NUR 204 Exam 2 (TestBank Questions and answers with Explanations) GRADED A

NUR 204 Exam 2 (TestBank Questions and answers with Explanations) GRADED A A When the nurse walks into the patients room, she notices fire coming from the patients trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last. A. Activate the fire alarm. B. Move the patient out of the room. C. Close all doors and windows. D. Put out the fire using the proper extinguisher. B, A, C, D The nurse should first move the patient out of the room, then activate the alarm, close all doors and windows and turn off oxygen valves, and use the proper extinguisher to put out the fire. A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine if he has a strain or a fracture. How should the nurse reply? 1) You don't need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture. 2) Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain. 3) We will need to get a venous Doppler study to make sure that there is not a fracture. 4) First, we need to get an MRI to diagnose your injury as a fracture instead of strain or sprain. 2--Signs and symptoms associated with a sprain, strain, or fracture are the same. An x-ray allows the medical provider to visually observe for any breaks in a bone. An x-ray is a more practical than an MRI to diagnose a fracture. A venous or arterial Doppler is used to detect blood flow. The nurse planning the care for a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patients integument? 1) Offering the patient six small meals a day 2) Assisting the patient to sit in a chair three times a day 3) Turning the patient at least every 2 hours 4) Administering fluid boluses as directed by the healthcare provider 3--External pressure from lying or sitting in one position compresses capillaries and obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at least every 2 hours to protect their skin and relieve pressure. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning) 1--Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers. A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next? 1) Perform the Get Up and Go Test. 2) Ask the patient if he has fallen in the past year. 3) Refer the patient for a comprehensive fall evaluation. 4) Administer the Timed Up and Go Test. 2--If a patients gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older. The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3) A small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair. 4--Whenever an electrical safety hazard is suspected or visible, the nurse should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient at risk for injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use the equipment. A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first? 1) Apply a cloth vest restraint. 2) Encourage a family member to stay with the patient. 3) Administer lorazepam (an antianxiety medication). 4) Keep the patients bed side rails up. 2--The nurse should use one-to-one supervision with this patient to maintain the patients safety. One way to accomplish this is by encouraging a family member to stay with the patient. Restraints should be used only when all other less-restrictive measures have failed and are absolutely necessary to prevent injury to the patient. Restraints have been shown to jeopardize patient safety. It is not appropriate to administer sedation for the purpose of keeping the patient in bed; this is a form of restraint. Keeping the side rails up is also a form of restraint and increases the risk for falling. Despite less-restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation? 1) Obtain a physicians order before applying restraints. 2) Monitor the patients status every 4 hours while restrained. 3) Release the restraints and check circulation every hour. 4) Continually reevaluate the patients need for restraint. 4--The patient must be continually monitored, and the need for restraint must be continually reevaluated. As a rule, a medical order should be obtained before applying restraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nurse must then evaluate the patient within 1 hour of restraint application. The order for restraint must be renewed daily. The restraints must be released at least every 2 hours, and circulation must be checked. A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient? 1) Avoid giving the patient a complete bed bath. 2) Limit the amount of time spent with the patient. 3) Allow extra time for the patient to express feelings. 4) Do not allow anyone to visit the patient. 2--When caring for a patient with a radiation implant, the nurse should organize nursing care to limit the amount of time with the patient to limit radiation exposure. The nurse must meet the patients personal hygiene needs by bathing the patient, if necessary. The nurse should encourage the patient to express her feelings; however, she should limit her contact with the patient. Pregnant women should not visit the patient; however, others may visit as long as they uphold the principles of time, distance, and shielding. A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first? 1) Administer a dose of syrup of ipecac. 2) Administer activated charcoal immediately. 3) Give water to the child immediately. 4) Call the nearest poison control center. 3--If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the agent ingested. A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately. 1--The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the area with soap and water and rinse. Have someone call the poison control center. It does not need to be a local poison control center. Additionally, it is most important to remove contact between the skin and poison before doing anything. Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning? 1) Store medications on countertops out of the childs reach. 2) Purchase medication in child-resistant containers 3) Take medications in front of the child, and explain that they are for adults only. 4) Never leave the child unattended around medications or cleaning solutions. 4--The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners even for a moment. Medications should never be stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into them. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them. A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1) Chest pain, pneumonitis, and inflammation of the mouth 2) Intestinal obstruction and numbness of the hands 3) Hypotension, oliguria, and tingling of the feet 4) Tachycardia, hematuria, and diaphoresis 1--Acute adverse effects of mercury inhalation include chest pain, inflammation of mouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears, Chronic effects include numbness or tingling of the hands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury ingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acute effects of mercury inhalation. Which aspect of restraint use can the nurse delegate to the nursing assistive personnel? 1) Assessing the patients status 2) Determining the need for restraint 3) Evaluating the patients response to restraints 4) Applying and removing the restraints 4--The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. The nurse responsible for care of the patient must assess the patients need for restraint and the patients status and must evaluate the patients response to restraints. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1) Encourage the child to continue coughing. 2) Deliver upward abdominal thrusts with a fisted hand. 3) Deliver five rapid back blows between the shoulder blades. 4) Perform a blind finger sweep of the child's mouth. 1--If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should encourage the child to continue coughing. If coughing weakens, the nurse should perform the choking maneuver by administering five rapid back blows alternated with five upward thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger sweep should never be performed because it could push the foreign object into the airway. Which is the most commonly reported incident in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays 2--Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as patient falls. The Joint Commissions national Speak Up campaign encourages patients to become active and informed participants on the healthcare team. The goal is to: 1) prevent healthcare errors. 2) help control the cost of healthcare. 3) reduce the number of automobile accidents. 4) provide a forum for people without health insurance. 1--The Joint Commission, with the Centers for Medicare and Medicaid Services, urges patients to take a role in preventing healthcare errors by becoming active, involved, and informed participants on the healthcare team. A reduction in healthcare errors could indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign has nothing to do with automobile accidents, as might be deduced from the fact that the Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has little relationship to insurance, other than to encourage clients to speak up, ask questions, and know their rights. A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse is(are) advisable? 1) Reassure the patient by entering the room alone. 2) Ask the patient if he is carrying any weapons. 3) Stay between the patient and the door; keep the door open. 4) Make eye contact while stating firmly I will not tolerate cursing and threats. 3--The nurse should keep the door open and position herself so that the patient cannot block her exit from the room (stay between the patient and the door). The nurse should not enter a room alone with an angry patient. The progression to physical violence is first anxiety, then verbal aggression, and finally physical aggression. The nurses first priority in this situation is her own safety and the safety of others in the environment. The object is to relieve the patients anxiety and not respond to anger with anger. Questioning about weapons, or being firm and defending against verbal aggression will likely provoke even more anger from the patient. The nurse must be calm and reassuring. Select all that apply Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1) Make sure the child sleeps on his back at night. 2) Keep the telephone number of the poison control center accessible. 3) Use a front-facing car seat placed in the back seat of the car. 4) Keep syrup of ipecac on hand in case of accidental poisoning. 2, 3--The nurse should teach the mother of a toddler to keep the telephone number of the poison control center accessible because toddlers are at risk for accidental poisonings. Toddlers should also have front-facing car seats. Syrup of ipecac is no longer recommended to induce emesis after poisonings. Infants, not toddlers, should sleep on their backs to prevent sudden infant death syndrome. Select all tha tapply During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurse intervene? 1) Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it. 2) Notify the hazardous material management team immediately. 3) Evacuate the area immediately. 4) After putting on a gown, gloves, and a mask, clean up the mercury. 5) Wash her hands well after removing the spill. 6) Ventilate the area well for several days. 1, 5, 6--The nurse should put on gloves and use a paper towel to pick up the mercury. Then place the mercury, broken thermometer, and soiled paper towel into a plastic bag along with the gloves. Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the area well. It is not necessary to notify the hazardous material management team or evacuate the area for a spill this small, unless agency policy actually mandates that. The nurse does not need to put on a gown and mask to dispose of the mercury. Rank the following leading causes of accidental death in the United States according to their frequency of occurrence. Rank as 1 the one that occurs most frequently; rank as 4 the one that occurs least frequently. A. Motor vehicle accidents B. Falls C. Suffocation D. Poisonings A, D, B, C Motor vehicle accidents are the leading cause of accidental death in the United States, followed by poisonings, falls, and suffocation What action is most important in limiting the nurses risk of back injuries? 1) Use good body mechanics at all times. 2) Work with another nurse or an aide when lifting and turning patients. 3) Avoid manual lifting by using assistive devices as often as possible. 4) Develop a lift team at the clinical site. 3--Back injuries are the leading cause of injury among nurses. Good body mechanics and teamwork limit the risk of injury. However, the American Nurses Associations (ANA) Handle with Care program advocates the regular use of assistive devices as well as avoiding manual lifting. The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? 1) Skeletal 2) Smooth 3) Cardiac 4) Slow-twitch fibers 1--Skeletal muscle moves the bones with ligaments. Smooth muscle is found in the digestive tract and other hollow structures, such as the blood vessels and bladder. Cardiac muscle contracts spontaneously and is blood ejected out of the heart. Slow-twitch fibers are a subtype of skeletal muscle cell. Slow-twitch fibers (type I), or red muscle, have a rich blood supply and are rich in mitochondria (the powerhouse of the cell) to give the muscle more oxygen and energy to sustain aerobic activity. The fast-twitch fibers (type II skeletal muscle type) are known as white muscle. These fibers increase the speed of muscle contraction. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? 1) Active ROM 2) Turning the patient every 2 hours 3) Passive ROM 4) Administering glucosamine supplements 3--Passive ROM involves moving the joints through their ROM when the patient is unable to do so for himself. Passive ROM promotes joint mobility. Active ROM would not be possible for a quadriplegic patient. Turning the patient every 2 hours prevents skin breakdown but does not promote mobility or prevent contracture. Glucosamine is a building block for the formation and repair of cartilage. However, there is inconclusive, scientific evidence regarding the benefit of this substance to improve joint function. A nurse is assessing a 74-year-old male patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, I have to stop. I cant do this anymore. The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? 1) Anxiety 2) Orthostatic hypotension 3) Limited activity tolerance 4) Respiratory distress 3--To assess for activity tolerance, assess and record vital signs before and after exercise. A rapid change from baseline vital signs or a slow return to baseline indicates limited activity tolerance. Anxiety might primarily exhibit signs of difficulty getting enough air and elevated heart rate and systolic blood pressure. Vitals would resolve when anxiety is reduced and not after exercise. Orthostatic hypotension is a temporary lowering of blood pressure when suddenly standing up. It is not a finding related to exercise. What is the correct method for turning an adult patient who recently sustained a spinal cord injury? 1) Ask the patient to assist with the turn by holding the side rails of the bed. 2) Place a draw sheet under the patient to assist with turning. 3) Request help from another nurse to perform the logrolling technique. 4) Use a mechanical lift for safe turning and protecting the nurses back. 3--The patients spine should be maintained in straight alignment. Logrolling moves the patients body as a unit and maintains the patients spine in straight alignment. Holding on to the side rail or using a draw sheet or mechanical lift will not keep the spine in alignment. An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis? 1) Loss of bone density that increases the risk of fracture 2) Degenerative joint disease that produces pain and decreased function 3) Chronic inflammatory joint disease that must be treated with steroids 4) Acute infection in the bone that must be treated with antibiotics 1--Osteoporosis is a decrease in total bone density. The internal structure of the bone diminishes, and the bone collapses in on itself. Women experience a rapid decline in bone mass after menopause. Osteoarthritis is a degenerative joint disease. Osteomyelitis is a serious infection in the bone. When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease? 1) Take a calcium supplement twice a day. 2) Start a weight-bearing exercise program. 3) Avoid strenuous activity that puts stress on the bones. 4) Schedule regular healthcare checkups. 2--Osteoporosis causes bones to become porous and weak. Starting a weight-bearing exercise program is the most important aid in promoting bone strength and decreasing the rate of bone loss. Calcium supplementation helps maintain bone density. Which course of action taken by her patient with osteoporosis would allow the nurse to know that her teaching was effective? 1) Taking a calcium supplement every day and increasing her phosphorous intake 2) Participating in an aerobic barbell strength class at the gym three times a week 3) Using a wheelchair to reduce the risk of spontaneous fractures to her legs and feet 4) Seeking healthcare by scheduling a follow-up examination with bone density testing 2--Active participation in a weight-bearing and weight-lifting program demonstrates not only understanding of the treatment of osteoporosis but commitment to an action plan to reduce bone loss that comes with osteoporosis. Calcium supplementation is also part of the treatment for osteoporosis. However, high phosphorous intake lowers calcium levels and would not be appropriate for a client with osteoporosis. Restricting weight-bearing activity to a wheelchair will actually lower bone density. Although follow-up care is appropriate for a client with osteoporosis, it does not indicate commitment to a daily treatment plan. Which of the following is true of synarthroses? Joints are: 1) Freely movable. 2) Capable of only limited movement. 3) Immovable. 4) Painful with movement. 3--Synarthroses joints are immovable joints. The sutures between the cranial bones are considered synarthroses joints. Although these joints have some flexibility in youth to allow for growth, they gradually become rigid and immovable with age. There is no pain associated with synarthroses. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing? 1) Fowlers position 2) Sims position 3) Lateral recumbent position 4) Lateral position 1--Fowlers position is a semi-sitting position in which the head of the bed is elevated 45 to 60 degrees. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. Sims position is a side-lying position where the patient is on his left side with left leg extended and right leg flexed. This position is commonly used for rectal examination. Lateral recumbent position is another term describing Sims position. Lateral position simply means side lying. A nurse has been asked to design an exercise program with the goal of increasing a clients muscular strength and endurance. Which exercise program would specifically focus on meeting that goal? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning 2--Resistance training involves movement against resistance, which increases muscular strength and endurance. Most commonly, resistance training refers to weight lifting and isotonic movement. When exercising for strength, the amount of resistance is increased with each exercise. When exercising for endurance, the number of repetitions is increased with each exercise. Flexibility training will not increase muscular strength. Aerobic and anaerobic conditioning may have some benefit on strength and endurance, but their primary focus is cardiovascular conditioning. In order to achieve balance, body mass must be distributed around which point? 1) Center of body alignment 2) Center of balance 3) Center of gravity 4) Base of support 3--Balance is achieved when the body is in alignment. To be balanced, a persons line of gravity must pass through his center of gravity, and the center of gravity must be close to his base of support. The center of gravity is the point around which mass is distributed. A frail 78-year-old man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight-bearing on his left lower leg. What is the best intervention to help him use his walker? 1) Aerobic exercise with deep breathing 2) Quadriceps and gluteal repetitions 3) Isometric toning of lower legs 4) Arm resistance training 4--Arm strength is necessary for ambulating with a walker and other assistive devices. Upper body resistance training increases muscles strength and tone, which will aid him in using the walker more easily. Toning the lower body through exercise of the quadriceps and gluteal muscles, although important for regaining strength in general after surgery, does not aid in using a walker. Aerobic exercise with deep breathing produces the greatest benefit to cardiovascular health but does little to improve the upper body strength needed for ambulating with an assistive device. Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery who also has a history of emphysema. 1) Impaired Mobility related to weakness 2) Ineffective Breathing Pattern related to disease process 3) Activity Intolerance related to injury 4) Risk for Injury related to medical condition 4--The patients medical condition places him at an increased Risk for Injury: He is at risk for falls and for further injury to his hip. The patient does have Impaired Mobility; however, his Impaired Mobility puts him at Risk for Injury. A diagnosis of Impaired Mobility would focus the outcomes on improving his mobility rather than protecting him from further injury. We have no data other than a diagnosis of emphysema to indicate that he is experiencing Ineffective Breathing Pattern. He is experiencing Activity Intolerance, but this is not his primary safety risk. A diagnosis of Activity Intolerance would focus the goals on increasing his endurance and conserving his energy. What would be the most appropriate goal for a frail, elderly patient with a nursing diagnosis of Risk for Injury after hip surgery? 1) Remain free from injury or falls throughout hospital stay. 2) Increase activity tolerance by discharge from hospital. 3) Demonstrate effective breathing when ambulating. 4) Increase mobility by discharge from hospital. 1--Remaining free from injury or falls is a measurable goal, and it is directly related to the patients nursing diagnosis, Risk for Injury. Increasing activity tolerance and mobility by the time of discharge is not specific and measurable. Additionally, these outcomes do not relate to Risk for Injury. A goal of effective breathing for a frail, elderly patient after hip surgery does not relate to Risk for Injury. A 16-year-old was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, Our son is just staring off into space; he wont talk to us. We are worried because he has not even listened to his iPod, watched television, or played his video games for 2 days. That is so unlike him. What is the best response the nurse can make? 1) I will inform his doctor and see if we can get your son started on an antidepressant medication. 2) He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse. 3) Your son had a major injury; and his immobility might be causing him to feel isolated and depressed. 4) He is bored because he has been in the hospital for 3 weeks; Ill try to find something new for him to do. 3--Being immobile, whether in the hospital or home, leads to isolation and mood changes. Patients who are in bed for long periods can suffer from psychological changes such as depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities. A healthy, 32-year-old man wants to start a fitness program to increase his muscle tone and muscle strength. What advice should the nurse offer him? The United States Department of Health and Human Services recommends: 1) That exercising even once a week is beneficial. 2) 30 minutes or more of moderate-intensity physical activity three times a week. 3) 1 hour, three times a week of moderate-intensity physical activity. 4) 150 to 300 minutes or more of moderate-intensity physical activity per week. 4--Exercise involves physical activity and increases muscle tone and strength. The U.S. Department of Health and Human Services recommends 150 to 300 minutes or more of moderate- or vigorous-intensity physical activity per week. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises comply with the surgeons orders? 1) Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds, and repeat 5 to 10 times. 2) Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds, and repeat 5 to 10 times. 3) Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. 4) Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. 4--Isometric exercise involves muscle contraction without motion. Isometric exercises are useful for developing strength. This type of exercise is appropriate for the patient who has had an extremity confined to a cast because muscle atrophy occurs when the muscle is not used. Performing repetitions light weight increases strength but this would stress the healing fracture at this point in the rehabilitation. Pulling an arm across the body improves flexibility but does not benefit the ulna while healing. A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time she has not had a bowel movement, although normally, passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? 1) Immobility often causes constipation. 2) A stool softener daily will relieve the problem. 3) Use of a bedpan results in bloating and constipation. 4) A low-fiber diet will resolve the problem. 1--Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. Increasing fiber in the diet often prevents constipation. A stool softener may be ordered if other measures are unsuccessful. Some people do find use of a bedpan difficult. A patient is on strict bedrest for 5 days. During this time she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who is on bedrest is Constipation related to: 1) Change in previous pattern. 2) Immobility. 3) Dietary intake. 4) Change in environment. 2--Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. Based on the scenario, this nursing diagnosis would specifically address the patients condition. A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently and has developed strong upper-body strength to maximize his independence. Which transfer device should be used when transferring him from the bed to his wheelchair? 1) Mechanical lift 2) Transfer belt 3) Draw sheet 4) Transfer board 4--A transfer board is used by patients with longstanding mobility problems; it offers them the greatest amount of independence while ensuring safety. Patients using a transfer board should have sufficient upper-body strength to perform the transfer safely. A mechanical lift could be used, but it does not promote independence. A transfer belt is used for clients who are able to stand. A draw sheet is useful for moving a patient in bed rather than from bed to wheelchair. An 82-year-old patient is unsteady on her feet when walking about the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate? 1) Crutches 2) Transfer belt 3) Cane 4) Walker 2--Crutches are commonly used when the patient has an injured lower extremity. A cane or walker is generally used for the patient with a lower extremity injury or weakness. The most appropriate equipment to use would be a transfer belt. A transfer belt allows the patient the greatest amount of independence while ensuring safety. The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, I feel so light-headed and weak, as her knees begin to buckle. The nurses best action at this time would be to: 1) Assist the patient to slide down his leg as he guides her to a seated or lying position. 2) Grab her under the arms and hold her up as he calls for assistance. 3) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall. 4) Instruct the patient to grab the rail in the hallway while he calls for assistance. 1--If a patient becomes weak or begins to fall when walking, do not attempt to hold the patient up. Instead, protect the patient as you guide her to a seated or lying position. Create a wide base of support, and project forward the hip closest to the patient. Assist the patient to slide down your leg as you call for help. Protect the patients head as her body descends. According to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct? 1) The risks of physical activity outweigh the health benefits. 2) Physical activity in excess of recommendations for age is harmful. 3) Combining aerobic and muscle-strengthening activities promotes better health. 4) Lesser amounts of activity provide little to no health benefits 3--The combination of aerobic and bone- and muscle-strengthening physical activities leads to health benefits for people of all ethnic groups and ages. Physical activity is safe for almost everyone, and the health benefits of physical activity far outweigh the risks. Additional health benefits are provided by increasing to 300 minutes a week of moderate-intensity aerobic physical activity, or 150 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both. For all individuals, some activity is better than none. When encouraging a fitness program for older adults, what must the nurse consider? 1) Older adults should engage in 75 to 150 minutes of moderate-intensity physical activity per week. 2) More than 150 minutes of moderate-intensity physical activity can be harmful to bones. 3) Structured fitness programs achieve greater health benefits for older adults. 4) Older adults at risk for falling should do activities that maintain or improve balance. 4--Older adults should do exercises that maintain or improve balance if they are at risk of falling. Older adults should follow the adult guidelines, which are for 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in periods of at least 10 minutes, preferably spread throughout the week. If this is not possible because of limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Structured calisthenics programs are no more beneficial for achieving health benefits than other forms of moderate- and vigorous-intensity physical activity. Structured fitness programs can become boring for some individuals. A varied routine often improves compliance and consistency of exercise. Select all that apply Which of the following body systems must interact to produce mobility and locomotion? Choose all that apply. 1) Digestive system 2) Muscles 3) Skeleton 4) Nervous system 2, 3, 4 Activity and exercise require bodily movement (mobility) and locomotion (self-powered movement from one place to another). Mobility depends on the successful interaction among the skeleton, the muscles, and the nervous system. Select all that apply Which of the following patients would you expect to be at risk for decreased activity? Choose all that apply. 1) Older adult who walks at the mall for physical activity 2) Someone living in a skilled nursing facility 3) Healthy adult who works as a computer programmer 4) Obese child who enjoys video games 2, 3, 4 The person who lives in a skilled nursing facility might be sedentary because of advancing age and other age-associated medical problems that lead to inactivity. With obesity, movement becomes more difficult and strain on joints increases. A sedentary lifestyle, whether adult or child, contributes to obesity; activities, such as computer work and video games, are sedentary and require little physical activity. Physical activity doesnt have to be a structured fitness class but can also be walking, even walking in a mall or neighborhood, just as long as the intensity is moderately vigorous. Select all that apply A patient has started a fitness program. What program features illustrate that he has started a well-rounded program? 1) Flexibility 2) Isometric exercises 3) Resistance training 4) Aerobic conditioning 1, 3, 4 Flexibility training helps warm up the muscles and prevents injury during exercise. Resistance training increases muscular strength and endurance. Aerobic conditioning affects fitness and body composition. Isometric exercise is an active form of physical activity using opposing resistance where the joints dont move and muscles dont lengthen. Isometrics are done in static positions, rather than moving through a range of motion. Select all that apply The nurse is instructing a patient about the need to replace fluid before, during, and after exercise in order to avoid dehydration. She should teach the patient to determine the amount of fluid to consume on the basis of: 1) Duration of exercise. 2) Environmental temperature. 3) Level of fitness. 4) Degree of thirst. 1, 2 Lost fluids must be replaced to decrease the risk of dehydration, regardless of level of fitness. During intense exercise, the body can lose 2 liters of fluid for every hour of exercise. Elevated environmental temperatures also increase the amount of fluid lost through sweating. When athletes drink according to thirst, the risk that they will over-drink and so develop exercise-associated hyponatremia is minimized (Noakes, 2007). On the other hand, exercise can suppress thirst, making it an unreliable signal to replace fluids lost with exercise. Select all that apply Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Choose all that apply. 1) Stand with the body in alignment and erect posture. 2) Bend at the waist to lift heavy objects from the floor. 3) Use a wide base of support with your feet at shoulder width. 4) Keep objects close to your body when carrying them. 1, 3, 4 Proper body mechanics involves good body alignment, erect posture, and a wide base of support. To prevent back injury resulting from reaching and straining muscles, carry objects close to the trunk. Bending at the waist to lift objects uses the back muscles and increases the risk of injury. Instead, squat to lower your center of gravity, and use your leg muscles for lifting. What is the function of the stratum corneum? 1) Provides insulation for temperature regulation 2) Provides strength and elasticity to the skin 3) Protects the body against the entry of pathogens 4) Continually produces new skin cells 3--The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface. Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity. 2) Increase the risk of ischemia. 3) Delay wound healing. 4) Predispose to hematoma formation. 2--Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury. What is the primary difference between acute and chronic wounds? Chronic wounds: 1) Are full-thickness wounds, but acute wounds are superficial. 2) Result from pressure, but acute wounds result from surgery. 3) Are usually infected, whereas acute wounds are contaminated. 4) Exceed the typical healing time, but acute wounds heal readily. 4--The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? 1) Partial-thickness wound 2) Penetrating wound 3) Superficial wound 4) Full-thickness wound 1--Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1) Primary intention healing. 2) Secondary intention healing. 3) Tertiary intention healing. 4) Approximation healing. 2--Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges. When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? 1) The patient will need to take antibiotics until the wound is completely healed. 2) Because the patients wound was left open, the wound will likely become infected. 3) The patient will have more scar tissue formation than for a wound closed at surgery. 4) The patient should expect to remain hospitalized until complete wound healing occurs. 3--Because the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting. What is the primary goal that the nurse should establish for a patient with an open wound? 1) The wound will remain free of infection throughout the healing process. 2) Client completes antibiotic treatment as ordered. 3) The wound will remain free of scar tissue at healing. 4) Client increases caloric intake throughout the healing process. 1--Wounds healing by secondary intention are more prone to infection; therefore, the primary goal would be to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake. While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? 1) Sanguineous 2) Serosanguineous 3) Serous 4) Purosanguineous 2--Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged. Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incisional site 2) Dehiscence of the wound 3) Hematoma under the skin 4) Formation of granulation tissue 1--Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature). Which of the following describes the difference between dehiscence and evisceration? 1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. 3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. 4) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue. 1--With dehiscence there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: 1) begins an aggressive exercise program. 2) follows a diet plan of 1,200 calories per day. 3) is fitted for deep-depth diabetic footwear. 4) remains free of foot wounds. 4--Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know his plan of care is effective when the clients feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. Similarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal. Pressure ulcers are directly caused by which of the following conditions at the site? 1) Compromised blood flow 2) Edema 3) Shearing forces 4) Inadequate venous return 1--Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury. A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? 1) Stage II pressure ulcer 2) Stage III pressure ulcer 3) Stage IV pressure ulcer 4) Unstageable pressure ulcer 4--An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? 1) Stage I pressure ulcer, healing 2) Stage II pressure ulcer, healing 3) Stage III pressure ulcer, healing 4) Stage IV pressure ulcer, healing 4--Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing. A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1) Draw a circle around the area of drainage on a dressing. 2) Classify drainage as less or more than the previous drainage. 3) Weigh the patient at the same time each day on the same scale. 4) Weigh dressings before they are applied and after they are removed. 4--By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound, but it does not provide information how much fluid is draining. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer? 1) Antibiotic therapy for 2 weeks 2) Normal saline irrigation of the ulcer daily 3)Debridement to the left heel 4) Elevation of the left heel off the bed 4--Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patients left heel off the bed would relieve pressure to this area. Why is the information obtained from a swab culture of a wound limited? 1) A positive culture does not necessarily indicate infection, because chronic wounds are often colonized with bacteria. 2) A negative culture may not indicate infection, because chronic wounds are often colonized with bacteria. 3) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. 4) A swab culture result does not include bacterial sensitivity information necessary to provide treatment. 1--The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider. For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? 1) Client will maintain intact skin throughout hospitalization. 2) Client will limit pressure to wound site throughout treatment course. 3) Wound will close with no evidence of infection within 6 weeks. 4) Wound will improve prior to discharge as evidenced by a decrease in drainage. 3--The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer. A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? 1) Risk for Infection related to subcutaneous injuries 2) Risk for Impaired Skin Integrity related to immobility 3) Impaired Tissue Integrity related to ventilator dependency 4) Impaired Skin Integrity related to ventilator dependency 2--This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses. What intervention would be most appropriate for a wound with a beefy red wound bed? 1) Mechanical debridement 2) Autolytic debridement 3) Dressing to keep the wound moist and clean 4) Removal of devitalized tissue and a sterile dressing 3--A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment. Dbridement is not necessary in this situation because there is no devitalized tissue present. A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? 1) Dry gauze dressing changed twice daily 2) Nonadherent dressing with daily wound care 3) Hydrocolloid dressing changed as needed 4) Wet-to-dry dressings changed three times a day 3--A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic debridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical debridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well. The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: 1) The ulcer is completely healed with minimal scarring. 2) The patient reports no pain at the site. 3) A minimal amount of drainage is noted. 4) The wound bed contains 100% granulated tissue. 4--A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, and bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar. Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? 1) Alginate dressing 2) Dry gauze dressing 3) Hydrogel 4) Hydrocolloid dressing 1--Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin. Of the following, which is the best choice for performing wound irrigation? 1) Water jet irrigation 2) 35-cc syringe with a 19-gauge angiocatheter 3) 5-cc syringe with a 23-gauge needle 4) Bulb syringe 2--A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-cc syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound. Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: 1) Remove all of the soiled dressings before beginning wound treatment. 2) Cleanse wounds from most contaminated to least contaminated. 3) Treat wounds on the patients side first, then the front and back of the patient. 4) Irrigate wounds from least contaminated to most contaminated. 4--To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1) Steri-Strips 2) Abdominal binder 3) T-binder 4) Paper tape 2--An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be needed for an approximated incision that has intact staples, sutures, or surgical glue. A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) Transparent film dressing 2) Sheet hydrogel 3) Frequent turn schedule 4) Enzymatic debridement 3--The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic debridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure. When applying heat or cold therapy to a wound, what should the nurse do? 1) Leave the therapy on each area no longer than 15 minutes. 2) Leave the therapy on each area no longer than 30 minutes. 3) When using heat, ensure the temperature is at least 135F (57.2C) before applying it. 4) When using cold, ensure the temperature is less than 32F (0C) before applying it. 1--Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59F and 113F (15C and 45C), depending on the type of therapy chosen and what is comfortable to the patient. Temperatures colder or warmer than those recommended can damage tissue. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? 1) Primary intention 2) Regenerative healing 3) Secondary intention 4) Tertiary intention 4--Tertiary intention is a technique used when a wound is clean contaminated or dirty (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed. What is a common characteristic of aging skin? 1) Increased permeability to moisture 2) Diminished sweat gland activity 3) Reduced oxygen-free radicals 4) Overproduction of elastin 2--Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infants skin is thinner and more permeable to moisture in the environment. Which client does the nurse recognize as being at greatest risk for pressure ulcers? 1) Infant with skin excoriations in the diaper region 2) Young adult with diabetes in skeletal traction 3) Middle-aged adult with quadriplegia 4) Older adult requiring use of assistive device for ambulation 3--The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal. The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? Choose all that apply. 1) Is actively bleeding 2) Has swollen, tender insect bite 3) Has just sprained her ankle 4) Has