NURSE 420 Leadership_Proctored_Summary_2 | NURSE420 Leadership_Proctored_Summary_A Grade

NURSE 420 Leadership_Proctored_Summary_2 - West Coast University LEADERSHIP : 2016 Version : 1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure . Which of the following findings indicate wound healing a . Erythema on the skin surrounding a client's wound b . Deep red color on the center of the clients wound C. Inflammation noted on the tissue edges of a client's wound d . Increase in serosanguineous exudate from the clients wound ( damaged capillaries in Rationale : Leadership 7.0 pg 329 : • Stages of Wound Healing • Inflammatory stage - beginning stage , also usually suggests infection - Begins with the injury and lasts 3 to 6 days - Effects to the wound : controlling bleeding with vasoconstriction and retraction of blood vessels , and with clot formation . Delivering oxygen , WBCs , nutrients to the area via blood supply . Hemostasis occurs along with fibrin formation . Macrophages engulf microorganisms and cellular debris ( phagocytosis ) . • Proliferative stage - Lasts the next 3 to 24 days - Effects to the wound : replacing lost tissue with connective or granulated issue or collagen . Contracting the wound's edges . Resurfacing of new epithelial cells . Healthy granulation tissue does not bleed easily . Dark granulation tissue can be a sign of - - - - - - - - - - - - - proliferative stage of wound healing , epithelial cells resurface the injury . • Maturation or remodeling stage • Occurs after day 21 and involves that strengthening of the collagen scar and restoration of a more normal appearance . It can take more than 1 year to complete , depending on the extent of the original wound . When scar tissues are forming . Appearance : Note the color of open wounds . Red : healthy regeneration of tissue . Yellow : presence of purulent drainage and slough Black : presence of eschar that hinders healing and requires removal . a . 2. A nurse received change of shift report at 0700 for four clients . Which of the following actions should the nurse perform first ? Obtain a breakfast tray for a client who received a morning dose of insulin aspart . - ( fast - acting insulin ... usually takes effect after 15 minutes ) b . Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400 . C. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 d . Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours 3. A nurse is orienting a newly licensed nurse on the neurological unit . Which of the following clients should the nurse assign to the newly licensed nurse ? a . A client who has multiple sclerosis and ataxia - ( normal finding for someone that has multiple sclerosis = most stable - showed up on online practice tests ) - - -- - - - - - -- - - - b . A dient who has brain tumor and is admitted for chemotherapy dead C. A client who has guillain - barre syndrome and a tracheostomy unstable d . A client who sustained a concussion and is being monitored for complication -unstable a . C. 4. A nurse is providing teaching to a client about advance directives . Which of the following statements by the client indicates an understanding of the teaching ? " Once I sign my living will , a family member must co - sign it b . " I will wait until I have a serious health problems to sign my advance directives " " My doctor will need to provide approval for the decisions outlines in my living will d . " My durable power of attorney for health care is part of my advance directives " -durable power of will and living will are components of advance directives . Rationale : Leadership 7.0 page 38 5. A nurse is chairing a committee about preventing infant abduction in a new birth care center . Which of the following quality control tasks should the nurse assign to be completed first ? a Identify the industry standards for infant safety b Evaluate the selected infant safety system C Choose an infant safety system d . Establish measurement criteria for infant safety systems 6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals . The nurse plans to perform dysphagia - - - - - - - - - - - -- - - - - - - - Continued