bottle. c. Tell the child you have candy for him. d. Add the medication to a cup of milk.

Answer 1

a. Give the medication with a spoonful of ice cream. Rationale: Ice cream or another nonessential food disguises the taste of the medication. The other options are incorrect. If the child does not drink the entire contents of the bottle, medication is wasted and the full dose is not administered. Using the word candy with drugs may lead to the child thinking that drugs are actually candy. If the medication is mixed with a cup of milk, the child may not drink the entire cup of milk, and the distasteful drug may cause the child to refuse milk in the future.

Answer 2

c. Offer a brief, concrete explanation of the procedure at the patient’s level and with the parent or caregiver present. Rationale: For a 4-year-old child, offering a brief, concrete explanation about a procedure just beforehand, with the parent or caregiver present, is appropriate. The other options are incorrect for any age group.

Answer 3

a. The levels of microsomal enzymes are decreased. b. Perfusion to the kidneys may be decreased and may result in reduced renal function. d. First-pass elimination is reduced because of the immaturity of the liver. f. Gastric emptying is slowed because of slow or irregular peristalsis. Rationale: In children, first-pass elimination by the liver is reduced because of the immaturity of the liver, and microsomal enzymes are decreased. In addition, gastric emptying is reduced because of slow or irregular peristalsis. Perfusion to the kidneys may be decreased, resulting in reduced renal function. The other options are incorrect. In addition, remember that total body water content is greater in children than in adults.

Answer 4

a. The levels of microsomal enzymes are decreased. b. Fat content is increased because of decreased lean body mass. e. The number of intact nephrons is decreased. f. Gastric pH is less acidic. Rationale: In the elderly, levels of microsomal enzymes are decreased because the aging liver is less able to produce them; fat content is increased because of decreased lean body mass; the number of intact nephrons is decreased as the result of aging; and gastric pH is less acidic because of a gradual reduction of the production of hydrochloric acid. The other options are incorrect statements.

Answer 5

a. A placebo Rationale: To prevent bias that may occur as a result of unrealistic expectations of an investigational new drug, a placebo is incorporated into the study. The other options are incorrect. FDA approval, if given, does not occur until after phase III. Informed consent is required in all drug studies. Safety information is not determined until the study is underway.

Answer 6

a. Phase I Rationale: Phase I studies involve small numbers of healthy volunteers to determine optimal dosage range and the pharmacokinetics of the drug. The other phases progressively involve volunteers who have the disease or ailment that the drug is designed to diagnose or treat.

Answer 7

c. The patient may have no more than five refills in a 6-month period. Rationale: Schedule C-III medications may be refilled no more than five times in a 6-month period. The patient should be informed of this regulation. No prescription refills are permitted for Schedule C-II drugs. Requiring refills by written prescription only applies to Schedule C-II drugs. Schedule C-III prescriptions (written or oral) expire in 6 months.

Answer 8

d. The patient has had the study’s purpose, procedures, and possible benefits, as well as risks involved, explained to him. Rationale: Informed consent involves the careful explanation of the purpose of the study, the procedures to be used, and the risks involved. The other options do not describe informed consent. Participation in studies is voluntary and patients have the right to end participation at any time.

Answer 9

c. Native Americans Rationale: Some Native Americans believe in preserving harmony with nature and that disease is a result of ill spirits. The groups listed in the other options do not typically reflect these practices.

Answer 10

d. The nurse’s assessment needs to include gathering information regarding religious practices and beliefs regarding medication, treatment, and healing. Rationale: All beliefs need to be considered clearly so as to prevent a conflict from arising between the goals of nursing and health care and the dictates of a patient’s cultural background. Assessing religious practices and beliefs is part of a thorough cultural assessment. The other options are incorrect. The nurse should not ignore a patient’s cultural practices. The concept of balance among body, mind, and environment and the valuing of protective bracelets and root doctors reflect beliefs or practices that usually do not apply to the Hispanic cultural group.

Answer 11

a. Drugs with high potential for abuse that have accepted medical use Rationale: Schedule II drugs are those with high potential for abuse but that have accepted medical use. Drugs that have a high potential for abuse but do not have accepted medical use are Schedule I drugs. Medically accepted drugs that have moderate physical or high psychologic dependence potential are Schedule III drugs. Medically accepted drugs with limited potential for causing physical or psychological dependence are Schedule IV and V drugs.

Answer 12

b. Prescription drugs Rationale: The term legend drug refers to prescription drugs, which were differentiated from over-the-counter drugs by the 1951 Durham-Humphrey Amendment. Orphan drugs are drugs that are developed for rare diseases. The other options are not examples of legend drugs.

Answer 13

b. Veracity Rationale: Veracity is defined as the duty to tell the truth. Justice is the ethical principle of being fair or equal in one’s actions. Beneficence is the ethical principle of doing or actively promoting good. Autonomy is self-determination, or the ability to make one’s own decisions

Answer 14

a. Autonomy Rationale: Autonomy includes self-determination, or the ability to act on one’s own, including making one’s own decisions about health care. Veracity is defined as the duty to tell the truth. Justice is the ethical principle of being fair or equal in one’s actions. Beneficence is the ethical principle of doing or actively promoting good.

Answer 15

d. They are used only with approved protocols. Rationale: Schedule C-I drugs are used only with approved protocols. Schedule C-II drugs are available only by written prescription, and refills are not permitted. Being available over-the-counter with a signature may be true of Schedule C-V drugs in certain states.

Answer 16

b. Nursing negligence Rationale: Negligence is the failure to act in a reasonable and prudent manner or failure of the nurse to give the care that a reasonably prudent (cautious) nurse would render or use under similar circumstances. Nurses are expected to assess patients thoroughly before medications are given, and to be familiar with medications they are administering (see Box 4-2). In this case, nursing negligence applies to nurses, not medical negligence. Nonmaleficence is defined as the duty to do no harm; autonomy is defined as the right to make one’s own decisions or self-determination.

Answer 17

b. Inherited factors c. The patient’s diet and nutritional status e. The patient’s cultural practices Rationale: Inherited factors, diet and nutritional status, and cultural practices are some of the factors that contribute to drug polymorphism. The other options are not factors that contribute to drug polymorphism.

Answer 18

a. The patient uses aspirin as needed for pain. c. The patient uses herbal tea to relax in the evenings. d. The patient does not speak English. f. The patient does not eat pork products because of religious beliefs. Rationale: The past use of medicines, use of herbal treatments, languages spoken, and religious practices and beliefs are components of a cultural assessment. The other options reflect components of a general medication assessment or health history.

Answer 19

C. Pharmacodynamics Rationale: In simple terms, pharmacodynamics is the study of what drugs do to the body.

Answer 20

B. Have the same chemical composition as the brand-name drug C. May have several brand names E. Are usually less expensive than a brand-name drug

Answer 21

A. excretion. Rationale: The kidneys are responsible for the majority of drug excretion

Answer 22

C. Liver failure E. Concurrent use of medication with the same pathway of metabolism Rationale: (c)- liver failure decreases metabolism and increased the concentration of this med. (e)- when the same pathway metabolizes two meds, they compete for metabolism.

Answer 23

B. “Medications given intravenously are not affected by the first-pass effect.” Rationale: When drugs with a high first-pass effect are administered orally, a large amount of drug may be metabolized before it reaches the systemic circulation. The same drug given intravenously will bypass the liver. This prevents the first-pass effect from taking place, and therefore more of the drug reaches the circulation. Parenteral doses of drugs with a high first-pass effect are much smaller than oral doses, yet they produce the same pharmacologic response.

Answer 24

B. Call the pharmacy and ask for the liquid form of the medication. Rationale: The liquid form is appropriate because it is also given via the oral route. Enteric-coated tablets should not be crushed, and the patient should not be forced to take the tablets. This medication does not have an IV form, but even if it did, the routes cannot be changed without a health care provider's order.

Answer 25

C. Drug transfer to a fetus is most likely to occur during the last trimester of pregnancy. Rationale: Drug transfer to the fetus is most likely to occur during the last trimester of pregnancy. Exposure of a fetus to drugs is most detrimental during the first trimester of pregnancy, and fetuses are at greatest risk for drug-induced developmental defects during the first trimester of pregnancy. Pregnant women need to take medications to control situations such as high blood pressure.

Answer 26

D. have immature liver and kidney function Rationale: In pediatric patients, body temperature is less well regulated, and dehydration occurs easily; pediatric patients lack stomach acid to kill bacteria and have skin that is thinner and more permeable. It is true that pediatric patients have immature liver and kidney function, resulting in impaired drug metabolism and excretion.

Answer 27

A. Contact the prescriber immediately. Rationale: The nurse should contact the prescriber immediately and before administering the medications. Giving only half the prescribed dose is making a prescribed order which is not within the scope of practice for the nurse. Pharmacy cannot make treatment changes without the direction of the prescriber.

Answer 28

D. The number of intact nephrons is decreased. Rationale: In older adults, the gastric pH is less acidic because of a gradual reduction in the production of hydrochloric acid in the stomach, fat content is increased because of decreased lean body mass, and there is decreased production of proteins by the aging liver and reduced protein intake. It is correct that the number of intact nephrons decreases in older adults.

Answer 29

C. Dosage calculation by body surface area because it takes into account the difference in size for children and neonates

Answer 30

A. Decrease the amount of drug given. Rationale: A lower binding capacity leaves more drug available for action; thus, a lower dose would be required to prevent toxicity. An increase in the drug dose would result in higher risk of toxicity. A shorter time interval between doses would increase the risk of toxicity. IV administration of a drug may increase the risk of toxicity due to quicker onset of action.

Answer 31

C. Drug half-life is lengthened. Rationale: Drug half-life is extended secondary to the diminished liver and renal function in the older adult. Metabolism is slower, not faster, in older adults. Drug elimination is also generally slower in the older adult, and protein binding is not more efficient in the older adult.

Answer 32

A. Drug interactions Rationale: The highest priority for patients with multiple medications (polypharmacy) is the assessment for drug interactions. The more medications a patient takes, the higher is the risk of drug interactions.

Answer 33

C. Administration of some drugs may elicit varied responses in specific racial/ethnic groups. Rationale: Knowledge about drugs that may elicit varied responses in specific racial or ethnic groups must remain current. For example, genetic changes in certain metabolic enzymes affect the rate of drug metabolism and thus affect drug levels and dosage amounts. Cultural practices vary among individuals and should be implemented as an integral part of holistic nursing care. Dietary habits and practices can affect the pharmacokinetics of medications and are thus an important aspect of the patient's history.

Answer 34

D. Use of herbs or over-the-counter medications Rationale: The nurse should ask the patient whether the patient has taken any herbs, over-the-counter medications, or other non-prescribed medications. The patient is of Asian culture and may use herbal remedies that he or she does not consider medications.

Answer 35

A. Genetic influences B. Body composition C. Diet and nutrition D. Level of education E. Socioeconomic factors F. Use of alternative therapies G. Patient compliance with therapy

Answer 36

c. Joint inflammation Rationale: Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility. Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range of motion (ROM) and abnormal movement patterns.

Answer 37

b. The patient is wearing socks. Rationale: If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. Keep the call light in reach and remind the patient to use it and keep the bed in the low position.

Answer 38

c. “I should leave her slippers by the wheelchair.” Rationale: Leave lights on or off at night, depending on the patient’s cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).

Answer 39

c. Stop the range of motion. Rationale: Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient’s joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen later.

Answer 40

b. Patient will ambulate to the bathroom with assistance. Rationale: Patients with a diagnosis of Impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention.

Answer 41

c. Patient will have no further skin breakdown. Rationale: The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this Nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

Answer 42

c. “An example of this type of exercise is Kegels.” Rationale: Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weight lifting.

Answer 43

c. Dizziness Rationale: Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse’s ability to safely ambulate the patient.

Answer 44

b. Using a slide board Rationale: A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure.

Answer 45

b. The patient to partially moves all joints. Rationale: Active assistive range of motion occurs when the caregiver minimally assists the patient, or the patient minimally assists himself/herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient’s joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy

Answer 46

b. Reposition the patient using the trapeze. Rationale: Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments or evaluations but should notify the nurse about any skin or musculoskeletal issues (not the healthcare provider).

Answer 47

b. Life-threatening situations Rationale: Many manual patient handling tasks are unsafe, because the weights lifted and movements required are beyond the ability of most caregivers. The key is to identify the task to be accomplished, and then use the required equipment and personnel so that the task fits the capabilities of the staff (U.S. Department of Veterans Affairs, 2016). The patient’s level of cooperation is taken into consideration when using the safe patient-handling and mobility (SPHM) algorithms to decide the best method of moving the patient. The patient’s weight, medical conditions, and ability to assist are also considered (U.S. Department of Veterans Affairs, 2016). Postsurgical patients as well as patients less than 150 or 200 lb may not fit the criteria.

Answer 48

d. Raise the bed to a working height. Rationale: Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet.

Answer 49

d. “I should teach the patient how to walk with the cane.” Rationale: Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness, difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient.

Answer 50

d. The strong leg is closest to the chair. Rationale: The patient’s strongest leg needs to be closest to the chair. The patient’s hand on the weak side holds the hand bar of the crutches, and the hand on the patient’s strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair.

Answer 51

a. “I should do weight-bearing exercises.” b. “I should get adequate intake of calcium and vitamin D.” c. “I should exercise regularly.” Rationale: Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.

Answer 52

a. Decreased tissue perfusion d. Diminished respiratory capacity Rationale: Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity directly affect a person’s ability to perform activities of daily living (ADLs) and exercise. Hemiparesis and loss of sensation are associated with nervous system disorders. Muscle weakness can be from a number of causes.

Answer 53

b. “I will gain weight.” e. “I won’t have any lung problems.” Rationale: Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, DVTs, pulmonary embolism, and skin breakdown. Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient’s risk and recognize signs of impending complications.

Answer 54

a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall Rationale: The nurse should document the general assessment, include the patient’s medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices are also documented. Thoroughly document a fall or reported fall.

Answer 55

b. A decrease in diastolic blood pressure by 10 mm Hg d. An increase in systolic blood pressure by 20 mm Hg Rationale: A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.

Answer 56

a. UAP assigned to reposition the patient. c. UAP assigned to provide range-of-motion exercises. d. UAP assigned to ambulate the patient in the hallway. Rationale: UAPs provide hands-on care for immobilized patients under the direct supervision of registered nurses. Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP. UAPs may not assess patients because that is a nursing responsibility. The MORSE falls risk scale is a risk assessment as is the Timed Up and Go (TUG) test

Answer 57

b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. Rationale: Transfer belts are used for patients with an unsteady gait or generalized weakness. Canvas transfer or gait belts are applied snugly around the patient’s waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation. Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient’s waist while ambulating.

Answer 58

c. The patient moves the cane forward first. d. The patient’s arm is comfortably bent when walking. Rationale: The top of the cane should be level with the hip joint, and the patient’s arm should be comfortably bent when the patient is walking. The patient should hold the cane on his/her stronger side and move the cane forward first, followed by the weaker leg and then the stronger leg. This ensures that another point of support is always on the ground when the weaker leg is bearing weight and gives the patient a wide base of support. A patient using a cane should be encouraged to stand up straight and look forward. Leaning to one side or looking down can jeopardize safety and cause poor posture.

Answer 59

a. “I need to remove the throw rugs.” d. “I need to place a nonskid mat in front of the kitchen sink.” Rationale: To ensure patients do not have hazards that can cause falls at home, the nurse should evaluate where the living quarters are. If the patient has stairs, they need to be able to safely learn how to use the stairs. They need to remove throw rugs that are a trip hazard and place nonskid mats in front of sinks, tubs, and showers. They can shower with a bench or chair in the shower for sitting. Patients need a clear the exit so they can get out of the house quickly in case of an emergency, but do not specifically need two different exits because of the walker.

Answer 60

a. Both sleeves are connected to the SCD device. c. There are no kinks in the tubing. e. The cooling control is on. Rationale: Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. Wrap the sleeve around the leg and fasten it with Velcro straps. Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated. Connect the sleeves to the device, ensure that there are no kinks in the tubing, and turn on the cooling and set it to 35 to 55 mm Hg.

Answer 61

b. “Your immobility in the hospital is known as deconditioning.” Rationale: When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely cause in this patient’s situation.

Answer 62

c. “Talk with your physician about a calcium supplement.” Rationale: Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones, but the patient should consult with the healthcare provider before any exercise regimen is implemented for the older adult. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

Answer 63

d. Growth and development Rationale: Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don’t always affect mobility.

Answer 64

d. “Patients must be moved correctly in bed to prevent shearing.” Rationale: Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur.

Answer 65

a. “Patients with impaired bed mobility have an increased risk for pressure ulcers.” Rationale: Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

Answer 66

c. 90% Rationale: About 90% of falls end with a hip fracture.

Answer 67

a. Demineralization, calcium loss Rationale: Weight-bearing helps to strengthen the bone. Lack of weight-bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight-bearing. Range of motion may be decreased with a lack of weight-bearing movements.

Answer 68

c. “Monitor spots for color change.” Rationale: The ABCDE method (check for asymmetry, border irregularity, color variation, diameter and evolving) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer

Answer 69

c. Protection from excessive ultraviolet (UV) exposure Rationale: Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

Answer 70

c. Apply a thin coat to affected areas; avoid the face and groin. Rationale: The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

Answer 71

b. Decreasing pruritus Rationale: Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

Answer 72

d. Apply sunscreen 30 minutes prior to exposure. Rationale: Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

Answer 73

b. “I don’t bother with sunscreen on overcast days.” Rationale: The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

Answer 74

c. Staphylococcus aureus Rationale: Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

Answer 75

a. “That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.” Rationale: Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

Answer 76

d. Turning the patient at least every 2 hours Rationale: The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

Answer 77

d. “It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.” Rationale: The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

Answer 78

a. A large bruise on the side of the face Rationale: In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin’s surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

Answer 79

b. “The wound will have pus.” Rationale: An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105/g of tissue sampled when cultured. The wound will need to be treated for the infection.

Answer 80

d. A wound that was left open initially and closed later with sutures. Rationale: When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

Answer 81

c. Wound dehiscence Rationale: Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

Answer 82

d. Cover the wound with gauze soaked with normal saline. Rationale: If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the surgeon immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.

Answer 83

b. Wound will show signs of healing within 2 weeks. Rationale: A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

Answer 84

a. The nurse asks the UAP to assess the wound. Rationale: Assessment and evaluation of a patient’s skin and wounds, and the effectiveness of the treatment plan, are a nurse’s responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

Answer 85

c. 30 degrees Rationale: When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

Answer 86

d. Enzymatic dressing Rationale: Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

Answer 87

c. “Occlusive dressings can be used on infected wounds.” Rationale: Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in infected wounds. It is the most comfortable form of debridement for the patient.

Answer 88

d. A wound with a moderate amount of drainage Rationale: Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

Answer 89

c. The drain is not sutured in place so care is taken to not dislodge it. Rationale: The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

Answer 90

c. “I can warm up my hot pack in the microwave.” Rationale: Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically designed for this type of heating. Ice bags are filled two-thirds full, distilled water is used in Aqua-K pads, and application time for heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).

Answer 91

d. 30-mL syringe Rationale: A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.

Answer 92

c. Prevent skin breakdown from moisture. Rationale: Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether it is occlusive. The drying does not prevent infection.

Answer 93

c. Stop the procedure. Rationale: If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient’s response.

Answer 94

c. Patient will be able to assist with position changes using over bed trapeze within 1 week. Rationale: Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired nutritional status.

Answer 95

b. A pressure ulcer that does not extend through the fascia. Rationale: Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

Answer 96

c. Subcutaneous layer Rationale: The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

Answer 97

a. A patient who has diabetes. b. A patient with COPD. c. A patient with on bed rest who is repositioned. d. A patient who is obese and sweats excessively. e. A patient on long-term steroid therapy. Rationale: Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin’s ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin’s normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

Answer 98

a. Intensity of the pressure b. Duration of the pressure c. Tissue’s ability to tolerate the pressure d. Person’s age e. Person’s nutritional status Rationale: The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue’s ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

Answer 99

a. Location and size b. Characteristics of the wound bed c. Patient’s response to wound treatment e. Presence of drainage Rationale: A focused wound assessment includes an evaluation of the wound’s location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient’s response to the wound or wound treatment. The patient’s pain level would be documented with his/her pain assessment.

Answer 100

a. Activity b. Friction and shear c. Moisture d. Sensory perception Rationale: The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

Answer 101

b. Label each drain and record them separately. c. Recompress the device after emptying. e. Check for kinks in the tubing. Rationale: Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient’s hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

Answer 102

a. Edema b. Shivering d. Circulatory problems Rationale: Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy. Advanced age would require frequent observation due to thin skin.

NSG 100 Exam 3 Flashcards

(126 cards)