Nursing Care Plans Hygiene, Wound Care, and Patient Self-Care

BSN 206 week 5-8 Question Which cues would be found in a patient with a nursing hypothesis of Impaired Health Maintenance? Which hypothesis would the nurse select for a patient with redness and swelling at the site where a mole was recently removed? The nurse has selected the hypothesis of Pressure Ulcer/Injury for a patient because of cues identified on the patient’s sacrum. Which other sites would the nurse examine thoroughly? A patient has a wound that makes bathing difficult. Which short-term goal would the nurse add to the plan of care after a discussion with the patient? For which reason is it important for hygiene and personal care goals to be measurable? Which statement is phrased as a desired outcome for a pediatric patient being treated for head lice? Which activities can be delegated to the unlicensed assistive personnel (UAP) for a patient unable to perform self-care activities? Which action by the nurse demonstrates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care? Which action would the nurse take when a patient requests a same gender caregiver for hygiene and personal care because of cultural preferences? Answer Cognitive changes Unkempt appearance Poor hygiene Forgetfulness Traumatic Wound Elbows Heels Shoulders Patient will accept bathing assistance until wound healing occurs. Provides a means for measuring patient self-care progress. Child refrains from sharing personal items with school classmates. Personal grooming Partial bath Denture care Hair care Partnering with the occupational therapist Accommodate the patient’s wishes. will achieve the personal care goal? What action must Which questions will the nurse ask when formulating Who the patient perform? When will the patient have performed a measurable hygiene and personal care goal? the action? Which example shows a correctly stated hygiene and Patient will shower independently by the end of 1 month. personal care long-term goal? A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing Self-Care Deficit hypothesis would the nurse select? A patient is recovering from leg surgery and is unable to stand for self-care. Which hypotheses would be Traumatic Wound Self-Care Deficit selected for hygiene and self-care? Which cues would be found in a patient with a Fatigue with minimal activity c. Unkempt appearance d. nursing hypothesis of Activity Intolerance relating to a. Shortness of breath with activity e. Poor hygiene hygiene? Which piece of clothing would the nurse remove when looking for excoriations? When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment? Which type of injury results in a puncture wound? A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider? Which assessment findings are indicative of poor hygiene? The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient’s activities of daily living (ADLs)? An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse Adult diaper Open wound over the sacrum Dog bite Presence of pediculosis Body odors Tangled and matted hair Excessively long and dirty toenails "Do you always make it to the bathroom on time?" "How often do you take a bath or shower?" "Can you bathe yourself without help?" Redness Swelling Drainage would observe the patient’s skin for which signs of infection? An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient’s discharge from the hospital? Which factors are potential causes of halitosis? Which type of bath is appropriate for an older adult patient who ambulates with a cane and has a history of unsteadiness? Which benefit does a sitz bath provide for a new mother? Which action must the nurse perform before a patient receives a shower? Which findings would the nurse document as unexpected after providing perineal care? Which actions would the nurse avoid when clipping the nails of a patient diagnosed with peripheral neuropathy and circulatory impairment? Massage uses a range of techniques to provide which benefits? Patients with which conditions should avoid soaking their feet? While assisting a patient with teeth brushing, the nurse notices the patient has difficulty grasping and maneuvering the toothbrush. Which action would the nurse take to further assist this patient? A patient who is scheduled for surgery has been prescribed nothing by mouth (NPO) yet wants to have her teeth brushed. Which item would the nurse use to brush the patient’s teeth? Which patient condition requires the nurse to pay special attention to the oral cavity given increased susceptibility to oral infections, dryness, and tissue damage? A nurse is instructing a newly blind patient how to clean the eyes. Which instruction would the nurse provide? Which action is taken for a patient receiving oxygen with a nasal cannula to prevent nasal passages from drying? The nurse asks a patient whether he uses cottontipped applicators to clean the ear canals. For which reasons would the nurse make this inquiry? A postsurgical patient is requesting hair care from the nurse. Which information would the nurse document after hair care is performed? Which cues indicate a patients hair care status is declining? A male patient with a long beard does not wish to shave. Which hair care processes would the nurse implement for this patient? Which statement by the nurse best expresses the proper approach to perineal care to a patient of the opposite sex? The nurse is tasked with catheter insertion on a patient of Middle Eastern descent who is of the opposite sex. Which approach would the nurse take when initiating the procedure? Assist the patient with community referrals. Diabetes Medications Poor oral hygiene Infections of the oral cavity Chair shower Decreases swelling Check the health care provider’s prescription to determine if showering is safe. Redness Drainage Odor Edema Drying the patients finger nails Relaxation Comfort Circulation Sleep Peripheral neuropathy Diabetes Sensory deficits Request a large-handled toothbrush. Moistened toothette Undergoing chemotherapy Use plain water and wipe from the inner canthus to the outer canthus. Humidifying the oxygen Cotton-tipped applicators should never be inserted into the ear canal as they can cause cerumen impaction. use of a cotton-tipped applicator to clean the ear canals could result in the rupturing of the tympanic membrane. The nurse can request special Condition of patient’s scalp, Patient’s tolerance of procedure, Patient’s satisfaction Patient develops ingrown hairs, Dandruff is present. Combing, Trimming, Shampooing “If at any time you feel uncomfortable, please let me know.” Knock first, explain the procedure, and ask for the patient’s comfort level. A patient with chronic arthritis is having difficulty with teeth brushing. Which statement best shows how the nurse can help with sensitivity in mind? An obese patient complains of itchy and uncomfortable skin. What interventions might the nurse expect to implement? A nurse is reviewing personal care procedures with nursing students. Which statement by a nursing student indicates understanding of the importance of hygiene care? A patient has a surgical wound with staples. The health care provider has prescribed that the patient shower with the incision covered, but the patient has refused twice. Which statement would be most appropriate for the nurse to make? While providing patient care to wash away bacteria, which layer of the skin will be affected? A nurse is caring for an older adult woman with advanced dementia who is incapable of self-care. However, the patient insists on brushing her own teeth at bedtime. Which action would the nurse take? Which component of the integumentary system is the first line of defense against microorganisms? The nurse provides thorough cleansing of the axillary regions of the patient to ensure the products from which glands are washed away? A female patient with tremors and circadian rhythm disorder complains that she is having difficulty sleeping and is often awakened. She frequently works nights during shift rotation. Which questions by the nurse are appropriate? A patient with a fluctuating heart rate is in which stage of sleep? Which patient is most likely in the rapid eye movement (REM) sleep stage? A nurse is teaching a patient about the effects of medication on sleep. Which statement indicates a need for further teaching? Which nighttime snack is appropriate for a patient with a history of insomnia? Which patients would most likely suffer from sleep disturbances? Which structures of the central nervous system are affected by a light or dark environment? Sleep deprivation can lead to an increased risk for which diseases? A patient displaying small muscle jerks is in which stage of sleep? A patient has been diagnosed with obstructive sleep apnea (OSA) and is experiencing daytime sleepiness and excessive snoring. Which nursing hypotheses are appropriate for this patient? Which outcome is most appropriate for a patient who snores during sleep and reports feeling very tired after awakening? Which example is an appropriate long-term goal for the nurse to include in a plan of care for a patient who is suffering from insomnia related to psychological job stress? I know you're used to doing this alone. If you let me help, we can get it done quickly Clean the body with soap and water, apply anti-fungal powder to the itchy skin, assure all areas are cleaned with soap and water are thoroughly dried. “Personal care is the best time to perform a skin assessment.” Bathing cleanses microorganisms from the skin and lessens the chance of infection. Epidermis Allow her to brush her teeth with supervision. Skin Exocrine, Apocrine, Sudoriferous "Have you considered switching to days permanently?" "Are you taking any medications that may be causing you to have trouble sleeping?" -"How do you feel about a care plan to reduce awakenings?" -"Have you been tested for Parkinson's disease?" Rapid eye movement (REM) Adolescent who awakens from a night terror. “Barbiturates increase REM sleep.” Graham crackers Young adult female with marital problems Older adult male who recently lost his wife in death Child who is spending the summer away from home at camp Adult female caring for a family member with a chronic illness Hypothalamus Pineal gland Brain stem Depression Obesity Cardiovascular disease Diabetes NREM 2 Fatigue, Impaired Sleep (quality) Patient experiences fewer apneic-hypopneic episodes per night. Patient will achieve 6 to 7 hours of sleep each night within 4 weeks. A hospitalized patient reports disturbed sleep caused by the nurse monitoring vital signs at regular intervals in the night. Which outcome is appropriate for this patient with the nursing hypothesis Impaired Sleep (quality)? A patient admitted to the hospital with a concussion after falling while sleepwalking is currently alert and oriented. Which outcomes are appropriate when planning care for this patient? Which outcome would the nurse include in the plan of care for a patient who frequently sleepwalks? Which outcome is appropriate for the nurse to include in the plan of care for an older patient who feels sleepy during the day despite getting enough sleep at night? Which solutions would be appropriate for a patient with a nursing hypothesis of Fatigue? A patient with no known medical conditions reports constant fatigue and inability to stay awake. The patient also reports falling asleep while at work, having vivid hallucinations upon awakening, and brief episodes of paralysis at the beginning of sle Which patient has the greatest risk of developing obstructive sleep apnea (OSA)? In which way are sleep deprivation and narcolepsy similar? Which factors are measured by polysomnography? Which question would the nurse ask when assessing for narcolepsy? Which behavioral cues may validate a sleep disturbance? Which statement made by the adult patient, while providing a sleep history, needs further follow-up? Which interventions related to sleep would the nurse recommend to the parent of a pediatric patient? Which nonpharmacologic intervention would the nurse initiate for a patient who is having difficulty falling asleep because of mild back pain? Which type of exercise would the nurse suggest a patient perform just before bed to promote sleep? Which statement by the patient regarding foods that promote sleep indicates the need for further education from the nurse? Which nonpharmacologic intervention is most appropriate to promote rest in a patient with restless legs syndrome (RLS)? Which pharmacologic interventions would the nurse suggest for a patient with chronic insomnia who prefers to use supplements over medications? Which statement made by a patient after education regarding the safe administration of common sleep medications indicates a need for further teaching? Which statements made by the patient would indicate a sleep medication was ineffective? Which cues reflect behavioral responses to pain? The nurse is providing care for a patient with Alzheimer disease. Which factors would the nurse consider when conducting a pain assessment on a patient with a cognitive disorder? Which theory of pain was based on studies of phantom limb pain in amputees and proposes that Patient will sleep for at least 90 minutes at a time during hospitalization. Patient will remain injury-free during hospitalization. Patient will reduce the number of sleepwalking episodes prior to discharge. Patient will remain injury-free during hospitalization. Patient should take two 20-minute naps daily. Patient education about sleep hygiene Adjusting work schedule to allow for healthy sleep schedule Patient education about stress management Narcolepsy Obese, adult male smoker with a large neck circumference Both disorders can cause hallucinations. Eye movements Brain activity Heart rate Oxygen level Do you fall asleep unexpectedly at random times? Slow speech Frequent yawning I usually feel tired in the mornings. Give a warm bath Read a bedtime story Provide a favorite soft toy or blanket Play soft, soothing music Giving the patient a massage Yoga “I should drink a few glasses of red wine in the evening to enhance the sleep I get overnight.” Encouraging deep knee bends Melatonin Valerian “Maybe I should take a higher dose of antidepressants since it is my first time taking them for my sleep problems.” “It took a lot longer to fall asleep than normal.” “I woke up more frequently in the night.” “My mind was very active last night after taking the medication.” Grimaces Clenched teeth The patient is able to experience pain. The patient may not be able to express the location of pain. Neuromatrix theory pain cannot be explained solely by physical factors? A patient has suffered burn injuries related to a house fire and is in the burn center for pain control and dressing changes. Which function does pain serve when it is associated with a thermal injury? Response process begins with conversion of a stimulus to an Which statement regarding nociception is accurate? The electrical impulse. Which step of nociception involves recognition of a painful stimulus and conversion of the stimulus to an Transduction electrical impulse? Which step of nociception involves translation of Perception nerve signals? Based on the density of nociceptors throughout the body, which condition would the nurse expect to Burn require the most analgesia? Immune cells release which neurotransmitter during Histamine the inflammatory response? A patient having a heart attack feels pain in the jaw. Referred pain Which type of pain is the patient experiencing? Nociceptors encounter harmful stimuli. Nerves are injured or impaired. No physical source of pain is nociceptive neuropathic psychogenic evident Quick onset, Lasts less than 3 months Linked to injury or Which characteristics describe acute pain? trauma A patient is taking a prescribed sedative that affects the patient’s pain perception. Which type of Physiologic factor influencing factor reflects this patient’s experience? Presence of parent to provide support for child Social experiencing pain Acknowledgment of pain as a weakness for men Cultural Influence of genetics on pain tolerance Physiologic Ability to cope with pain and perceived loss of Psychological control Which intervention demonstrates psychological Using guided imagery factors that influence pain? Complete a pain assessment. Organize and link patient cues Place the steps in the order that the nurse related to pain. Identify hypotheses related to pain and pain implements them when caring for a patient management. Prioritize hypotheses related to pain and pain experiencing pain. management. Determine patient goals/outcomes pain management. After assessing a patient with a fractured wrist, the nurse selects a hypothesis of Difficulty Coping. The patient is grimacing. The patient appears restless. Which cues would lead the nurse to select this hypothesis? Following a back injury that occurred while gardening, a patient states that the pain level increases when walking or bending but is relieved Risk for Activity Intolerance when lying down. Which hypothesis would the nurse identify? A patient presents to the emergency department immediately following an arm injury that occurred during a football game. The patient rates the pain in Acute Pain the left arm and shoulder an 8 on a 0–10 pain scale. The nurse is caring for a patient who was involved in a mountain bike accident and is experiencing severe Which hypotheses have the potential for complications? pain. Which question would allow the nurse to prioritize hypotheses according to risk? The nurse is caring for a patient who reports pain of 9 on a 0–10 scale. The nurse administers the Patient will report a pain level of less than 3 on a 0–10 scale prescribed pain medication. Which statement reflects a patient goal developed in accordance with within 1 hour of starting prescribed dose of analgesia. the SMART acronym? Which collaborative team members may be involved in providing care to a patient with pain? Which strategy can the nurse use to care for an athlete who experiences occasional stress and muscle pain before or after sports? The nurse collaborates with unlicensed assistive personnel (UAP) to implement care for patients experiencing pain. Which action can the nurse delegate to UAP? provider prescribed pain and anxiety medications for a postoperative patient.lowest pain rating the patient 7 on a 0–10 pain scale. Which interprofessional team members would the nurse collaborate with to determine nonpharmacologic solutions Which solution involves the collaboration of a primary health care provider, nurse, and pharmacist when caring for a patient with pain from an injury to an extremity? A 40-year-old patient presents to the emergency department with a fracture of the right femur following a four-wheeler accident. The nurse organizes relevant cues and links them to form hypotheses, as depicted in the table. Physical therapist Massage therapist Pain management specialist Muscle manipulation specialist Which statement by the new nurse indicates understanding of the nurse’s role in pain management? educate the patient about pain treatment options.” assess for pain as a part of my initial assessment.” advocate for adequate pain relief for my patient if current therapies seem ineffective.” evaluate theresponse to interventions Which statement reflects the purpose of the Rights of Medication Administration? The nurse tells a patient that oxycodone can cause itchiness and sleepiness and that it must be taken only as prescribed. The nurse also recommends taking a stool softener with this medication as it may cause constipation. oral analgesic every 4 hours as needed for pain. At hour 3, the patient still complains of severe pain rated 8 on a 0–10 scale and verbalizes feelings of frustration as a result of lack of pain relief. Which action is most effective A patient who is in labor reports intense, painful contractions and feels very nauseous. The patient wants to proceed without the use of medication. Which nonpharmacologic interventions can the nurse implement for this patient? A patient is 2 days post–knee surgery. The pain management plan includes pharmacologic treatment, but the patient also requests nonpharmacologic methods, so the nurse brings the patient an ice pack A patient who presents to the emergency department with mild leg strain requests nonpharmacologic pain treatment. Which alternative therapies would the nurse suggest? A patient has a broken femur and is in excruciating pain. The health care provider prescribes an intravenous opioid and acetaminophen combination for pain relief. Which statement explains why the two medications are prescribed for pain? A patient is prescribed a nonsteroidal antiinflammatory drug (NSAID) for arthritis. The nurse would educate the patient about which potential side effects? A patient rates pain a 9 on a 0–10 scale and requests pain medication. The nurse reviews the medication administration record (MAR) and finds oxycodone, ibuprofen, acetaminophen, and ketorolac are Prevent medication errors Collaborate with a massage therapist Darkening the room to create a peaceful environment Music therapist Physical therapist Massage therapist Pain management specialist Administering acetaminophen/oxycodone Neurovascular checks of right leg within normal limits Education Implementing massage and positioning techniques -Repositioning the patient. -Massaging the patient's back. Assisting with deep breathing exercises. “Rest periods from cold therapy should be provided to prevent tissue injury.” Yoga Meditation Biofeedback The mixture of medications produces fewer side effects. Multimodal analgesia requires lower doses for effective pain relief. The combination of medications is more effective than just the opioid alone. Increased bleeding Gastrointestinal upset Cardiac complications Oxycodone prescribed. Which medication would the nurse administer? The nurse gives a patient a dose of intravenous morphine for pain relief. A few minutes later, the patient’s respiratory rate is 5 breaths/min. Which medication would the nurse administer to reverse the effects of the opioid? Which action is eliminated by the use of patientcontrolled analgesia (PCA) pumps? A patient is admitted to the hospital with a broken hip, and the health care provider prescribes a patient-controlled analgesia (PCA) system to manage the pain. Which patient statement reflects understanding of education about the use of PCA The nurse provides literature to a patient about side effects and activities to avoid while taking a prescribed medication. Which nursing action is demonstrated when the nurse asks the patient to repeat back the information? Which action allows the nurse to begin collecting cues about a burn patient’s pain experience? Which questions would the nurse ask when conducting a pain assessment for a trauma patient? A nurse is conducting a pain assessment using the SOCRATES acronym. Which concept reflects the meaning of the letter “T” in SOCRATES? The nurse assesses the patient’s pain using the SOCRATES acronym. Which additional question would be relevant to the pain assessment? The nurse working in an urgent care office assesses a patient who presents with a possible broken ankle that is edematous. The patient rates the pain a 9 on a 0–10 scale. The nurse asks a patient experiencing painful kidney stones to rate the pain on a scale from 0 to 10. The patient rates the pain as a 7. Which phrase describes the patient’s level of pain indicated by the rating? Which statement reflects how the gastrointestinal system responds to pain? Which statement describes how pain experienced by postoperative patients increases the risk for development of pneumonia? Which patient cues are indicative of chronic pain? A patient with diabetes presents at the emergency department with a broken arm and pain rated 8 on a 0–10 pain scale. Which effect on the patient’s blood glucose would be anticipated? Which cue reflects that the patient is experiencing pain? Which cues are psychological expressions of pain? Which cues are relevant to the adult patient’s acute pain experience? A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient’s pain? Which observation indicates that a patient’s analgesic has been effective in managing pain that Naloxone Waiting for the nurse to administer pain medication “This infusion pump is programmed to give me a set dose of medication at a set time interval.” Assessing Taking the patient’s vital signs Where is the pain located?" "What makes the pain worse or better?" "Does the pain radiate anywhere?" Time course "What are your past pain experiences?" Pain rating of 9 on a 0–10 scale is subjective Severe pain Decreases intestinal motility Causes a reluctance to breathe deeply Constricted pupils Decreased heart rate Decreased systolic blood pressure Increased blood glucose level Decreased urine output Fear Depression Helplessness Dilated pupils Heart rate of 120 Pain rated 7 on 0-10 pain scale The patient rates his pain a 7 on a scale of 0 to 10. "Let me know at least 30 minutes before you transport her so I can administer her analgesics." The patient rates her current pain as 3 out of 10 on the pain rating scale. she rated a 6 out of 10 on a pain rating scale before the intervention? A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient? The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? Acute pain Which patient is most at risk of developing permanently impaired mobility? passive shoulder and elbow exercises for a patient who is recovering from surgery to remove a softtissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? Which of the following are basic guidelines when assisting a patient with passive range of motion? Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? Which description correctly identifies a health care– associated infection (HAI)? Performing neck, back, and shoulder exercises prescribed by a physical therapist The absence of physiological signs and symptoms is associated with chronic pain. Determine health literacy of the client Conduct a focused physical and neurologic exam Severity of pain Provocation/initiating factors . A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) To ensure stability while exercising the joint Perform range of motion to the left elbow until resistance is met. Each joint is exercised to the point of resistance but not pain. The patient has orthopedic trauma. The infection was not present at the time of admission. Chain of infection Infectious agent, reservoir, portal of exit, transmission, portal of entry, host susceptibility It is determined that the patient has developed a health care–associated infection of Pseudomonas pneumonia that developed from the presence of contaminated water and a dirty health care environment. What measures can be taken to help break the chain reduces the number of microorganisms present. Performing hand hygiene before and after contact with the patient Discarding standing water and rinsing cups after use. Teaching the patient and family about the source and transmission of infections, the reason for susceptibility, and infec Medical asepsis (clean technique) Surgical asepsis (sterile technique) Nonsterile (contaminated) Sterile medical asepsis Performing hand hygiene Using clean, disposable gloves Rinsing out the bedside commode after use Sterile gloves Autoclaving instruments Using a sterile syringe for an injection Using a sterile cup to obtain a specimen for culture Previously opened bottle of normal saline, undated Edges of an opened sterile package Sterile barrier saturated with spilled hydrogen peroxide Sterile gloves on sterile draped table at waist level Sterile gown front from chest to waist Center of an opened sterile package Having chemotherapy Being malnourished Overcrowded health care facility Identify risk factors for this patient developing an infection. Select all that apply. The use of standard precautions is determined by the patient's likelihood of carrying a communicable False illness. Standard precautions are used to protect you from True potential contact with blood and body fluids. "Standard precautions" means that you should use False gloves, mask, eye protection, and a gown when a patient is placed on isolation. A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. presents to the clinic wit The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient s bladder. What link in the chain of infection is the nurse breaking by doing so? The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) The patient may now have a systemic infection. Surgical asepsis (sterile technique). Following standard precautions Portal of entry Standard precautions are used to protect you from potential contact with blood and body fluids. Standard precautions should be observed in every patient encounter. A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A sterile barrier that has been permeated by moisture contaminated. A sterile object or field out of the range of vision or an object held below a person's waist contaminated ny doubt item's sterility, the item considered unsterile. A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? The nurse is caring for four individuals. Which patient would be most at risk for infection? 92-year-old female complains of frequent nonproductive cough. States has been taking PO steroids as prescribed. Denies having received pneumonia vaccine. The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? The recommended duration for lathering hands is at least ________ seconds. Hand hygiene practices are ________ for health care workers. The most effective way to prevent transmission of infection is performing hand hygiene and ________. According to the Centers for Disease Control and Prevention (CDC) Guidelines, an alcohol-based hand rub is used for routine decontamination in which of the following situations? Select all that apply. Keep nails less than one-quarter of an inch long. Inspect hands for visible soiling. Immunizations help protect children from being susceptible hosts. The patient who is receiving immunosuppressive medication hospitalized vaccination status age medical therapy if worn, nail polish shouldn't be chipped - cough hygiene practices should be followed - always know a patient's susceptibility to infection 15 mandatory wearing gloves Before having direct contact with patients. After contact with objects in the immediate vicinity of a patient. After removing gloves. Enables cleaning under nail Enables cleaning under nail Determines need for hand washing cuts or wounds can harbor high concentrations of Cover any skin lesions before providing patient care Open microorganisms. Avoid wearing artificial nails. Harbors microorganisms You include performing hand hygiene in your nursing care to help break the chain of infection. At which link in the chain of infection is hand hygiene primarily Mode of transmission effective? Under which of the following circumstances should the nurse reinforce the importance of hand washing and disinfection, and provide further instruction to the NAP regarding hand hygiene? You are evaluating the performance of hand washing and notice an area of soiling at the wrist. What action The NAP turns off the water faucet with her hand. The NAP removes her gloves after assisting the patient with toileting and answers the next call light. Repeat the hand-washing procedure. should you take next? You are evaluating the cleanliness of your hands after performing hand hygiene with an antiseptic hand rub. You feel your hands stinging and notice that they are very chapped. What action should you take? student nurses voices concern that she will bring home “something” to her 2-year-old child and husband because she is exposed to so many different illnesses in the clinical setting After hand hygiene, use a small amount of lotion/barrier cream from a single-use container. "Following good hand hygiene practices will protect both you and your family." the dressing on a wound Administering an IV Determine which tasks indicate hand hygiene should Changing push medication into a patient's IV with a needleless be performed. system Before applying gloves to insert an IV. After moving a When should you perform hand hygiene? patient up in bed. Before assessing a patient's vital signs. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all the force of the water - the method used to turn off the faucet that apply.) Why are the hands rinsed with the fingertips held Water flows from the least to the most contaminated area, lower than the wrist? rinsing microorganisms into the sink. What is the best nursing practice to reduce the potential transmission of microorganisms within the Performing hand hygiene. health care setting? Under which circumstance(s) should hand washing Hands touch the sink during hand washing. Areas under be repeated? fingernails remain soiled. After adjusting a nasal cannula on a patient. After removing When is it acceptable to use antiseptic hand rub gloves after changing a wound dressing. After moving rather than soap and water? patient’s belongings on the bedside table. The nurse is observing the NAP perform hand take the patient's BP and leave the room to document - puts hygiene. Which of the following, if performed by the patient's socks and begin to feed them - has an uncovered NAP, requires intervention by the nurse? cut on the back of non dominant hand The NAP complains of his hands hurting and skin - use hand lotion - be sure to rinse and dry hands being chapped. What would be appropriate thoroughly - avoid excessive amount of soap or antiseptic suggestions for the NAP? According to the basic rules of creating and maintaining a sterile field, which of the following is The sterile field is within your view. correct? You are preparing a sterile field when you realize you Turn on the call light and request more sterile gauze from will need more sterile gauze for the dressing change. the person that responds. What action should you take? ou must perform a dressing change and provide pin care, which requires creating and maintaining a sterile field. What would be evidence of the patient meeting the expected outcome 24 hours after the procedure? What method would the nurse use to evaluate the outcome of a sterile dressing change? (Select all that apply.) Which action breaks a sterile field? preparing a sterile field to insert a Foley (urinary) catheter in a patient. While adding the sterile catheter to the sterile field, it accidentally touches the patient’s bedding. The student has added the catheter to the sterile field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? ( Afebrile WBC within normal limits of 5000 to 10,000 per mm3 Absence of tenderness or edema at surgical sites Inspect the treated area for signs of localized infection. Evaluate the patient for signs of systemic infection. You pour the necessary amount of solution into the sterile receptacle with only a moderate amount of splashing onto the barrier. Discontinue field preparation, and start over with new equipment. Opening the outermost flap Pouring a sterile solution Some of the sterile normal saline spills onto the sterile barrier Nonsterile items are added to the sterile field The nurse prepares the sterile field and leaves the room to get more sterile supplies. The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse’s best action? The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? A nursing instructor is reviewing sterile gloving with a group of students. Which statement, if made by a student, indicates correct understanding? Which of the following are high-risk factors for latex allergy? Select all that apply. You are going to perform a procedure. What considerations should be made regarding the choice of gloves? The expected outcome for wearing sterile gloves is: Which of the following outcomes are related to sterile gloving? (Select all that apply.) The nursing student is preparing to do a sterile dressing change. The patient has a reported allergy to latex. What should the nursing student do at this time? The nurse notices that there is increased redness around the wound and purulent yellow drainage on the dressing that was removed. The nurse prepares a sterile field, applies sterile gloves, cleans the wound by using sterile technique, and applies a ne The nurse is applying sterile gloves. Which series of steps would require correction? Which of the following is a correct description of glove removal? The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? Which of the following are symptoms of latex allergy? (Select all that apply.) retired but her previous occupation was registered nurse. reports allergic to morphine and penicillin. history of five laminectomies (back surgeries) resulting from scoliosis Which factors high-risk factors for latex allergy? Which situation represents collaboration? Which situation represents effective delegation? Match the right of delegation to its description. Place the drape so the top half of the drape is over the top half of the work surface. The nurse asks the patient if he has ambulated in the hall today. Temperature of 102.5° F (39.2° C). Discard the needle and replace with a new one before administration. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. "Synthetic gloves may be used for individuals with a latex allergy." "Sterile gloves prevent the transmission of pathogenic microorganisms." Food allergy to bananas, tomatoes, and peaches History of multiple surgeries The presence or absence of latex allergy Glove size Sterile or nonsterile procedure Prevention of localized or systemic infection Foul odor from wound Redness at wound site Increased warmth of skin at wound site Skin appears red and itches Change gloves to synthetic or nonlatex gloves. Notify the physician of the assessment findings. Monitor the patient's temperature every 4 hours or as ordered. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure. You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside Once sterile gloves are applied, the inside of the glove is still considered sterile. Skin redness Itching. Edema Difficulty breathing. History of multiple surgeries as a child. Occupation. Nurse and physical therapist discussing options for patient care Nurse assigns another registered nurse (RN) to care for an unstable patient. Appropriate patient care situation Right circumstance Appropriate task assigned to the right individual Right Which nursing behaviors demonstrate safe delegation? Which tasks would the nurse assign to unlicensed assistive personnel (UAP)? Which patient scenario fits within Background for SBAR? person Appropriate (clear, concise) instructions Right direction Appropriate follow-up and feedback by the nurse Right supervision Validating that instructions are understood Assessing the patient before assigning a task Vital signs Hygienic care Ambulation with a walker Recent past medical history of an arm fracture Which behaviors would the nurse implement for collaboration? Using humor. Maintaining clinical competence Using Situation, Background, Assessment, and Recommendation (SBAR) Reading progress notes Which response from the nurse indicates effective collaboration and communication with the health care provider? Which result is associated with competency in teamwork and collaboration? “I believe the patient might be dehydrated and recommend fluids.” Place the information in the correct order for Situation, Background, Assessment, and Recommendation (SBAR) communication. Shared decision-making short of breath with swelling in ankles and feet. admitted with heart failure and diabetes 2 days ago. include lungs filling with fluid and having too much fluid hvp notified medication to help the patient breathe easier and rid the body of fluid. Asking an unlicensed assistive personnel to feed a patient Which nursing scenario represents delegation? Match the health care team member to the patient’s Patient needs help determining interactions of medications needs. Patient needs help with activities of daily Patient needs help obtaining supplies for a new living Occupational therapist Patient needs help with Pharmacist treatment Social worker joint and muscle movement Physical therapist The nurse delegated a stable patient to a licensed practical nurse (LPN). The nurse identified an allergy to a medication Which situations indicate the nurse used critical and notified the health care provider. The nurse offered a thinking? review of best practices in an interdisciplinary care conference. Which organizations use collaboration in their code American Nurses Association (ANA) International Council of ethics? of Nurses (ICN) Need to find source of infection and contamination Infection rate up 14% in cardiac rehabilitation unit Assessment Review all equipment used and match Situation Never used to have infections in the cardiac infection to source Recommendation rehabilitation unit Background Which action by the nurse is an important aspect of Communicating to the team collaboration? Which concepts are associated with collaboration? Competency Standard Skill Level of quality Which behaviors are skills of collaboration in the Starts conflict resolution when necessary States own Quality and Safety Education for Nurses (QSEN) personal viewpoints in patient care conferences competencies? Which nursing action facilitates team building directly with the patient? Which attitude for collaboration is described in the Quality and Safety Education for Nurses (QSEN) competency? Which scenario complies with regulations of confidentiality? Which scenario complies with professional role boundaries? Keeping the patient aware about the status of the health care team collaboration Which standard communication strategies would the nurse use to positively influence the nurse–patient helping relationship? Leaning toward the patient as the patient speaks Holding the patient’s hand while the health care provider provides the results of a biopsy Remaining silent while being present in the room Reminiscing with the patient Accepting the patient’s erroneous line of thinking Which communication strategies would the nurse use for a patient with dementia? Which response would the nurse use when the patient avoids eye contact when discussing a sensitive subject? Which action would the male nurse take when a female patient from another culture does not want Esteems the expertise of all group members Refusing to tell the patient’s partner about the diagnosis without patient authorization Visiting a patient to provide home health care ) "You seem uncomfortable." Request a female nurse to perform the assessment. him to perform an assessment? Which actions would the nurse implement for a patient with visual and hearing impairments? Which question or comment is an effective verbal technique for obtaining more information? Which key concepts of professional communication are represented when the circulating nurse in the operating room says, “The patient’s arm is not straight; it needs to be repositioned”? Which techniques would the nurse use for a male patient who identifies as a female? Which approach would the nurse use to communicate with a patient who is on a ventilator and is paralyzed in all extremities? Which response would the nurse make to a patient who is about to undergo a stressful procedure in 1 hour and yells at the nurse who is 5 minutes late with the medications? Which action would the nurse take for an older adult female patient who left her glasses at home but is wearing her hearing aid and wants information about her newly prescribed medications? Which nursing behaviors are therapeutic? Raise voice slightly above normal level. Speak to the patient before touching. Display active listening. "Tell me more about your diet." Assertiveness Advocacy Establish trust. Touch the patient’s shoulder for comfort. Use eye movements to indicate “yes” or “no.” “I understand that you are probably nervous; tell me about how you are feeling.” Sit down with the patient to verbally answer questions. Allowing the older adult more time to answer questions Not touching the top of a patient’s head who is from another country Asking family members to leave when talking about personal issues Which response would the nurse make to a female patient who is crying and asks the nurse if she should “What are your concerns about the chemotherapy?” get chemotherapy treatments? Which phase of the nurse–patient helping relationship is represented when the nurse is Termination summarizing care? have no reason to be crying.” Approval/disapproval“You Match the communication technique to its example. You won’t get better care anywhere else.” Defensiveness“ Which techniques are being used when the nurse says, “Mrs. Sharp, we have discussed your Summarizing Using open-ended questions Calling the medications, treatments, and next appointment. patient by name What else would you like to discuss?” Which patient situation describes projection? An adult patient feels ugly but calls the nurse ugly. Which actions would the nurse take for a patient Speaking before touching the patient Observing for who is comatose? grimacing Monitoring for restlessness leaving a severely anxious patient alone Postponing Which actions would strengthen the nurse–patient Not teaching if the patient is in severe pain Observing family helping relationship? dynamics when interacting with patients and families Which element is first in the communication process? Which aspects of communication are exemplified when the patient telephones the nurse to ask about the next appointment? Which example is a representation of the auditory channel in the communication process? Which information is accurate about communication? Which examples are associated with verbal communication? Which phase of small-group communication is described when the group is very committed to a positive outcome? Which behavior occurs in the storming phase of small-group communication? Referent Verbal communication is present. Patient is sender. Interpersonal communication occurred. Paying attention to the patient’s breath sounds A receiver is essential for communication to occur. Detecting body odor is using the olfactory channel. Verbal communication includes electronic interactions. Nonverbal communication can be exhibited by a person’s clothes. Writing Emailing Blogging Texting Performing Addressing conflicts Match the element of the communication process with its example. Which statements by the nurse indicate a correct understanding of nonverbal communication? Which phase is the group experiencing when trying to resolve treatment for a patient’s nonhealing wound? Which aspects of communication are occurring when the patient frowns and points to an area of pain while the nurse is in the room? When the nurse asks how a patient slept, the patient says, “Fine.” Which component is the sender in this transaction? Which area is affected when the health care provider tells the patient, “The MRI, the PET scan, and the CBC with differential were inconclusive”? Which nonverbal behavior would help a nurse who is speaking in public? Nurse tells patient that the procedure is tomorrow. Feedback Patient asks nurse when procedure will be performed. Message Patient reviews planner but does not see date for procedure. Referent The patient Sender “Holding patients’ hands when they are scared or worried is a technique for nonverbal communication.” “My professional appearance can communicate a message of caring.” “I should keep my arms uncrossed to convey openness to the patient.” Performing Nonverbal communication Visual channels of communication Gestures from the patient The nurse Content Walk to the podium with confidence and intention. Which situations are examples of public communication? Nurse teaching about high blood pressure at a health fair Nurse offering advice to a large classroom of nursing students Nurse suggesting ways to decrease the risk for infection on television Which components are basic elements of the communication process? Referent Channel Feedback Nurse is obtaining health history from a patient. Interpersonal Nurse is serving as an expert for a facility’s social media platform. Public Nurse is facilitating a quality task force. Small group Nurse feels confident by using meditation. Intrapersonal Which facial expression by the nurse would facilitate sharing of information from the patient? Which aspect of voice inflection is reflected when the patient says, “I just can’t . . . seem to . . . deal with . . . this”? Saying “I can get through this” Positive self-talk Internally saying “I can get through this” Nonverbal communication The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field? A patient requires all of the following interventions. Which one would the nurse perform last? Which direction to nursing assistive personnel (NAP) would help to maintain a sterile field while conducting a sterile procedure? Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field? While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure? While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained? Neutral Rhythm or rate Nurse purposefully talking to patient Conversational interpersonal communication Nurse using a quiet, soft voice Formal interpersonal communication Placing the needed supplies near the back of the sterile field Change the dressing on the patient's newly established suprapubic catheter. I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing. Do not allow the wrapper to touch the sterile field. Nothing Follow sterile technique during the procedure. Ask the assistant who has been helping with the procedure to bring the necessary supplies. What direction would the nurse provide to nursing assistive personnel (NAP) while establishing and maintaining a sterile field? While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient's gown. Which action is most appropriate in this situation? Why might the nurse offer the patient a bedpan before establishing a sterile field? Which action is the most effective in minimizing the risk of contamination when using sterile liquids during a sterile procedure? What direction would the nurse provide to nursing assistive personnel (NAP) assisting with a sterile procedure in which sterile solutions are being used? What would the nurse do if a sterile solution splashed onto a sterile field and contaminated the field during a dressing change? When pouring a sterile liquid into a container on a sterile field, why does the nurse hold the bottle with the label facing the palm of the hand? When adding a sterile liquid to a sterile field, which action will contaminate the field? Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient? What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation? The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse? When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown? When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first? Remember, reaching over the sterile field constitutes a break in sterile technique. Collect the supplies necessary and establish a new sterile field. Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement. Avoid splashing when pouring sterile liquids onto the sterile field. Would you please get me another bottle of sterile water? A. Collect new supplies, and prepare another sterile field. The label may become illegible if it is splashed. Extending your arm over the sterile field to pour the liquid into the receptacle Gown, gloves, mask, and eye protection Perform hand hygiene "I really dislike wearing a mask, so it's the first thing I take off." To prevent touching contaminated material with unprotected hands Review the patient's need for a specific isolation precaution patient information for planning care Provides Which are primary functions of the electronic health Provides interdisciplinary documentation review Allows access to record? decision support tools for ease of care The new nurse is learning to use the electronic health Computer literacy Password protection and security record (EHR). Which knowledge and skills must Communication management nurses have to effectively use the EHR? The nurse is caring for a patient admitted with opioid use disorder. Match the electronic health record benefit with the step used in patient care. Assessing opioid blood level System connectivity Determining health care needs Point-of-care information Providing external provider support Remote access Using CPOE to manage prescriptions System integration The nurse made an error in documenting a patient’s care. Which method would the nurse use for correcting a documentation error in a paper chart? The nurse is caring for a patient transferred from the intensive care unit to the unit. In which ways would the use of standardized nursing language contribute to more favorable patient outcomes? Nursing documentation is both a patient care and legal process. Which actions would indicate that the nurse requires further education on the legal implications of documentation? Match the documentation type to its description. Place the nurse's initials beside the error, and draw a line through the error. Provides documentation consistency Facilitates communication Enables data trending across units Documenting patient data in front of other colleagues Using white correction fluid to correct an error on a paper chart Completing documentation at the end of shift Includes rows and columns for assessments and outcomes Flowsheet Is the most used problem-oriented method SOAP Requires evaluation of nursing intervention PIE Incorporates established best practices for patient outcomes Clinical pathway The nurse is documenting patient care using a non– problem-oriented team approach. Which type of documentation is the nurse using? Which standard electronic health record (EHR) component is required for patient care? In which way can nurses perform effective hand-off reporting? Flowsheet documentation Electronic medication system Ensure that complete and accurate information is conveyed. -Details about the patient's intubation procedure. -Planned Which information should be included in an treatment if the patient's condition worsens. -Change in the ANTICipate hand-off report? patient's status from "critical" to "serious". Which hand-off processes could reduce the potential Standardization of critical data Increased communication of a sentinel event? between shifts Accurate and up-to-date patient summaries The nurse is caring for a postoperative patient. Original pain medication prescription Date and time of the Which documentation would be needed when an incident Name of the nurse who administered the unexpected opioid-related event requires the medication completion of an incident report? To provide a framework for implementing change To Which rationales explain how an incident report is provide information to guide solutions To disseminate used for constructive analysis? information regarding the incident Which situations require an incident report? Respiratory distress caused by ventilator malfunction Nurse slips and falls on a wet floor Incorrect opioid dosage administration Which phrase describes the purpose of informatics competencies for nurses? Information literacy for patient safety and care quality Which skill demonstrates information literacy? Using the electronic health record to extract information from a patient's last visit Which action describes a Quality and Safety Education for Nurses (QSEN) knowledge-based competency? Applying technology to patient safety Clinical data elements for use in all nursing settings-NMDS: Nursing Minimum Data Set Nursing diagnoses--NANDA-I: NANDA International Diagnoses, interventions, and outcomes--CCC: Clinical Care Classification Nursing administrative data elements for use in all nursing settings--NMMDS: Nursing Management Minimum Data Set Which phrase provides the rationale for using standardized nursing terminology when treating a patient as part of a multidisciplinary nursing team? Which multidisciplinary standardized terminology is essential for controlled nursing vocabulary coding? Which questions would the nurse ask about an online health resource to determine the objectivity of the resource? Which phrase describes a use of information technology in nursing education? Which question would the nurse ask about an online health information website to verify its content? Which functions are provided by the electronic health record (EHR)? Allows all nurses to use the same vocabulary to facilitate communication The nurse is caring for a patient experiencing chest pain. Which benefits of the electronic health record (EHR) would help the nurse care for this patient? The nurse is preparing a patient for discharge. Which technology would help with discharge planning? A patient’s blood pressure and temperature are examples of which informatics construct? Which scientific fields are encompassed within the broad academic field of informatics? In which areas has the application of information technology in health care resulted in major Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT) Is there evidence bias in the website? What are the goals of the website? Is bias explicit or hidden? Provides virtual immersion scenarios Is the information found in other sources? 1 Enables visualization of the patient’s blood pressure, latest electrocardiogram, and oxygen saturation Enables visualization of laboratory test trends through access to laboratory data Provides access to all health care provider notes for input Computerized provider order entry (CPOE) system Data Public health science Computer science Medical science Information science Patient safety Health care costs Decision-making improvements? Which statements regarding HIPAA are true? Which purpose did the Health Information Technology for Economic and Clinical Health (HITECH) Act serve? The nurse is caring for a patient in a medical facility. Which patient information is protected by multiple ethical and federal regulations? When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what? The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient's mouth? What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided? When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line? What must the nurse avoid when brushing the tongue of an unconscious patient? Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient? A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety? The nurse is preparing to give a patient a bath using a disposable bath-in-a-bag product. What should the nurse do first? What can the nurse do to keep the patient from becoming chilled while receiving a bath with a disposable bath-in-a-bag product? The nurse has washed a patient's arms. Which area should the nurse wash next? Which patient should not have his or her feet soaked during a complete bed bath? The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient's eyes? A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. HIPAA outlines legal penalties for health care providers who breach security of health care data. Nurses are legally and professionally responsible for understanding sets standards for how confidentiality of health care information must be maintained. Provides funding for the meaningful use of electronic health records Personal health information Assessing the patient's gag reflex Upside down, or with the curve facing up To reduce the risk of aspiration To allow the bristles to reach beneath the gum line Stimulating the gag reflex Do not massage any reddened areas on the patient's skin. Make sure the call light is within the patient's reach. Warm the product in the microwave. Lightly cover the patient with a bath towel. Hands A patient with diabetes mellitus Use eye patches or shields taped in place. FALSE 4-5 DAYS tRUE Distention or swelling of the affected body part A decreased blood pressure and increased pulse A change in the type and amount of drainage from a surgical drain Which of the following patients has the least risk for A 30-year-old female who had an episiotomy after developing a wound infection? childbirth When teaching a patient about wound healing, what Inadequate nutrition delays wound healing and increases should the nurse tell the patient? risk of infection. Which of the following may indicate internal hemorrhage? The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient’s knee appears red and is very warm to the touch. The patient requests pain medication. The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? The nurse reports that a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient: A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient’s history indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Which of the following are common sites for the development of pressure injuries? Identify contributing factors to pressure injury formation. Identify prevention strategies for pressure injuries. The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? A family member calls the nurse to ask for advice regarding their mother who has developed a “bedsore” on her right heel. The family member describes the pressure injury as “a blister that has now popped and you can see redness. The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? The patient is demonstrating signs of a postoperative wound infection. The nurse should be alert for an increase in serosanguineous drainage from the wound. is at greater risk for infection. Wound dehiscence. Heels. Sacrum. Lateral malleoli. Trochanters. Ischial tuberosities. Malnutrition. Decreased sensory perception/mobility. Anemia. Excessive sweating. When the patient is in the side-lying position in bed, use the 30-degree lateral position. Place patient on a pressurereducing support surface. Oral supplements should be instituted if the patient is found to be undernourished. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. Stage 2. "To provide suction to remove and collect drainage from your wound to help it heal." "If drainage suddenly stops, it means the drain is ready to be removed." When should wound drainage be cultured? When there is a change in color, amount, or odor of drainage. The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient: Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this? Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? empties the Hemovac drain, replaces the plug, and records the amount of drainage. Because drainage can be irritating to the skin and may cause skin breakdown. Assessment of wound drainage. sure there is slack in the tubing from the reservoir to The patient complains "It feels like the drain is pulling Make the wound, allowing the patient movement and avoiding on my surgical site." What is the nurse’s best action? pulling at the insertion site. To promote hemostasis. Wound debridement. To prevent Which of the following are functions of dressings? contamination. Which of the following patients would be expected to Packs wound tightly. Leaves contact or primary dressing benefit from a damp-to-dry dressing? dripping moist. A patient with a wound vacuum-assisted closure to the white polyvinyl alcohol (PVA) soft foam. (wound V.A.C.) continues to complain of pain. What Switch Decrease the pressure setting. Administer pain medication. measures may be taken? During a sterile dressing change, when are the gloves changed? A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? After the old dressing is removed and before cleansing the wound. "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing." A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? "Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes." nurse can check for air leaks by listening with a How can the nurse determine that negative pressure The stethoscope or by moving the hand around the edges of the is being achieved with a wound V.A.C.? wound while applying light pressure. Remove old dressing, discard gloves and perform hand Which of the following is a correct sequence for hygiene, create sterile field, apply sterile gloves, clean changing a gauze dressing? wound, blot dry, apply new dressing. Which statement regarding the skin is accurate? Which cells join the epidermis and dermis and are arranged in a single layer? Match the type of healing to its characteristic. Which characteristics of aging cause the skin to be fragile, loose, dry, and transparent? Which response is likely when a patient who has a full-thickness wound receives a steroid? Which characteristic accurately describes the dermis? Which effect on the wound would likely occur if a patient with pressure injuries smoked? Which strategy would the nurse use to classify a burn? Which features describe the subcutaneous layer of skin? Which nutrients would need to be increased in the diet of a patient with full-thickness burns? Which classification would the nurse use for staging a pressure injury that has a full-thickness wound and extends into the subcutaneous tissue, but not into the fascia, muscle, or bone? Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site “bleeds easily”? Which type of opening occurs in a patient who has an enterocutaneous fistula? Which complication would the nurse identify for the health care provider in a patient whose surgical incision “popped” open and is draining fluid? Which processes occur in the proliferative phase of wound healing? Which patient situation is a medical emergency? Match the type of wound to its typical colors. Which interpretation would the nurse make about a wound that is colonized? Which factor that affects skin integrity is depicted in this image? Which classic signs would the nurse observe in a wound that is in the inflammatory phase of healing? Which pressure injury stage is depicted in the image? Which factors can directly cause the fibroblasts and collagen to be altered or ineffective in the proliferative phase of wound healing? Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity? It is closely linked to personal identity. Basal cells Healing is from the bottom and sides of the wound. Secondary intention Edges are approximated. Primary intention There is a delay between injury and closure. Tertiary intention loss of elastin A decrease in the number of sweat glands A smoothing of the layer of skin under the epidermis Healing time will slow. Is an area for sebaceous glands Receives less oxygen According to the skin layer damaged Provides insulation to protect against both heat and cold Cushions bony prominences and internal organs Zinc Copper Protein Vitamin A Vitamin C Stage 3 Proliferative Between the skin and the intestine Dehiscence Stimulation of angiogenesis Creation of granulation tissue Shock Purple or maroon Suspected deep-tissue injury White, brown, or black Full-thickness burn Beefy red and bumpy Wound in proliferative phase Red and purulent Infected wound Contains microorganisms on the surface of the wound only Prolonged pressure Swelling Erythema 2 Prolonged decrease of oxygen perfusion to skin Lack of protein Lack of vitamin C History of diabetes Bone Tendon Muscle Which hypothesis would the nurse develop for an immobile patient who has intact skin? Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat? Risk for Impaired Skin Integrity Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? Therapies consistent with guidelines for treatment of wounds Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) Agreement of the patient Capability of the patient to purchase supplies Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum? Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound? For which patient hypotheses would the nurse select turning and positioning as a solution? Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound? Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8? Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake? Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.? After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel? Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter’s surgical leg incision and the incision edges are red and warm? Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement? Which action for skin hygiene would the nurse take for an obese patient who is immobile? Which patient situations would prompt the nurse to question a prescription for heat therapy? Wound, ostomy, and continence nurse (WOCN) Social worker Nutritionist Which actions would the nurse take for a patient receiving heat therapy? Low prealbumin levels Stage 2 pressure injury Immobility Repositioning the patient Reporting any changes in patient’s skin integrity or condition Applying a nonsterile dressing for chronic wounds with an established treatment plan Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week. “My wound will look beefy red within 1 week.” Impaired Skin Integrity Risk for Pressure Ulcer/Injury Impaired Tissue Integrity Risk for Impaired Skin Integrity Patient’s wound will exhibit granulation tissue in the wound by 1 week. Patient will eat a high-protein diet at every meal. Patient will help with transfers within 24 hours. Patient who is experiencing shock from a profusely bleeding wound Patient who just had an incision eviscerate Patient with a stage 4 pressure injury Turn the patient every 2 hours for repositioning. Pad and protect any bony prominences. Wash and dry the patient’s skin after each liquid stool. Replace soiled linens. Carrots Sweet potatoes 1500 Turning a patient with a pressure injury Cleaning an incontinent patient of stool and urine Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately. Autolytic Keep skinfolds dry from perspiration. A patient with a local tooth abscess A patient with possible appendicitis A patient with bleeding from a small wound Obtain distilled water for aquathermia treatments. Check on the disoriented patient more frequently. Cover the container and hand when providing warm hand soaks. Which action would the nurse take when irrigating a Use sterile technique. patient’s abdominal wound? Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of Foam wound drainage? Which evaluative cue would alert the nurse that a Braden Scale score was a 9 but is now an 8. patient with a pressure injury is declining? Use an abdominal binder to help a patient who has an abdominal wound to cough. Use Montgomery straps for a Which techniques would the nurse use to patient who needs frequent dressing changes. Use a splint troubleshoot issues with patients’ dressings? to help a patient who has an abdominal incision to deep breathe. Which actions would the nurse take when the Notify the primary health care provider. Take the patient’s patient’s wound has increased redness, swelling, temperature. Review white blood cell count. induration, and drainage? Which action would the nurse take when placing noncommercial ice packs on a patient’s injured Remove air from the pack before closing. shoulder? Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with Transparent minimal drainage? Which action would the nurse take when caring for a Reactivate the drain after emptying. patient’s Jackson-Pratt drain? Which action by the nurse is priority when providing discharge teaching to a patient and spouse about Provide written instructions. wound care when the spouse is the primary caregiver? Which parameters would the nurse monitor after Pain Pallor Paralysis Paresthesia Pulselessness applying a wrap to an ankle? Monitor for granulation tissue in the wound. Avoid using NPWT for a patient with a cancerous wound. If the patient Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)? reports pain, change from the black foam to white foam. Report to the health care provider if there is an increase in wound drainage. Which reasoning explains why a nurse measures To help assess progression of wound healing wound size during an initial wound assessment? Which cues related to skin integrity may reflect an Cracking Tenting Pathogens identified in a wound culture overall health problem? Which term would the nurse use to describe Diaphoresis excessive moisture on the patient’s skin? Match the type of wound drainage to the color of Clear and watery Serous Pink to pale red Serosanguineous fluid the nurse would observe on a patient’s dressing. Bright red Sanguineous Greenish, yellow Purulent Which factors may impact the development of Smoking Diabetes Urinary incontinence pressure injuries or nonhealing wounds? Which statements by the nurse caring for a “The Norton Scale is used to assess for pressure injury risk.” postoperative patient who suffered a spinal cord “When assessing for open wounds, I can use the Wound injury indicate correct understanding about Characteristic Instrument.” assessment tools? Which type of fluid would the nurse likely observe if Sanguineous the patient was hemorrhaging? Which interpretation would the nurse make about a It is infected. patient’s wound culture that is positive? Match the unexpected skin assessment finding to its Blue skin Cyanosis Pinpoint, flat, red spots Petechiae Red description. skin Erythema Bruise Ecchymosis Which factors can place a patient at risk for a pale, Anemia Diabetes Vascular disease Nutritional deficiencies dry wound? Erythema noted on the superior portion of the wound Which cues would the nurse observe for a patient Purulent, malodorous drainage Temperature of 102°F with an infected lateral malleolus wound? (38.9°C) Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure 13-14 injury development? Which patient is likely at risk for developing a Patient with unrelieved pressure who has a fractured hip pressure injury? Which steps would the nurse take to measure the dimensions of a sacral pressure injury?Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. Which assessment technique indicates the nurse properly determined if the patient’s incision is healing or is becoming infected? Which patient situations are of immediate concern? Match the wound bed condition to its cues. M the w laterally l to r at the widest portion of the wound. M the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. M the length vertically the t to the b Palpating the area of induration around the incision line A patient is experiencing shock. A patient is profusely bleeding from a wound. A patient has an eviscerated wound. Pale, soft, wrinkled Macerated Beefy red, shiny, moist Granulated Black, hard, dry Necrotic Purulent yellow Infected