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010624198
D439 OA Remediation Step 1
During the administration of a warm tap-water enema, a patient starts to have
cramping abdominal pain that he rates a 6 out of 10. What nursing action should
the nurse take first?
@ Stop the installation.
2. Ask the patient to take deep breaths to decrease the pain.
3. Tell the patient to bear down as he would when having a bowel movement.
4. Continue the installation; then administer a pain medication.
Place the following steps for applying a wrist restraint in the correct order:
1. Pad the skin overlying the wrist. 3 W S ( o | 4
2. Insert two fingers under the secured restraint to be sure that it is not too
tight.
3. Be sure that the patient is comfortable and in correct anatomical alignment.
4. Secure restraint straps to bedframe with quick-release buckle.
5. Wrap limb restraint around wrist or ankle with soft part toward skin and
secure snugly.
Which skin-care measures are used to manage a patient who is experiencing
fecal and/or urinary incontinence? (Select all that apply.)
\@ Frequent position changes
2. Keeping the buttocks exposed to air at all times
3. Using a large absorbent diaper, changing when saturated
@ Using an incontinence cleaner
@ Applying a moisture barrier ointment
Match the pressure injury stages with the correct definition.
i fi 1. Stage 1
2. X 2. stage?2
, 3. D 3.Stage3 | .
4. U 4. Stages
5 _@_ 5. Unstageable pressure injury
a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink
or red, and moist, and may also present as an intact or ruptured serum-filled
blister. Adipose tissue (fat) and deeper tissues are not visible. Granulation tissue,
slough, and eschar are not present. These injuries commonly result from adverse
microclimate and shear in the skin over the pelvis and shear in the heel. This stage
should not be used to describe moisture-associated skin damage (MASD),
including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD),
medical adhesive—related skin injury (MARSI),or traumatic wounds (skin tears,
burns, abrasions). '
b. Intact skin with a localized area of nonblanchable erythema, which may appear
differently in darkly pigmented skin. Presence of blanchable erythema or changes
in sensation, temperature, or firmness may precede visual changes. Color changes
do not include purple or maroon discoloratio.r;‘;_,these may indicate deep-tissue
pressure injury.
c. Full-thickness skin and tissue loss with exposed or directly palpable fascia,
muscle, tendon, ligament, cartilage, or bone“‘fi}g;the ulcer. Slough and/or eschar
may be visible. Epibole (rolled edges), underm;"ping, and/or tunneling often
occurs. Depth varies by anatomical location. I'f;:élough or eschar obscures the
extent of tissue loss, this is an Unstageable pressure injury.
, d. Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer, and
granulation tissue and epibole (rolled wound edges) are often present. Slough
and/or eschar may be visible. The depth of tissue damage varies by anatomical
location; areas of significant adiposity can develop deep wounds. Undermining
and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are
not exposed. If slough or eschar obscures the extent of tissue loss, this is an
unstageable pressure injury.
e. Full-thickness skin and tissue loss in which the extent of tissue damage within
the injury cannot be confirmed because it is obscured by slough or eschar. If
slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.
Stable eschar (i.e., dry, adherent, intact, without erythema or fluctuance) on the
heel or ischemic limb should not be softened or removed.
Place the following steps for insertion of an indwelling catheter in a female
o S 0’1( 4! \ ‘ v, -31 % | q
patient in appropriate order.
Insert and advance catheter.
e
Lubricate catheter.
Inflate catheter balloon.
S
Cleanse urethral meatus with antiseptic solution.
Drape patient with the sterile square and fenestrated drapes.
A
When urine appears, advance another 2.5to 5 cm.
Prepare sterile field and supplies.
Gently pull the catheter until resistance is felt.
S
Attach drainage tubing.
Which nursing interventions should a nurse implement when removing an
indwelling urinary catheter in an adult patient? (Select all that apply.)
1. Attach a 3-mL syringe to the inflation port.
@ Allow the balloon to drain into the syringe by gravity.
@ Initiate a voiding record/bladder diary.
4. Pull the catheter quickly.
010624198
D439 OA Remediation Step 1
During the administration of a warm tap-water enema, a patient starts to have
cramping abdominal pain that he rates a 6 out of 10. What nursing action should
the nurse take first?
@ Stop the installation.
2. Ask the patient to take deep breaths to decrease the pain.
3. Tell the patient to bear down as he would when having a bowel movement.
4. Continue the installation; then administer a pain medication.
Place the following steps for applying a wrist restraint in the correct order:
1. Pad the skin overlying the wrist. 3 W S ( o | 4
2. Insert two fingers under the secured restraint to be sure that it is not too
tight.
3. Be sure that the patient is comfortable and in correct anatomical alignment.
4. Secure restraint straps to bedframe with quick-release buckle.
5. Wrap limb restraint around wrist or ankle with soft part toward skin and
secure snugly.
Which skin-care measures are used to manage a patient who is experiencing
fecal and/or urinary incontinence? (Select all that apply.)
\@ Frequent position changes
2. Keeping the buttocks exposed to air at all times
3. Using a large absorbent diaper, changing when saturated
@ Using an incontinence cleaner
@ Applying a moisture barrier ointment
Match the pressure injury stages with the correct definition.
i fi 1. Stage 1
2. X 2. stage?2
, 3. D 3.Stage3 | .
4. U 4. Stages
5 _@_ 5. Unstageable pressure injury
a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink
or red, and moist, and may also present as an intact or ruptured serum-filled
blister. Adipose tissue (fat) and deeper tissues are not visible. Granulation tissue,
slough, and eschar are not present. These injuries commonly result from adverse
microclimate and shear in the skin over the pelvis and shear in the heel. This stage
should not be used to describe moisture-associated skin damage (MASD),
including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD),
medical adhesive—related skin injury (MARSI),or traumatic wounds (skin tears,
burns, abrasions). '
b. Intact skin with a localized area of nonblanchable erythema, which may appear
differently in darkly pigmented skin. Presence of blanchable erythema or changes
in sensation, temperature, or firmness may precede visual changes. Color changes
do not include purple or maroon discoloratio.r;‘;_,these may indicate deep-tissue
pressure injury.
c. Full-thickness skin and tissue loss with exposed or directly palpable fascia,
muscle, tendon, ligament, cartilage, or bone“‘fi}g;the ulcer. Slough and/or eschar
may be visible. Epibole (rolled edges), underm;"ping, and/or tunneling often
occurs. Depth varies by anatomical location. I'f;:élough or eschar obscures the
extent of tissue loss, this is an Unstageable pressure injury.
, d. Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer, and
granulation tissue and epibole (rolled wound edges) are often present. Slough
and/or eschar may be visible. The depth of tissue damage varies by anatomical
location; areas of significant adiposity can develop deep wounds. Undermining
and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are
not exposed. If slough or eschar obscures the extent of tissue loss, this is an
unstageable pressure injury.
e. Full-thickness skin and tissue loss in which the extent of tissue damage within
the injury cannot be confirmed because it is obscured by slough or eschar. If
slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.
Stable eschar (i.e., dry, adherent, intact, without erythema or fluctuance) on the
heel or ischemic limb should not be softened or removed.
Place the following steps for insertion of an indwelling catheter in a female
o S 0’1( 4! \ ‘ v, -31 % | q
patient in appropriate order.
Insert and advance catheter.
e
Lubricate catheter.
Inflate catheter balloon.
S
Cleanse urethral meatus with antiseptic solution.
Drape patient with the sterile square and fenestrated drapes.
A
When urine appears, advance another 2.5to 5 cm.
Prepare sterile field and supplies.
Gently pull the catheter until resistance is felt.
S
Attach drainage tubing.
Which nursing interventions should a nurse implement when removing an
indwelling urinary catheter in an adult patient? (Select all that apply.)
1. Attach a 3-mL syringe to the inflation port.
@ Allow the balloon to drain into the syringe by gravity.
@ Initiate a voiding record/bladder diary.
4. Pull the catheter quickly.
