question

A stage 3 pressure ulcer is inficated by

answer

full thickness skin loss, drainage from the ulcer, damaged subcutaneous tissue

question

which of the following are main functions of the skin?

answer

protection, excretion, sensation, secretion

question

the changes in the integumentary system that are part of the normal aging process are

answer

hair bcomes thin and grows more slowly, skin is more fragile because of loss of collagen fibers, skin wrinkles and sags

question

a nurse is insructiona nursing student regarding prevention of pressure ulcers. the nurse would recognize further instruction is warranted when the nursing student says i will:

answer

position the patient directly on the trochanter

question

One of the facility's unlicensed assistive personnel (UAPs) is being instructed on foot care for a 74-year-old patient with severely overgrown ragged toenails. The UAP should be reminded to:

answer

cut the nail straight across with a nail clipper.

question

The nurse stages a pressure ulcer as a stage II based on the knowledge that such lesions have:

answer

partial thickness skin loss with the appearance of a blister.

question

A nurse notes that her patient has an area of red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage _____ pressure ulcer.

answer

I

question

A patient with insulin-dependent diabetes has a below-the-knee amputation on the right leg. What modification of his personal care is noted as most important?

answer

The patient's left foot should be soaked and gently dried, but his toenails should not be cut.

question

A usual routine for providing nail care to a patient includes:

answer

soaking the nails in warm soapy water to soften before cleaning under the nail edge with an orangewood stick.

question

When the nurse is assisting a male patient to shave his face, it is most important for her to:

answer

check whether a safety razor can be used or whether it is contraindicated.

question

It is most important for the nurse to write specific personal care plan modifications for the patient who:

answer

has an artificial eye and poor vision in the other.

question

Providing oral care to a patient who has dentures includes:

answer

removing, cleaning, and storing the dentures in a labeled container at bedtime.

question

A nurse is preparing to give a complete bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse:

answer

washes each eye with a fresh area of the washcloth before washing the rest of the patient's face.

question

A patient who has a dry, itchy dermatitis will most likely benefit from:

answer

an oatmeal or starch therapeutic bath with tepid water.

question

To perform oral care for an unconscious patient, the nurse takes which action first?

answer

Raise the bed to a comfortable working height and position the patient in a flat side-lying position.

question

A patient has a quarter-sized blackened eschar on both heels surrounded by a 1- to 2-cm indurated reddened area. The nurse is aware that these lesions are:

answer

pressure ulcers that cannot be accurately staged because of the eschar.

question

Because the elderly patient lies curled up in a side-lying position most of the time, the nurse, seeking to avoid a pressure ulcer, makes frequent assessments of the:

answer

ilium

question

The patient most at risk for a pressure ulcer would be:

answer

a 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed.

question

What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak?

answer

Encourage the patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary.

question

When instructing a nursing assistant about hygiene needs of a frail elderly patient, the nurse correctly educates the nursing assistant to:

answer

"Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling."

question

During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the:

answer

patient will shower or tub bathe with assistance twice a week.

question

The nurse instructs the patient that any injury to the skin initially puts the patient at risk for:

answer

infection with bacteria or viruses that may affect the person systemically.

question

An elderly patient who is unable to get out of bed complains that the room is too cold because of the air conditioning and asks the nurse to open the window. The nurse's best reply is:

answer

"I'll adjust the thermostat in your room and get a blanket for you."

question

A nurse is instructing a nursing student about restraint use. The nurse recognizes the need for further instruction when the nursing student states, "I will:

answer

tie the restraints to the side rails to ensure the restraints are secure."

question

The nurse clarifies to the worried family that the guiding principle for using protective devices is:

answer

to use only immobilization techniques necessary to keep the patient safe.

question

The physician orders wrist restraints for an agitated patient. To safely use this protective device, the nurse:

answer

checks that circulation is not impaired by evaluating color, warmth, and pulses distal to the device.

question

The doctor has written an order to place a resident in the nursing home in a vest protective device. It is the nurse's responsibility to:

answer

remove the device every 2 hours and change the patient's position.

question

A patient is agitated and confused and keeps getting out of bed and needs to be observed constantly. The best initial nursing intervention is to:

answer

have a family member or friend sit with the patient.

question

A nursing assistant on the day shift reports that he has raised the bed rails to keep an agitated patient from climbing out of bed. The nurse's best response to this information is:

answer

"The rails won't prevent falling; bring the patient out to sit by the nurses' station where we can watch her."

question

A patient who has right-sided weakness following a stroke is admitted to a long-term care facility and exhibits increasing wandering and inability for self-care. To protect the patient from the most frequent cause of injury among the elderly, the nurse's most efficient intervention would be:

answer

apply a personal alarm.

question

The nurse in a long-term facility who is making a fall assessment would identify the person most at risk for a fall to be a resident who:

answer

had a stroke with right-sided weakness 2 weeks ago and is confused.

question

The best way to maintain safety measures relative to helping a patient get into bed is to:

answer

make sure that the bed wheels are locked.

question

Lying flat on back, palms facing downward

answer

supine

question

Lying on stomach, palms facing downward

answer

prone

question

The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:

answer

a temperature abnormality.

question

The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:

answer

confirming that the bladder goes around three fourths of the arm.

question

An elderly patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need?

answer

Increase room temperature to 72° F (22.2° C) and add blankets to the bed.

question

Because the elderly have non-elastic blood vessels, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

answer

allow the patient to sit on the side of the bed for a minute before standing.

question

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

answer

measuring the oxygenated hemoglobin through a capillary bed.

question

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

answer

a breathing pattern of dyspnea followed by a short period of apnea.

question

When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is:

answer

concerned about the evidence of fever.

question

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

answer

decrease in blood pressure.

question

The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

answer

12-year-old patient with a recent seizure.

question

The nurse would document a patient as being febrile if the patient's temperature was over _____° F.

answer

100.5

question

A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient's core temperature would be:

answer

tympanic.

question

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as _____ mm Hg.

answer

54

question

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

answer

dizziness upon rising to a standing position. a drop of 15 to 20 mm Hg from baseline when changing position. syncope. blurred vision.

question

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a: (Select all that apply.)

answer

previous mastectomy. patent IV line. dialysis shunt.

question

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

answer

location, duration, character, intensity

question

The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, "I will:

answer

instruct the patient to remain on strict bed rest."

question

The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:

answer

being removed by fast air currents from a fan.

question

The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:

answer

a pulse rate of 120 beats/min.

question

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

answer

listens to the apical pulse for 1 full minute.

question

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

answer

check the patient's record to determine his baseline blood pressure.

question

The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:

answer

presence of the pedal pulse.

question

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

answer

sudden change or muffling of the sound.

question

Elderly patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

answer

continue to listen until the cuff is deflated.

question

For the nurse to assess the most accurate respiration count, the nurse should:

answer

continue to hold the patient's radial pulse, and count the respirations for 30 seconds and multiply them by 2.

question

Bradycardia

answer

heart rate of 44 bpm

question

Febrile

answer

T101 degrees F

question

Orthostatic Hypotension

answer

syncope, dizziness, blurred vision

question

Pain

answer

the 5th vital sign

question

Dyspnea

answer

difficulty breathing

question

Pulse Pressure

answer

systolic minus diastolic

question

A 74-year old client currently has a temperature reading of 36 degrees Celsius. The client walks 1 mile every day and takes naps during the day. Which of the following is most likely the reason for the lowered body temperature?

answer

The lowered temperature is a natural result of the aging processes.

question

The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape popsicle. An appropriate action would be to:

answer

Wait 30 minutes and take the oral temperature

question

Which of the following is an appropriate site for taking the pulse of a 2-year-old?

answer

Apical

question

A client complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs: blood pressure, 134/92; pulse, 100; and respiration 32. The nurse's most appropriate action is to:

answer

Give the meds

question

Considered the least accurate method of measuring temperature

answer

Axillary

question

The most appropriate position in obtaining a rectal temperature for an adult would be:

answer

Sim's

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