Excelsior-Health Safety (Old Nc 1)

Front 1

Which condition causes pallor and mottling of the skin in a patient who is immobile?

Back 1

tissue ischemia

Front 2

Inflammation from a soft tissue injury causes pain due to tissue edema and the release of which substance?

Back 2

histamine

Front 3

The nurse evaluates an open wound and notes pinkish-red granulation tissue in the wound. What does this finding indicate?

Back 3

normal healing process

Front 4

A patient who has stage 1 pressure ulcers on both heels is scheduled for surgery. Which nursing action should be included in the preoperative plan of care?

Back 4

apply film drsg to area

Front 5

The nurse is planning care for a patient who is having problems with wound healing. It is most important for this patient to adhere to a diet that is high in which vitamin?

Back 5

Vit C

Front 6

Which factor will increase the risk of dehiscence of an abdominal wound?

Back 6

coughing

Front 7

Which is an example of artificial, active immunity?

Back 7

Antibodies are
produced after vaccination with an antigen

Front 8

The nurse inspects a patient's skin and notes clusters of round, elevated lesions filled with clear fluid on the right side of the trunk. Which type of lesion does the patient have?

Back 8

vesicles

Front 9

The nurse notes yellow pigmentation in the sclera of a dark-skinned patient. What action should the nurse take next?

Back 9

inspect the pt’s hard palate

Front 10

A patient who exhibits poor skin turgor is showing signs of which problem?

Back 10

dehydration

Front 11

Which response represents the loss of a normal body defense mechanism for preventing infection?

Back 11

decreased number of cilia in the respiratory tract related to smoking

Front 12

The nurse has been changing a patient's postoperative dressings for several days. Which evidence would be most indicative that a wound infection is developing?

Back 12

suppuration at the site of healing

Front 13

Which action should take priority when the nurse comes into contact with a patient's blood?

Back 13

cleanse the exposed area with soap and water

Front 14

A patient's nursing diagnosis is impaired skin integrity related to pressure. Which nursing action is essential to promote healing?

Back 14

provide high protein foods in the diet

Front 15

Why is heat applied to an area of inflammation?

Back 15

to promote vasodilation and increase cellular nutrition

Front 16

Which manifestations are indicative of systemic postoperative infection?

Back 16

lymph node enlargement and lack of appetite

Front 17

Which finding would indicate that a patient is susceptible to infection?

Back 17

decreased WBCs

Front 18

Which assessment data suggests that a patient is at risk for infection?

Back 18

has an indwelling catheter in place

Front 19

Which action by the nurse demonstrates adherence to the principle of surgical asepsis?

Back 19

holds wet forceps with tips below the handles

Front 20

Which data supports the nursing diagnosis of impaired skin integrity?

Back 20

excoriation under the breasts

Front 21

A patient with an intravenous line in place is confused and begins pulling on the IV line. The physician orders arm restraints. Which action should the nurse take?

Back 21

release the restraints Q2H

Front 22

What is the purpose of a three-pronged plug on the electric cord to a medical device?

Back 22

to direct stray electric current to the ground

Front 23

Induction of emesis with syrup of ipecac is indicated following the ingestion of which substance?

Back 23

insecticide

Front 24

The nurse is caring for an older adult patient who is disoriented and frequently attempts to climb out of bed. Which measure should the nurse implement to best protect the patient?

Back 24

Keep the bed at the lowest level possible.

Front 25

Which assessment finding indicates that a hospitalized patient is at risk for physical injury?

Back 25

weak right hand grasp

Front 26

A patient receives an electric shock, yet remains alert and oriented. Which action should the nurse carry out first?

Back 26

Take vital signs.

Front 27

Which represents a potential hazard in a home with an infant?

Back 27

presence of school-age siblings who play with dolls or action figures

Front 28

When carbon monoxide is released in the environment, which physiological reaction occurs?

Back 28

The carbon monoxide
binds with hemoglobin preventing oxyhemoglobin formation.

Front 29

When instructing a patient about the use of a walker for ambulation, the nurse should include which instruction?

Back 29

Wear properly fitted nonskid shoes.

Front 30

On admission, why should the nurse document a patient's risk for falling?

Back 30

to provide a basis for prevention strategies

Front 31

The nurse is assessing a patient's condition when the patient states, "I get so dizzy when I first get up in the morning, the room just spins." Which accurately describes the cause of the patient's condition?

Back 31

orthostatic hypotension

Front 32

Which statement by an adolescent indicates the need for instruction about the adverse effects of sunlight?

Back 32

"I am going to a tanning salon to get my tan started early."

Front 33

Which patient statement is the best indicator of sensory overload in a 70-year-old patient who has been in the intensive care unit for two weeks?

Back 33

"I feel like my thoughts are racing and I can't concentrate."

Front 34

Sustained noise at what level can lead to progressive hearing loss?

Back 34

90 decibels

Front 35

Which type of knot should the nurse use to tie a wrist restraint to the bed frame?

Back 35

half-bow

Front 36

Based on Maslow's hierarchy of needs, which nursing diagnosis should be given priority?

Back 36

fluid volume deficit

Front 37

Which patient statement reflects the constructive use of self-discipline?

Back 37

"Whatever the crisis, I usually manage to keep my cool."

Front 38

Which is a physiological sign of stress?

Back 38

Blood pressure is elevated.

Front 39

Vital signs are an example of which type of information?

Back 39

objective data

Front 40

Which nursing action would promote patient autonomy in the hospital?

Back 40

Allow the patient to choose meal preferences from a menu.

Front 41

Which statement by the nurse would best help a patient in the postoperative period cope with stress and anxiety and allow the patient a feeling of control over the hospital environment?

Back 41

"In which arm would you like the IV placed?"

Front 42

What is the primary source of information for a patient's health history?

Back 42

the patient

Front 43

An Asian toddler is admitted to the hospital with a persistent fever. The nurse notices circular, red areas on the child's back. Which action should the nurse take?

Back 43

Engage the parents in a discussion of health beliefs.

Front 44

A person has just been in a motor vehicle accident. The person's pulse is rapid, pupils are dilated, and respirations are deep. These findings are a result of which process?

Back 44

sympathetic nervous system activation

Front 45

A nurse caring for a child who is from Mexico notes that the child is reluctant to make eye contact. How should the nurse interpret this behavior, and which action should the nurse take?

Back 45

The child is showing a sign of respect, and should receive care as planned.

Front 46

How is pulse pressure best described?

Back 46

the difference between the systolic and diastolic blood pressure

Front 47

email me for 150 more questions

Back 47

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