Adult & Elder Exam 2 - Textbook Questions \| \| \| \| \| \| \| \|
with answers \|
A nurse who is changing dressings of postoperative patients in the hospital
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documents various phases of wound healing on the patient charts. Which
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statements accurately describe these stages? Select all that apply.
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a) Hemostasis occurs immediately after the initial injury.
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b.) A liquid called exudate is formed during the proliferation phase.
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c.) White blood cells move to the wound in the inflammatory phase.
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d.) Granulation tissue forms in the inflammatory phase.
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e.) During the inflammatory phase, the patient has generalized body response.
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f.) A scar forms during the proliferation phase. - CORRECT ANSWERS
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✔✔A,C,E
A nurse is developing a care plan for an 86-year-old patient who has been
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admitted for right hip arthroplasty (hip replacement). Which assessment
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finding(s) indicate a high risk for pressure injury development for this
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patient? Select all that apply.\| \| \| \|
a.) The patient takes time to think about responses to questions.
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b.) The patient is 86 years old.
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c.) The patient reports inability to control urine.
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,d.) The patient is scheduled for a hip arthroplasty.
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e.) Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and
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creatinine 0.9 (adult female normal 0.61 to 1 mg/dL).
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f.) The patient reports increased pain in right hip when repositioning in bed
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or chair. - CORRECT ANSWERS ✔✔B, C, D, F
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The nurse uses the RYB wound classification system to assess the wound of a
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patient whose arm was cut on a factory machine. The nurse documents the
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wound as "red." What would be the priority nursing intervention for this type
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of wound?
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a.) Irrigate the wound.
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b.) Provide gentle cleansing of the wound.
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c.) Debride the wound.
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d.) Change the dressing frequently. - CORRECT ANSWERS ✔✔B
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A nurse is developing a care plan related to prevention of pressure injuries for
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residents in a long-term care facility. Which action accurately describes a
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priority intervention in preventing a patient from developing a pressure
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injury?
a.) Keeping the head of the bed elevated as often as possible
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b.) Massaging over bony prominences
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c.) Repositioning bed-bound patients every 4 hours
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d.) Using a mild cleansing agent when cleansing the skin - CORRECT
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ANSWERS ✔✔D \|
, A nurse administers a dose of an oral medication for hypertension to a patient
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who immediately vomits after swallowing the pill. What would be the
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appropriate initial action of the nurse in this situation? \| \| \| \| \| \| \| \|
a.) Readminister the medication and notify the primary care provider.
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b.) Readminister the pill in a liquid form if possible.
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c.) Assess the vomit, looking for the pill.
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d.) Notify the primary care provider. - CORRECT ANSWERS ✔✔C
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A nurse is administering phenytoin via a gastric tube to a patient who is
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receiving tube feedings. What would be an appropriate action of the nurse in
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this situation? \|
a.) Discontinue the tube feeding and leave the tube clamped for required
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period of time before and after medication administration.
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b.) Notify the primary care provider that medication cannot be given to the
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patient at this time via the gastric tube.
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c.) Remove the tube in place and replace it with another tube prior to
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administering the medication. \| \|
d.) Flush the tube with 60 mL of water prior to administering the medication. -
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CORRECT ANSWERS ✔✔A
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A nurse who is administering medications to patients in an acute care setting
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studies the pharmacokinetics of the drugs being administered. Which
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with answers \|
A nurse who is changing dressings of postoperative patients in the hospital
\| \| \| \| \| \| \| \| \| \| \| \|
documents various phases of wound healing on the patient charts. Which
\| \| \| \| \| \| \| \| \| \| \|
statements accurately describe these stages? Select all that apply.
\| \| \| \| \| \| \| \|
a) Hemostasis occurs immediately after the initial injury.
\| \| \| \| \| \| \|
b.) A liquid called exudate is formed during the proliferation phase.
\| \| \| \| \| \| \| \| \| \|
c.) White blood cells move to the wound in the inflammatory phase.
\| \| \| \| \| \| \| \| \| \| \|
d.) Granulation tissue forms in the inflammatory phase.
\| \| \| \| \| \| \|
e.) During the inflammatory phase, the patient has generalized body response.
\| \| \| \| \| \| \| \| \| \|
f.) A scar forms during the proliferation phase. - CORRECT ANSWERS
\| \| \| \| \| \| \| \| \| \| \|
✔✔A,C,E
A nurse is developing a care plan for an 86-year-old patient who has been
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
admitted for right hip arthroplasty (hip replacement). Which assessment
\| \| \| \| \| \| \| \| \|
finding(s) indicate a high risk for pressure injury development for this
\| \| \| \| \| \| \| \| \| \| \|
patient? Select all that apply.\| \| \| \|
a.) The patient takes time to think about responses to questions.
\| \| \| \| \| \| \| \| \| \|
b.) The patient is 86 years old.
\| \| \| \| \| \|
c.) The patient reports inability to control urine.
\| \| \| \| \| \| \|
,d.) The patient is scheduled for a hip arthroplasty.
\| \| \| \| \| \| \| \|
e.) Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
creatinine 0.9 (adult female normal 0.61 to 1 mg/dL).
\| \| \| \| \| \| \| \|
f.) The patient reports increased pain in right hip when repositioning in bed
\| \| \| \| \| \| \| \| \| \| \| \| \|
or chair. - CORRECT ANSWERS ✔✔B, C, D, F
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The nurse uses the RYB wound classification system to assess the wound of a
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
patient whose arm was cut on a factory machine. The nurse documents the
\| \| \| \| \| \| \| \| \| \| \| \| \|
wound as "red." What would be the priority nursing intervention for this type
\| \| \| \| \| \| \| \| \| \| \| \| \|
of wound?
\|
a.) Irrigate the wound.
\| \| \|
b.) Provide gentle cleansing of the wound.
\| \| \| \| \| \|
c.) Debride the wound.
\| \| \|
d.) Change the dressing frequently. - CORRECT ANSWERS ✔✔B
\| \| \| \| \| \| \| \|
A nurse is developing a care plan related to prevention of pressure injuries for
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
residents in a long-term care facility. Which action accurately describes a
\| \| \| \| \| \| \| \| \| \| \|
priority intervention in preventing a patient from developing a pressure
\| \| \| \| \| \| \| \| \| \|
injury?
a.) Keeping the head of the bed elevated as often as possible
\| \| \| \| \| \| \| \| \| \| \|
b.) Massaging over bony prominences
\| \| \| \|
c.) Repositioning bed-bound patients every 4 hours
\| \| \| \| \| \|
d.) Using a mild cleansing agent when cleansing the skin - CORRECT
\| \| \| \| \| \| \| \| \| \| \| \|
ANSWERS ✔✔D \|
, A nurse administers a dose of an oral medication for hypertension to a patient
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
who immediately vomits after swallowing the pill. What would be the
\| \| \| \| \| \| \| \| \| \| \|
appropriate initial action of the nurse in this situation? \| \| \| \| \| \| \| \|
a.) Readminister the medication and notify the primary care provider.
\| \| \| \| \| \| \| \| \|
b.) Readminister the pill in a liquid form if possible.
\| \| \| \| \| \| \| \| \|
c.) Assess the vomit, looking for the pill.
\| \| \| \| \| \| \|
d.) Notify the primary care provider. - CORRECT ANSWERS ✔✔C
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A nurse is administering phenytoin via a gastric tube to a patient who is
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
receiving tube feedings. What would be an appropriate action of the nurse in
\| \| \| \| \| \| \| \| \| \| \| \| \|
this situation? \|
a.) Discontinue the tube feeding and leave the tube clamped for required
\| \| \| \| \| \| \| \| \| \| \| \|
period of time before and after medication administration.
\| \| \| \| \| \| \|
b.) Notify the primary care provider that medication cannot be given to the
\| \| \| \| \| \| \| \| \| \| \| \| \|
patient at this time via the gastric tube.
\| \| \| \| \| \| \|
c.) Remove the tube in place and replace it with another tube prior to
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
administering the medication. \| \|
d.) Flush the tube with 60 mL of water prior to administering the medication. -
\| \| \| \| \| \| \| \| \| \| \| \| \| \|
CORRECT ANSWERS ✔✔A
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A nurse who is administering medications to patients in an acute care setting
\| \| \| \| \| \| \| \| \| \| \| \| \|
studies the pharmacokinetics of the drugs being administered. Which
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