FUNDS 2 FINAL Exam Questions and Answers

The nurse clarifies that the first stage of wound healing is: - inflammation. (Inflammation is the first stage of wound healing, followed by the proliferation, maturation, and reconstruction stages) The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by _____ intention. - first (A wound with minimal tissue loss, such as a surgical incision, heals by closure, which is first, or primary, intention. Wounds that are not closed heal by either second (secondary) or third (tertiary) intention.) The nurse gives an example of a wound that heals by second (secondary) intention as a: - laceration with edges that do not approximate. (A secondary intention healing occurs when there is a jagged wound whose edges do not approximate.) When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurses most helpful response would be that swelling indicates that: - vessels have dilated and allowed plasma to leak into the wound site. (As part of the healing process, histamines and prostaglandins have caused small vessels to dilate and leak plasma and electrolytes into the wound site causing swelling, which causes the wound to become reddened and swollen as the phagocytosis cleans up the microorganisms.) . The nurse warns the patient that one of the patients habits has caused the reduction of functional hemoglobin, which limits the hemoglobins oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit: - smoking cigarettes. (Smoking reduces the functional hemoglobin which, in turn, reduces the amount of oxygen carried to the cells of the body.) A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by _____ blood pressure. - restlessness, rising pulse, and falling The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by: - increased serosanguineous drainage from the wound. A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, I think something just let go. The initial intervention by the nurse should be to: - assist the patient in a supine position. A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she: - uses one alcohol wipe to clean both the spout and the plug. The nurse chooses a nonadherent dressing to apply to a wound because the nonadherent dressing: - allows drainage to seep through the barrier and be absorbed on the other side. . Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use: - Montgomery straps. A nurse caring for a patient with a stage I pressure ulcer would most appropriately select a(n) _____ dressing. - thin film (Thin film dressings are used on stage I ulcers to protect them from shearing forces and to keep them moist.) A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a(n): - hematoma. (A hematoma is a pooling of blood under unbroken skin. An abrasion is a scraping away of skin tissue. A laceration is a torn, ragged, or mangled wound, and a an avulsion refers to something being torn away) The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean: - in a circular motion around the wound circling to the outside. (A circular motion around the wound toward the outside keeps the wound area cleanest) A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing? - From each of the four sides toward the wound (The tape should be removed by pulling it off toward the wound. This helps prevent disruption of the wound.) A nurse explains that the major purpose of the use of a hydrocolloid dressing is to: - occlude air and promote breakdown of necrotic tissue. (Hydrocolloid dressings are air-occlusive dressings used on noninfected wounds that provide a moist environment for wound healing. They can be left in place for up to 7 days.) The nurse changing a wet-to-damp normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurses most beneficial intervention would be to: - add normal saline to loosen it. (If the dressing sticks to the wound, normal saline should be added to loosen it. Pulling loose a stuck dressing damages new tissue. Leaving it in place does not promote a clean wound. Povidone-iodine must be ordered.) A nurse performing a right eye irrigation will position the patient: - supine with the head tilted toward the right eye. (The patient should be positioned supine with the head tilted toward the affected eye. This position allows the irrigation solution to drain away from the eye and not contaminate the other eye.) A nurse removing wound staples would engage the staple puller and squeeze the handles completely and: - pull outward. (The handles should be squeezed together all the way. This depresses the center of the staple and allows it to be lifted outward from the skin.) The nurse clarifies that a vacuum-assisted closure supports healing of a wound by: - drawing the wound edges together by negative pressure. (A vacuum-assisted dressing that is accomplished by a special dressing and vacuum device applies negative pressure to the wound, which increases blood flow, increases oxygenation, and improves the delivery of nutrients to the wound.) The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the: - heel. (Debridement is not recommended for treatment of a pressure ulcer on the heel because of the small amount of tissue available at that site.) The nurse places Dakins solution in a wound to accomplish chemical ___________. - debridement (Dakins solution is placed in a wound to destroy the necrotic tissue so that granulation tissue can form to heal the wound (debridement).) The nurse assesses the large raised scar on the African-American patient. The nurse documents the lesion as a ___________. - keloid (Keloids are large raised permanent scars resulting from colloid overgrowth that are seen most frequently on darkly pigmented skin.) The nurse explains to the patient that the foot will be submerged in warm water for a maximum of ______ minutes. - 20 Twenty (Warm soaks that involve submerging the limb should only last for 15 to 20 minutes.) The nurse is concerned about an HIV immunocompromised patients ability to heal because of the lack of: (Select all that apply.) - B) adequate fibroblast function. C) synthesis of collagen. E) adequate phagocytosis. The nurse recognizes that of the drugs a patient is currently taking, several contribute to delayed healing, such as: (Select all that apply.) - B) antineoplastic drugs. D) heparin. E) steroids. The nurse reminds the 85-year-old patient that his healing will be slower because of age- related changes such as: (Select all that apply.) - B) atherosclerosis. C) diminished lung function. D) slow metabolism. e nurse irrigating an infected wound of the hand would: (Prioritize the steps. Separate the letters by a comma and a space as follows: A, B, C, D, E, F, G.) - A. Open sterile irrigation basin and solution. C. Pour irrigating solution in basin. G. Place pad under the infected hand. B. Don sterile gloves to apply dressing. D. Irrigate keeping the syringe tip 1 inch from the wound surface. F. Pat wound dry and redress. E. Document procedure. The nurse uses a diagram to show that when the diaphragm moves: a. up, the increased negative pressure in the thoracic space forces air into the lungs. b. down, the intercostal muscles retract, forcing air out of the lungs. c. down, the negative pressure in the thoracic space pulls air into the lungs. d. up, the decreased negative pressure allows air to enter the lungs. - down, the negative pressure in the thoracic space pulls air into the lungs The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is: a. hypoxia. b. hypercapnia. c. dyspnea. d. hypoxemia. - hypoxemia. The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned: a. halfway between the xiphoid process and the umbilicus. b. directly over the sternum. c. between the umbilicus and the symphysis pubis. d. directly over the umbilicus. - patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned: A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to: a. position the fingers over the carotid artery to feel for a pulse. b. tilt the head by placing one hand on the forehead and lift the chin. c. call for help or, if there is assistance, have that person get help. d. deliver two quick short breaths into the patient's airway. - call for help or, if there is assistance, have that person get help. The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in: a. one deep breath and quickly exhale. b. two breaths and force the air out quickly. c. two deep breaths, then inhale deeply again and force out the air quickly. d. one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open. - two deep breaths, then inhale deeply again and force out the air quickly. The nurse is aware that the best time to schedule a postural drainage treatment is: a. shortly after the patient arises in the morning, before breakfast. b. in the morning immediately after breakfast. c. 30 minutes after lunch. d. 1 hour after supper - shortly after the patient arises in the morning, before breakfast. A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup? a. High oxygen flow rate b.A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup? a. High oxygen flow rate b. A humidifier c. A Venturi mask d. A nasal cannula - A humidifier A patient has a history of chronic obstructive pulmonary disease. The patient's oxygen flow rate should be set to no more than: a. 5 to 10 L/min. b. 4 to 5 L/min. c. 2 to 3 L/min. d. 1 to 2 L/min - 2 to 3 L/min. The nurse loosens mucus plugs by using percussion on a patient over the area of the: a. sternum. b. thorax. c. spine between the scapulae. d. midaxillary line on the rib cage. - Thorax A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this? a. A simple face mask b. A nonrebreather mask c. A partial rebreathing mask d. A Venturi mask - A Venturi mask The nurse recognizes that a postoperative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefitted by a(n): a. pharyngeal airway. b. endotracheal tube. c. tracheostomy. d. partial rebreather oxygen mask. - . pharyngeal airway. A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between: a. 25 and 50 mm Hg. b. 50 and 75 mm Hg. c. 80 and 120 mm Hg. d. 120 and 180 mm Hg - 80 and 120 mm Hg. A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by: a. monitoring the rate of respirations. b. determining the last time the patient was suctioned. c. examining the character of the sputum. d. auscultating the breath sounds. - auscultating the breath sounds. A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should: a. apply suction while advancing the catheter into the airway. b. suction the nasotracheal passage after suctioning the mouth. c. hold the catheter with the dominant hand after donning sterile gloves. d. insert the nonlubricated catheter into the nasal passage - hold the catheter with the dominant hand after donning sterile gloves. The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should: a. be administered extra oxygen. b. have the pharynx suctioned. c. have the cuff pressure checked. d. be monitored for respiratory rate. - have the pharynx suctioned. The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include: a. using clothing of synthetic cloth for the patient. b. removing any adhesive from the patient's skin with acetone. c. assessing equipment in room for frayed cords. d. reducing humidification on the oxygen delivery device. - assessing equipment in room for frayed cords. A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should: a. immediately turn the patient to the side of the insertion site. b. check for air leaks in drainage system. c. document findings. d. clamp the chest tube and place the patient in high Fowler's position. - document findings. A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least: a. 500 to 1000 mL/day. b. 1000 to 1500 mL/day. c. 1500 to 2000 mL/day. d. 2500 to 3000 mL/day - 1500 to 2000 mL/day. The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient: a. took 10 slow, deep breaths every hour. b. took five quick "huffs" and then coughed vigorously. c. exhaled deeply and then inhaled quickly and forcefully three times. d. took five deep breaths slowly every 4 hours. - took 10 slow, deep breaths every hour. The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is: a. semi-Fowler's position with a single pillow behind the head. b. high Fowler's position without a pillow behind the head. c. right lateral with the head of the bed elevated 45 degrees. d. sitting upright and forward with arms supported on an over the bed table. - sitting upright and forward with arms supported on an over the bed table. The nurse performing tracheotomy care will: a. raise the head of the bed to high Fowler's position. b. remove the inner cannula with the ungloved hand. c. suction tracheotomy before beginning care. d. clean cannula with gauze and replace and lock - suction tracheotomy before beginning care The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by: a. taping all connections within the system. b. keeping the system at the level of the patient's chest. c. turning on suction to 35 cm. d. looping the tubing between the mattress and the bed rail to minimize length. - taping all connections within the system. The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is: a. dark skinned. b. jaundiced. c. obese. d. febrile. - jaundiced The nurse clarifies that the cough mechanism is stimulated when: a. foreign substances are propelled by the cilia toward the respiratory tract. b. dehumidified air enters the upper airway passages. c. more than 250 mL of air moves in and out of the lungs with each breath. d. the blood transports carbon dioxide to the lungs - foreign substances are propelled by the cilia toward the respiratory tract. When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration. This finding is documented as: a. apnea. b. dyspnea. c. stridor. d. retractions. - stridor. When a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (Select all that apply.) a. use sterile gloves during suctioning. b. avoid going to crowded theaters and malls. c. change catheters every 8 hours. d. keep the home environment free of dust. e. use bleach to clean suction equipment. - B,C,D,E The nurse is aware that changes occur in the respiratory system after the age of 70 that put the older adult more at risk for respiratory problems. These changes include: (Select all that apply.) a. decreased oxygen saturation. b. increased elasticity in thorax and respiratory tissues. c. incomplete expirations. d. thinning of alveolar membrane. e. impaired cilia. - A,C,E The multiple causes for hypoxia include: (Select all that apply.) a. extreme fright. b. aspirated vomit. c. pulmonary fibrosis. d. hiccoughs. e. high altitude. - B,C,E