Medical-Surgical Nursing Study Guide Questions with verified solutions already graded a+

The nurse sees in the patient's record that the patient has a Braden score of 20. Which nursing action is the nurse most likely to perform in the care of this patient? Continue routine assessments A thin, malnourished patient requires emergency abdominal surgery. After the surgery, in order to promote wound healing, what does the nurse encourage? High-quality protein diet Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:00 Full screen The nurse is directing the home health unlicensed assistive personnel (UAP) in the care of an older adult patient. The patient reports dry skin and wants help in applying an emollient cream. What does the nurse direct the UAP to do? Assist the patient to soak for 10 minutes in a warm bath and then apply the cream to slightly damp skin within 2 to 3 minutes after bathing Which patients are at risk for pressure ulcers? -A middle-aged quadriplegic patient who is alert and conversant -A bedridden patient who is in the late stage of Alzheimer's -A very overweight patient who must be assisted to move in the bed -A thin patient who sits for longer period and refuses meals The nurse is caring for an obese patient who has been on bedrest for several days. The nurse observes that the patient is beginning to develop redness on the sacral area. What intervention is used to decrease the shearing force? Place the patient in a side-lying position The nurse is reviewing the results of a pressure mapping on patient at high risk for pressure ulcers. The map shows a red area over the hips. How does the nurse interpret this evidence? Greater heat production associated with greater pressure The nurse is assessing the nutritional status of a patient at risk for skin breakdown who has been refusing to eat the hospital food. Which indicator is the most sensitive in identifying inadequate nutrition for this patient? Prealbumin level of 17.5 mg/dL Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the center of the are and see that the area blanches with pressure. The nurse interprets this finding as changes related to which factor? Blood vessel dilation The nurse is assessing a wound on a patient's abdomen. What is the correct technique? Assess the wound as a clock face with 12 o'clock towards the patient's head and 6 o'cock towards the patient's feet The nurse is assessing a patient's wound every day for signs of healing or infection. Which finding is a positive indication that healing is progressing as expected? Area appears pale pink, progressing to a spongy texture with a beefy red color The nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small opening in the skin with purulent drainage. Which technique does the nurse use to check for tunneling? Use a sterile cotton-tipped applicator to probe gently for a tunnel The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the coccyx with skin intact. These findings suggest which stage of a pressure ulcer? Suspected deep tissue injury When developing a plan of care for a patient who is at high risk for skin breakdown, what does the nurse include in the plan of care? -Applying a pressure reduction overlay to the mattress -Frequent repositioning of the patient -Using positioning devices to keep heels pressure-free Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral decubitus ulcer? Wound will show granulation and decrease in size A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for what potential complication? Bleeding Which class of medication would exclude a patient from participating in NPWT? Anticoagulants A patient on the unit has herpes zoster. Which staff members would be the best to assign to the care of this patient? Staff members who have had chicken pox A mother reports that her child has dry skin with itching that seems to worsen at night. What nonpharmacologic interventions does the nurse teach to the mother? -Keep the child's fingernails short and filed to reduce skin damage -Place mittens or splints on the child's hands at night if the scratching is causing skin tears -Read the child a relaxing and familiar story to reduce stress The health care provider recommended over-the-counter Benadryl to treat the patient's hives. What does the nurse suggest to the patient for self-care? Avoid alcohol consumption, which can potentiate the sedative effect of Benadryl In order to assist the health care provider in determining if avoidance therapy is appropriate for the patient, which question would the nurse ask? Have you used any new soaps, detergents, or personal care products? The nurse is teaching a patient about self-care for a minor bacterial skin infection. What is the most important aspect the nurse emphasizes? Bathe daily with an antibacterial soap What does the treatment for psoriasis include? -Ultravoilet light therapy -Calcipotriene (Dovonex) topical cream -Topical methotrexate (Folex) Corticosteroids The health care provider informs the nurse that the patient is having severe pruritus. Based on this information, the nurse is most likely to observe which assessment findings? Excoriations from scratching The nurse is teaching an older adult about how to deal with and prevent dry skin. What information does the nurse include? -Use a room humidifier during the winter months or whenever the furnace is in use -Avoid clothing that continuously rubs the skin, such as tight belts or pantyhose -Thoroughly rinse soap from skin The nurse is giving discharge instructions to a patient and family who must continue dressing changes and wound care at home. Which point does the nurse emphasize to help the family prevent infection and minimize cost? Scrupulous handwashing before and after wound care A patient has been prescribed acetretin (Soriatane) for psoriasis. What information foes the nurse tell the patient about this drug? Strict birth control measures are necessary A patient is prescribed a topical steroid for treatment of contact dermatitis. Which instruction does the nurse provide to the patient about this drug? Moisten dressings with warm tap water' place over topical steroids for short periods Which statement is true about the application and use of topical preparations? Using an oil-based ointment in the axillary area could cause folliculitis A patient has a partial-thickness wound. How long does the nurse anticipate the healing by epithelilization will take? 5-7 days The nurse is performing daily wound care and dressing changes on a patient with a full-thickness wound. The patient protests when the nurse attempts to debride the wound. What is the nurse's best response? "Harmful bacteria can grow in the dead tissue and it also interferes with the body's attempt to fill in the wound with new cells and collagen." A patient has a stage III pressure ulcer over the left trochanter that has a thick exudate. The wound bed is visible and beefy red, and the edges are surrounded with swollen pink tissue. The exudate has an odor. How does the nurse determine which dressing is best for this wound? Obtains an order to consult certified wound care specialist The nurse is caring for a patient with arterial insufficiency in the lower right leg. In order to prevent leg ulcers, what does the nurse do? Places the leg in a dependent position The nurse is caring for several patients who are incontinent of stool and urine. Which task is delegated to the UAP? Wash the skin with a pH-balanced soap to maintain normal acidity The nurse is caring for a patient in a prolonged coma after a serious head injury. The nurse uses which interventions to prevent the development of pressure ulcers for this patient? -Use pillows or padding devices to keep heels pressure-free -Delegate turning and positioning every 2 hours -Obtain an order for pressure-relief devices The nurse is assessing a patient's skin and observes a superficial infection with a raised, red, rash with small pustules. How does the nurse interpret this finding? Folliculitis The nurse hears in report that a patient admitted for elective surgery also has herpes zoster. The nurse initiates contact isolation for which factor? Lesions are present as fluid-filled blisters A patient reported painless, raised vesicles that itched. Within a few days, there was bleeding in the center and then it sank inwards. Now it looks black and leathery. Which question does the nurse ask in order to elicit more informtion about the patient's condition? "Do you work with or around animals?" A patient is diagnosed with chronic plaque psoriasis and is prescribed a topical therapy of anthralin (Lasan). What does the nurse teach the patient about proper use of this drug? Check for local tissue reaction