pt 2 exam 4; fundamentals of nursing

Question 1

An incontinent elderly patient is in the hospital and you are assessing her. You notice breakdown of her skin. What is the most appropriate reason for her skin breakdown.

Answer 1

Moisture= because the incontinence.

Question 2

A patient has a would on the coccyx. The wound has a break in the skin and the mucous membranes. What type of wound is it?
A. closed
B. acute
C. chronic
D. open

Answer 2

D opened= because there is an opening in the skin and/ or mucous membranes.

Question 3

A patient has had a wound that has been there for about a year due to hemiplegia and losing sensation in her right coccyx. What type of wound is this?
A. closed
B. acute
C. chronic
D. open

Answer 3

C= because chronic means ongoing.

Question 4

Living in a long term care facility Patty has got a wound port. It is starting to leak out green pus from the drainage bag. What classification does her wound fall under.
A. clean
B. contaminated
C. infected

Answer 4

C. infected means it is already occurring.
contaminated is a higher risk for infection, but the infection has yet to occur.

Question 5

You are assessing a patient that has a wound all the way to the subq layer. there is also ebole (sides folding in) What classification does the wound best fall under?
A. superficial
B. patial
C. full thickness
D. penetrating

Answer 5

C- because full thickness wounds are subq and farther. partial wounds are the epidermis layer but not the dermal layer

penetrating is a wound that involves your internal layers

Question 6

Your patient is healing from a wound. You notice there is total separation of the wound. You need to remove the contents. What type of complication is this?
A. Dehiscence
B. infection
C. evisceration
D. fistula formation

Answer 6

C- evisceration is removal of the contents of a cavity or protrusion of the viscera. (think evisc= evict)

Question 7

Select all that apply:
You are caring for a patient with a wound, you are trying to monitor the wound, what are the bets interventions in order for it to heal.
A. cleaning/ irrigating the wound
B. Applying negative pressure
C. leaving the wound open to breathe
D. debriding a wound
E. apply heat and cold

Answer 7

A
B
D
E
not c because that could cause contaminantes into the wound causing an infection

Question 8

An 82 year old patient has come into the hospital. While assessing her, you notice there is a pressure sore developing. What would be the cause of this sore?
A. immobility
B. impaired sensation
C. aging
D. fever

Answer 8

C- there is no other information to assume it is anything else. You do have her age though.

Question 9

You are sliding a patient up in bed with a bed pad because he keeps sliding down. Later when changing his bedding you notice a stage one pressure sore on his coccyx. What is the cause of the pressure sore.
A. friction and shear
B. pressure
C. immobility
D. moisture

Answer 9

A- when sliding the patient, and the patient sliding, that is causing friction

Question 10

What is the first assessment a nurse does when assessing a wound.
A. identify the size
B. identify color
C. identify the shape
D. identify the stage

Answer 10

D- you must know the stage in order to come up with interventions and other characteristics for it.

Question 11

You are assessing a wound that is reddened in the area for about an hour. the skin is still intact but the patient states there is pain with it. you observe the area is warm and firm. What stage is the pressure injury in?
A. stage one
B. stage two
C. stage three
D. stage four
E. deep tissue injury
F. unstageable

Answer 11

A- no breakage in the skin, only red, and pain. As well as 30+ minutes

Question 12

You are assessing a wound. The wound has full thickness skin loss and you notice some necrosis of the subq tissue. There is no bone or tendon visible. What stage is the wound in?
A. stage one
B. stage two
C. stage three
D. stage four
E. deep tissue injury
F. unstageable

Answer 12

C- no bone or tendon visible, but full thickness skin loss

Question 13

The wound you are assessing has full thickness skin loss, exposed bone and tendons. You are in charge of removing the slough and notice some eschar. What stage is the wound in?
A. stage one
B. stage two
C. stage three
D. stage four
E. deep tissue injury
F. unstageable

Answer 13

D- exposed bone and tendon, full thickness skin loss, and eschar.

Question 14

The wound you are assessing is open and there is no slough. There is a shallow opening that has a pink wound bed. What stage is the wound in?
A. stage one
B. stage two
C. stage three
D. stage four
E. deep tissue injury
F. unstageable

Answer 14

B- shallow opening, open, no slough, pink wound bed

Question 15

The wound you are assessing is intact and looks as if there is a terrible bruise. What stage is your wound in?
A. stage one
B. stage two
C. stage three
D. stage four
E. deep tissue injury
F. unstageable

Answer 15

E- skin intact or not intact, temperature and color change

Question 16

The wound you are assessing is showing eschar with full thickness skin loss. What stage is the wound in?
A. stage one
B. stage two
C. stage three
D. stage four
E. deep tissue injury
F. unstageable

Answer 16

F- full thickness skin loss, base of wound is obscured by slough or eschar

Question 17

When do risk assessments start for patients?
A. when a concern arises
B. on admission
C. when something bad happens
D. never

Answer 17

B- every patient must be assessed for all problems on admission to avoid NEVER events.

Question 18

Select all that apply:
What time do you reassess patients for a risk?
A. every hour
B. when something changes
C. every 12 hours
D. every 24 hours

Answer 18

B,C,D
a- not necessary unless patient is rapidly declining

Question 19

Your patient has a braden scale of 18. How high of a risk is your patient for developing a pressure sore.
A. your patient already has a sore
B. no risk for developing sore
C. medium risk for
D. low risk

Answer 19

C- 18 or lower, your patient is at risk for developing a sore. The lower the number, the higher the risk

Question 20

Select all that apply:
Your patient is constantly sliding down the best. What interventions are best of avoiding friction and shear?
A. use transfer devices
B. 2 person assist
C. dragging the patient
D. HOB 45 degrees or lower
E. apply moisture to skin prn or at least daily

Answer 20

A,B,E
not c because never drag your patient. not d, because HOB should be 30 degrees or less.

Question 21

The nurse is caring for a patient on the medical- surgical unit with a wound that has a drain and a dressing that needs changing. which of these actions should the nurse take first?
A. don sterile gloves
B. provide analgesic medications as ordered
C. avoid accidentally removing the drain
D. gather supplies

Answer 21

B

Question 22

A client has been lying on her back for two hours. When the nurse turns her, the nurse notices the skin over her sacrum is very white. By the time the nurse finishes repositioning her, the spot has turned bright red. The nurse should:
A. massage the spot with lotion
B. apply a warm compress for 30 minutes
C. return in 30-45 minutes to see if the redness has disappeared
D. wash the area with soap and water and notify the physician

Answer 22

C- if it still there after 30 minutes, the nurse can implement interventions for a stage one pressure sore

Question 23

During evening cares, the student nurse assesses the mepilex dressing on his client’s sacrum. The dressing was dated and initialed for earlier that day. the dressing was attached on all edges with no visible drainage present. Which of the following is most appropriate for the student nurse to document regarding the assessment.
A. base. site assessment clean, dry, intact
B. peri wound clean, dry, intact
C. wound healing ridge clean, dry, intact
D. dressing clean, dry, intact

Answer 23

D- the dressing has no drainage, it had no been moved or rolled, and since there was no drainage or moisture it was dry.

Question 24

Fill in the blank:
What are the 6 things you assess when assessing a wound?

Answer 24

location, appearance, size, redness, swelling, drainage

Question 25

If there is eschar, what is most likely the problem with the skin tissue?
A. slough
B. infection
C. necrotic tissue
D. skin is intact

Answer 25

C- necrotic tissue= dead
infection= green, slough= yellow

Question 26

How does an abrasion happen?
A. friction
B. moisture
C. pressure
D. immobility

Answer 26

A- abrasion is the wearing away of the upper layer of skin as a result of applied friction

Question 27

What is a laceration?
A. a scratch on top layer of skin
B. a deep cut or tear
C. another word for pressure ulcer

Answer 27

B

Question 28

Select all that apply:
You are assessing a patient with ecchymosis. What are some characteristics you notice with it?
A. reddish/ bluish discoloration
B. bruised looking area
C. breakage of skin
D. eschar
E. slough

Answer 28

A. B
ecchymosis is a rupture of small capillaries BENEATH the skin.

Question 29

The client calls the nurse to the room and states, “look, my incision is popping open where they did my hip surgery!” the nurse notes that the wound edges have separated 1 cm at the center and there is straw colored fluid leaking from one end. The nurse’s best action is to:
A. notify the surgeon stat
B. place a clean, sterile 4x4 over the incision and monitor the drainage
C. wrap an ace bandage firmly around the area dn have the client maintain bedrest
D. immediately cover the wound with sterile towels soaked in normal saline and call the surgeon

Answer 29

B- that is keeping the area clean, and a nursing intervention that could solve the problem. if problem continues, then contact the physician.

Question 30

you are in charge of describing where a wound is located on a patients foot. How would you document the location of the wound?
A. 8:00
B. 12:00
C. 6:00
D. 6:30

Answer 30

C- the head is 12:00 the feet is 6:00

Question 31

select all that apply:
Your patients had burst open, what are some ways to close the wound?
A. adhesive strips
B. sutures
C. surgical staples
D. surgical glue
E. a bandaid and wrapping it
F. you can’t you must have a physician’s order to do this

Answer 31

A, B, C, D

Question 32

Fill in the blank:
What is the mnemonic to remember when assessing wound drainage?

Answer 32

T- type
A- amount
C- consistency
O- odor

Question 33

Your patient has wound drainage, you note that it is bloody drainage. How would you document the drainage?
A. serous exudate
B. sanguineous
C. serosanguineous
D. purulent
E. purosanguineous exudate

Answer 33

B- bloody drainage

Question 34

Your patient has wound drainage, you note that it contains blood and pus. How would you document the drainage?
A. serous exudate
B. sanguineous
C. serosanguineous
D. purulent
E. purosanguineous exudate

Answer 34

E- pus and blood

Question 35

Your patient has wound drainage, you note that it is a thick, opaque drainage. it has a yellow and green color to it. How would you document the drainage?
A. serous exudate
B. sanguineous
C. serosanguineous
D. purulent
E. purosanguineous exudate

Answer 35

D- thick and opaque. could be yellow, green, tan, or brown

Question 36

Your patient has wound drainage, you note that it is a thin water like drainage that is also pink drainage. How would you document the drainage?
A. serous exudate
B. sanguineous
C. serosanguineous
D. purulent
E. purosanguineous exudate

Answer 36

C- thin, watery, pale red to pink plasma cells with red blood cells.

Question 37

Your patient has wound drainage, you note that it is watery like drainage. How would you document the drainage?
A. serous exudate
B. sanguineous
C. serosanguineous
D. purulent
E. purosanguineous exudate

Answer 37

A- thin, clear, watery drainage

Question 38

Your patient is having trouble going to the bathroom due to the lack of privacy. What type of factor is affecting her urinary elimination
A. personal
B. sociocultural
C. nutrition
D. hydration

Answer 38

A- personal is anxiety, lack of time, or privacy
sociocultural is religious requirements

Question 39

terms to know:
nocturia
polyuria
oliguria
anuria
dysuria
diuresis
enuresis

Answer 39

nocturia: going at night
polyuria: excessive urination
oliguria: decreased urine output
anuria: absence of urine
dysuria: pain when urinating
diuresis: increased urine production
enuresis: involuntary loss of urine

Question 40

terms to know:
frequency
urgency
residual urine
bladder training
proteinuria
pyuria
hematuria
pyelonephritis
cystitis

Answer 40

frequency: urinating in short intervals
urgency: uncontrollable need
residual urine: urine left in bladder
bladder training: behavioral/ schedule
proteinuria: protein in the urine
pyuria: pus in the urine
hematuria: blood in the urine
pyelonephritis: infection that spreads to urinary tract
cystitis: bladder infection

Question 41

You are talking with your patient and she states, “it always feels like i have to pee, even if i have already peed” What is the best intervention?
A. tell her she is okay, she should just try again
B. have her try going the bathroom again
C. call provider, and ask for a catheter
D. increase fluids

Answer 41

C- a catheter is an intervention to manage urinary retention

Question 42

Fill in the blank:
you are in charge of caring for a patient with a catheter. what are four things you do to ensure no infection?

Answer 42

prevent UTIs
prevent backflow of urine
encourage fluids
ensure perineal hygiene

Question 43

You had removed a catheter from a patient 9 hours ago, the patient has yet to void. What is your first plan of action?
A. call provider
B. wait till 12 hours
C. encourage more fluids
D. bladder scan

Answer 43

D, you do not need an order for this, and to look for any problems

Question 44

Select all that apply:
Your patient has severe dementia and is constantly ripping out her catheter. What are the best interventions for dealing with incontinence.
A. implement bladder training/ toileting schedule
B. preventing skin breakdown by checking for moisture
C. provide incontinence devices for patient
D. yell and scream at patient calling her stupid because she won’t remember anyways.

Answer 44

A- bringing her to the bathroom every hour
B- making sure to clean up messes ASAP to ensure no moisture
C- providing a molly and bed pad to help, as well as a bedpan
- please don’t yell at a dementia patient.

Question 45

Fill in the blank:
What are the four things to look for when assessing urine

Answer 45

color
odor
clarity
amount

Question 46

terms to know
defecation
feces
peristalsis
flatus

Answer 46

defecation: elimination of waste
feces: semi solid mass of fiber/ undigested food
peristalsis: contraction movement
flatus: moving of gas

Question 47

what are three things you look for in a stool assessment

Answer 47

color
amount
consistency

Question 48

You are talking to your patient about her BM’s. She states she has a bm about every three days. She worked out three times a day, and eats lots of vegetables. What is the best intervention to solve/ help this problem?
A. correcting her position
B. encourage fluids
C. providing privacy
D. medications

Answer 48

B, she could be dehydrated.

A and C would not be correct in this situation because the patient is free moving, and knows how to go the bathroom, is just struggling producing one.
D- medications is a possibility but making lifestyle changes first, is the best option.

Question 49

You are on night shift and have to change your patients bedding for the fourth time this night due to diarrhea. What is your best intervention?
A. monitor fluid imbalance.
B. proper diet teaching
C. Antidiarrheal medications
D. cry

Answer 49

A- you want to make sure she is okay, and not losing too many fluids. You can also provide a molly or things like that to help the mess.
Antidiarrheal medications are only for chronic diarrhea.

Question 50

there is a 24 hr urine collection in process for a client. the nursing assistive personnel inadvertently empties one specimen into the toilet instead of the collection hat. the nurse should
A. continue with the collection of urine until the 24 hr time period is over
B. dispose of the urine already collected and begin an entirely new 24 hr collection
C. make a note to the lab to inform them that one specimen was missed during the collection
D. begin filling a new collection container and take both containers ot the lab at the end of the collection period

Answer 50

B- you are not allowed to have any mistakes within a 24 hour urine collection.

Question 51

the nurse is assisting the client in caring for her ostomy. The client states “oh this is so disgusting. I’ll never be able to touch this thing. the nurses best response is:
A. it sounds like you are really upset
B. yes, it is pretty messy, so i’ll take care of it for you today
C. you should very angry. should i call the chaplain for you?
D. im sure you will get used to taking care of it eventually

Answer 51

A- confining with a patient first is most important. after that ask what the patient wants to do in order to ease her into the idea of getting used to it.

Question 52

what is considered a normal urine output per hour
A. 10-20 mL
B. 80-90 mL
C. 30-40 mL
D. 70-80 mL

Answer 52

C- roughly 30-40 or 50-60

Question 53

how fast can a pressure injury form?
A. 4 hours
B. 1 day
C. 6 hours
D. 1 hour

Answer 53

D- 1-2 hours is all it takes for a pressure injury to form

Question 54

how much sleep do adults need?
A. 7-9 hours
B. 3-4 hours
C. 10-12 hours
D. 5-6 hours

Answer 54

A

Question 55

light sleep and slowing brain and body processes are associated with which stage of NREM
a. NREM 1
B. NREM 2
C. NREM 3
D. REM

Answer 55

B- easily aroused, about to go into deep sleep

Question 56

What is the most common sleeping disorder?
A. night tears
B. narcolepsy
C. circadian rhythm disorder
D. insomnia

Answer 56

D- the inability to fall or remain asleep or go back to sleep

Question 57

the nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, i don’t know what is wrong with me. i have been napping all day and can’t seem to think clearly. the nurse’s best response is:
A. you are sleep deprived, but that will resolve in a few days
B. you are experiencing hypersomnia, so it will be important for you to walk in the hall more often
C. there has been a disruption in your circadian rhythm. what can i do to help you sleep better at night?
D. i will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep

Answer 57

C- your circadian rhythm is your bodies internal clock

Question 58

Your patients partner states she has uncontrollable leg movement when sleeping. he is constantly being kicked or pushed off a bed. what syndrome does your patient most likely have?
A. restless leg syndrome
B. hypersomnia
C. insomnia
D. narcolepsy

Answer 58

A

Question 59

for which sleep disorder would the nurse most likely need to include safety measures in the client’s plan of care?
A. snoring
B. enuresis
C. narcolepsy
D. hypersomnia

Answer 59

C- a person’s inability to stay awake- could fall asleep standing or driving

Question 60

Short answer: What regulates sleeps?

Answer 60

the amount of light that goes to your eyes.

Question 61

What macronutrient has the function of wound healing and body maintenance?
A. carbohydrates
B. Protein
C. lipids
D. glucose

Answer 61

B

Question 62

What macronutrient is the main source of energy?
A. carbohydrates
B. Protein
C. lipids
D. glucose

Answer 62

A

Question 63

What macronutrient is used as a backup energy source and organ protection?
A. carbohydrates
B. Protein
C. lipids
D. glucose

Answer 63

C

Question 64

identify the client with the greatest risk for developing protein- calorie malnutrition
A. a client who has multiple sclerosis and is in a wheelchair
B. a client weighing 300 lb who has entered the hospital for cardiac bypass surgery
C. a client with a broken arm and femur who is running a fever of 101.5
D. a client who is of native american heritage

Answer 64

C- traumatic injury and fever are both required protein to help with healing

Question 65

What BMI level is for underweight:
A. <18.5
B. > 25- 29.9
C. >30

Answer 65

A

Question 66

What BMI level is for normal weight:
A. <18.5
B. > 18.5- 24.9
C. >25-29.9
D. >30

Answer 66

B

Question 67

What BMI level is for overweight
A. <18.5
B. > 18.5- 24.9
C. >25-29.9
D. >30

Answer 67

C

Question 68

What BMI level is for obese:
A. <18.5
B. > 18.5- 24.9
C. >25-29.9
D. >30

Answer 68

D

Question 69

You have a patient that is having difficulty swallowing. You are trying to think of an intervention that can help them. Select all the options that are best for this:
A. provide and assistive device
B. avoid a straw
C. monitor weight and hydration
D. crush or chew pills
E. call provider

Answer 69

A, B. C, E

only crush or chew pills if it is stated, do not assume.

Question 70

Your patient has food that has been lodged into the respiratory tract. What type of diagnosis is this?
A. nothing you are fine
B. aspirations
C. choking
D. pneumonia

Answer 70

B- aspirations is food that enters the respiratory tract