Quiz 3- Tissue Integrity, Safety, Gas Exchange Flashcards
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention.
How can the nurse minimize the risk of dislodging the catheter when removing a dressing?
Remove the transparent dressing or tape and gauze in the direction of catheter insertion.
Which of the following describes the function of wound dressings?
Absorbs excess drainage
Protects surgical incision from infection
Creates a sterile field for the incision
While changing the client’s dressing, the nurse observes the wound’s drainage is pale red/pinkish. What does the nurse describe the drainage as?
Serosanguineous
The nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding.
False
Bloody drainage 7 hours after surgery is still normal so the provider does not need to be contacted. If drainage increases and dressings become heavily saturated, then the surgeon should be notified as internal bleeding could be present.
Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?
Wear clean gloves to remove soiled dressings
Which of the following are primary risk factors for pressure ulcers?
Low-protein diet
Lengthy surgical procedures
Fever
Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk?
30-degree side lying
A 30-degree side lying position puts the least amount of pressure on bony prominences.
When assessing the client that presents with a pressure injury, what description best describes an unstageable pressure injury?
A wound that presents with full thickness loss as well as Escher and sloughing
Which area of the body will the client have an increased risk of developing a pressure injury?
Heels and ankles
Scrum and coccyx
Bilateral hip bones
Knees and thighs
A nurse is assessing a sacral pressure injury on a client and evaluates that the wound base has yellow stringy slough noted. How should the nurse document this assessment?
The client has an unstable able pressure injury
An 89-year-old client had right hip surgery a week ago. The rehab nurse assesses a purple maroon-colored blood-filled blistered area to the client’s right heel. How should the nurse document her findings?
A right heel deep tissue injury
A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record?
Stage 2
This answer is correct because a stage 2 pressure injury is skin damage through two layers of skin, the epidermis and the dermis. A stage 2 pressure injury is open, red, and moist extending to the dermis of the skin.
The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information?
Encourage a diet high in protein and calories
Keep clients clean and dry by managing incontinence
Pressure redistribution turn every 1-2 hour
When drawing blood from a patient’s peripherally inserted central catheter (PICC), what should the nurse do to minimize the pressure on the device during flushing?
Use a 10-mL syringe for the flush
A 10-mL syringe would be used during the flush to minimize pressure on the device.
Which steps help to manage infection control with PICC line dressing changes?
Scrub skin with chlorhexidine using sterile gauze to hold the line in place
Don sterile gloves after removing previous dressing
Ensure the client and nurse wear a mask prior to the beginning the dressing change
Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)?
Use a sterile technique when changing the PICC dressing.
Why should PICC lines be changed every 7 days and prn?
The client is at a high risk for infection at the insertion site
Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient’s peripherally inserted central catheter (PICC) site?
Discard the first 6-9 mL of blood drawn
A client had a central venous line placed 15 minutes ago. What priority intervention should the nurse implement next?
Order a stat chest x-ray
when a central venous catheter is inserted, placement must be confirmed before using the line. Placement is confirmed by a stat chest x-ray. The tip of the catheter should lie in the superior vena cava.
A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient?
A gauze dressing placed over catheter exit site
A gauze dressing should be used with a patient who perspires excessively because it wicks the moisture away from the catheter exit site.
A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching?
Central parental nutrition
Central parenteral nutrition needs to be given through a central line. Administering through a midline line will cause phlebitis due to the osmolality of the CPN.
When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next?
Notify the practitioner
Redness, swelling, and drainage at the catheter exit site are signs of infection, and the practitioner should be notified to make a decision regarding blood and catheter exit site cultures for further evaluation.
A nurse is teaching a new nurse how to remove a midline catheter. The nurse asks the new nurse what the minimum amount of time is to hold pressure on the site after the catheter is removed. Which of the following responses would indicate the new nurse understood the teaching?
30 seconds
Applying pressure for 30 seconds is an adequate amount of time for clotting to occur and stop bleeding. Pressure should be held longer in patients taken anti-coagulants or anti-platelets.
A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the drain is to;
promote drainage of wound exudates
You are providing care to a patient with a chest tube. On the assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding that you would do first?
Check the drainage system for an air leak
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?
Intermittent bubbling may be noted in the water seal chamber.
A primary health care provider is inserting a chest tube to treat pneumothorax. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?
Petrolatum jelly gauze
The nurse assists the primary health care provider with the removal of a chest tube inserted to treat a client who experienced a pneumothorax. During the procedure, the nurse instructs the client to perform which action?
Take a deep breath and hold it
Chest tubes are used to drain fluid, blood, or air from the pleural space within the lung in order to re-expand a collapsed lung and restore the normal positive pressure in the pleural space.
False
The nurse goes into the room of a client with a chest tube. The nurse notices that the thoracic catheter has dislodged. Which action would the nurse take next?
Cover insertion site with petroleum gauze, apply firm pressure, notify the HCP
