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60 Cards in this Set

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A localized injury to the skin or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear and/or friction
pressure ulcer
Force exerted parallel to skin
shear
Force exerted when skin is dragged across bed linens
friction
A substance that reduces skin’s resistance to other physical factors
moisture
Which type of ulcer consists of full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, muscle is not exposed?
stage 3
While assessing the patient, the nurse noted a reddened spot on the intact skin around the coccyx area, the nurse will document it as a:
stage 1 pressure ulcer
The type of wound obtained from a sharp object
open wound
A wound that is caused by vascular compromise, chronic inflammation or repetitive tissue trauma is classified as
chronic wound
A patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. The nurse should:
a. Allow area to be exposed to air until drainage stops
b. Place cold packs over the area, with care taken to protecting the skin around the wound
c. Cover the area with sterile saline-soaked towels and immediately notify the surgical team as this is likely to indicate a wound evisceration
d. Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.
C. In wound evisceration, the bowel extrudes from the body. The nurse should cover the visible bowel with sterile saline-soaked towels and notify the surgical team. The area should not be allowed to be exposed or to dry out. Cold packs and binders are not acceptable options.
A wound that provides an entry to the GI, GU, respiratory or oropharyngeal tracts under controlled conditions (surgery) is classified as a:
clean-contaminated wound
Wound color that indicates active healing due to granulation
red
Serous drainage is defined as
clear, watery drainage
A ___ is applied to a muscle sprain which prevents edema formation, control bleeding, and anesthetize the body part
a. Binder
b. Ice application (ice pack)
c. Elastic bandage
d. Heat application
B. The application of cold will help constrict blood vessels, which will reduce swelling that occurs with bleeding and edema formation in a muscle sprain. It also provides a numbing effect. Binders and elastic bandages are not initial treatments for a sprain
Wound bed that extends into the adjacent tissue is defines as
tunneling
Wound margins that are held together is defines as
well-approximated
The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
B. Partial-thickness skin loss involving the epidermis and possibly the dermis is classified as a stage II ulcer. In stage I the ulcer appears as a defined area of persistent redness with no open skin areas. In stage III the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV the ulcer appears as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
The nurse is in the process of changing the wound dressing of the patient when the nurse observed granulation. In what phase of wound healing is the wound undergoing?
a. Hemostasis
b. Inflammation
c. Proliferation
d. Maturation
C. Tissue granulation occurs in the proliferative phase. Scar tissue formation happens in the maturation phase. Hemostasis occurs during the inflammation phase
While assessing the wound on the patient, the nurse observed the tissue starting to come apart. The nurse would document the wound as:
dehiscent
The total separation of wound layers and protrusion of an organ through the wound opening is called:
evisceration
The condition where there is an abnormal passage or opening between organs is called
fistula
A 40-year-old patient is a new paraplegic and is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the patient's education. In providing this education, the nurse should have included which of the following guidelines?
a. Patient should sit in the chair for no longer than 3 hours
b. Patient should use a donut-shaped chair cushion
c. Patient should use a rigid cushion for full support
d. Patient should shift weight in a chair every 15 minutes
D. Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer formation. The guideline for sitting up in a chair is to sit for 2 hours or less, but it is only a guideline. The nurse should individualize activity for each client. Sitting on rigid or donut-shaped cushions is contraindicated because they reduce blood supply to the area, which increases the area of ischemia
During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:
a. Massage the reddened area and reposition the client
b. Place the client in fowler’s position
c. Insert a urinary catheter to prevent accumulation of moisture from urinary incontinence
d. Reposition client off the coccygeal area and reassess the area in 1 hour
D. Repositioning the client and reassessing the area in 1 hour is the most appropriate action for the nurse. When pressure is relieved from an area, the blood flow returns and the redness will disappear if no damage has occurred. This is the appropriate assessment. Placement in Fowler's position would only increase pressure on the coccyx. Massaging of a reddened area is not recommended because it could cause further injury if the tissue is already compromised. Insertion of a urinary catheter will not relieve pressure on the coccyx
To promote healing, prevent pressure sores developing and prevent further tissue destruction while sleeping, clients who are at risk for pressure ulcers should consider to sleep in which postion?
a. Thirty- degree lateral inclined position
b. Supine with the head of the bed elevated
c. Full side-lying position supported with pillows
d. Supine with a foam wedge between the knees
A. This position best reduces pressure on bony prominences where pressure ulcers frequently develop. Pillows and foam wedges may be used for support and protection in this position. Full side-lying position results in prolonged pressure on the trochanter, another bony prominence where pressure ulcers frequently develop. While a wedge reduces the contact between the knees, lying supine leaves direct pressure on the sacral area and the heels. Elevating the head of the bed increases the potential for shearing forces to worsen skin integrity.
A type of wound intervention that removes nonviable, necrotic tissue – can be surgical or mechanical (wet-dry dressing, irrigation)
debridement
The nurse plans to administer a prescribed dose of linezolid (ZYVOX), an antibiotic. The prescription states, "ZYVOX suspension 600 mg PO q12h for 14 days." The medication is labeled, "100 mg/5 ml." and has a recommended daily dosage of 800 mg – 1200 mg
How much of the medication will the nurse administer for the first 12 hours?
a. 40 ml
b. 10 ml
c. 30 ml
d. 12 ml
C. 600 mg/100 mg × 5 ml = 30 ml
Which client has the highest risk of developing pressure ulcers
a. A 21 year old male who practices good personal hygiene, eats nutritious foods, doesn’t use drugs, doesn’t drink, goes to church every Sunday, that goes to law and medical school at the same time, has a 4.50 GPA, helps out in the community and the homecoming king of all the high schools in his state
b. The man who doesn’t use “lady-scented” body wash who’s on a boat holding an oyster that has tickets to the thing you love which he then turned into diamonds who’s now suddenly riding a horse
c. A 75 year old incontinent, obese, bed-bound person that has dementia who, despite the current condition, still likes to have long tub baths while eating anything deep fried
d. Spongebob Squarepants
C.
Amount of blood pumped by each ventricle per minute
cardiac output
Number of contractions of ventricles per minute
heart rate
Amount of blood ejected from each ventricle with each contraction
stroke volume
Carbon monoxide is a toxic inhalant that decreases the oxygen-carrying capacity of blood by:
a. Forming a weak bond with hemoglobin
b. Forming a strong bond with hemoglobin
c. Forming a weak bond with carbamino compounds
d. Forming a strong bond with carbamino compounds
B. carbon monoxide is the most common toxic inhalant and decreases the oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a functional anemia. Because of the strength of the bond, carbon monoxide does not easily dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.
The term that describes the end-diastolic volume when the ventricles stretch when filling with blood
preload
Term to describe the resistance to left ventricular ejection
afterload
Conditions such as shock and severe dehydration resulting from extracellular fluid loss cause
a. Hypoxia
b. Hypovolemia
c. Hypervolemia
d. Uncontrolled bleeding
B. Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume (hypovolemia)
Type of respiration muscle used when a person is having difficulty breathing, during heavy exercise or during an asthma attack
accessory muscles
Fever increases the tissues' need for oxygen, and as a result,
a. Metabolic demands increase
b. Blood glucose stores stabilizes
c. Carbon dioxide production increases
d. Carbon dioxide production decreases
C. Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, which results in muscle wasting and decreased muscle mass
Cyanosis, the blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries is:
a. A late sign of hypoxia
b. An early sign of hypoxia
c. A sign of a non-threatening condition
d. A reliable sign of oxygenation status
A. Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status.
Lack of blood supply to the myocardium can cause:
angina
A drug that cause respiratory depression / hypoventilation
morphine
An ER nurse is doing an assessment on a patient that show restlessness and apprehension. Those are early signs of:
hypoxia
A client is admitted to the emergency department with a suspected cervical spine fracture at the C3 level. The nurse is most concerned about the client's ability to:
a. Ambulate
b. Breathe
c. Maintain cardiac output
d. Be oriented to time, place, and person
B. Spinal cord injury at the level of C5 or above often results in damage to the phrenic nerve, which innervates the diaphragm and permits breathing. Cardiac output is not usually affected by spinal cord injury; however, cardiac output may be reduced as a result of trauma and blood loss. It is too early to be concerned with ambulation. Life-threatening problems take priority. Level of consciousness is certainly an important consideration, because this client most likely sustained a head injury. However, this is not a certainty given the data provided.
A client asks why smoking is a major risk factor for heart disease. In formulating a response, the nurse incorporates the understanding that nicotine:
a. Causes vasoconstriction
b. Causes vasodilation
c. Increase oxygen-carrying capacities of hemoglobin
d. Increase levels of HDLs
A. Nicotine causes vasoconstriction, which restricts blood flow to the heart and peripheral tissues and increases the risk of hypertension and subsequently heart disease as a complicating factor. Nicotine does not cause vasodilation. Nicotine decreases the oxygen-carrying capacity of hemoglobin. Nicotine decreases the level of high-density lipoproteins and elevates the level of harmful low-density lipoproteins, which leads to atherosclerosis.
Clinical manifestations of hypoventilation include (select all that apply):
a. Tachycardia
b. Paresthesia
c. Arrhythmias
d. Headache
e. Altered mental status
f. Tetany
g. Tachypnea
h. Chest pain
Tachycardia, paresthesia, tetany and tachypnea are clinical manifestations of hyperventilation.
Arrhythmias, headache and altered mental status are clinical manifestations of hypoventilation
A drug that stops a nonproductive cough or dry hacking cough
antitussives (codeine)
A drug that relaxes bronchial smooth muscle and used to treat acute exacerbations of asthma:
bronchodilators (theophylline, albuterol, spiriva)
Drugs that blocks or inhibits histamine action and used to treat allergic reactions:
antihistamines (Benadryl, Claritin)
Drugs that help release the mucus, creating a productive cough
expectorants (guaifenesin)
Patients with CHF take this drug to increase the heart’s force of contraction:
cardiac glycosides (digoxin)
Hypertension medication that increases coronary blood flow and decreases myocardial O2 demand:
calcium channel blockers (amiodipine, diltiazem)
Drugs that decrease heart contractility and increase myocardial O2 supply
beta blockers (atenolol, metoprolol)
Drugs that inhibit accumulation of inflammatory cells at inflammation sites:
corticosteroids (prednisone)
A ___ occurs if pressure that is applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time
tissue ischemia
Pressure ulcer stage where there is full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
unstageable
Type of wound healing process that occurs by granulation tissue formation, wound contraction and epithilialization
second intention
While assessing the wound on the patient, the nurse notices the wound bed extends under the skin, the nurse would document the wound bed is:
undermining
The benefits of using heat therapy include (select all that apply):
a. Decrease blood flow
b. Muscle relaxation
c. Remove waste products
d. Promote coagulation
e. Increase blood flow
f. Increase tissue metabolism
g. Increase capillary permeability
h. Reduce localized pain (anesthesia)
- Muscle relaxation, remove waste products, increase blood flow, increase tissue metabolism, increased capillary permeability are benefits of using heat therapy
- Decrease blood flow, promote coagulation, reduced localized pain (anesthesia) are benefits of using cold therapy
Respiratory regulators that maintain appropriate rate and depth of respirations based on changes in blood’s CO2, O2, and pH concentration
chemical regulator
Drugs that help increase oxygen supply and promote peripheral vasodilation
nitrates (nitroglycerin, isosorbide)
A device used to deliver O2 that requires low to medium concentration and is commonly for short-term use (after surgery, SOB, angina)
nasal cannula
A color-coded equipment that provides fixed concentrations of oxygen and usually used for patients who have chronic COPD
venturi mask
It’s your first day as a nurse in the hospital and the doctor gave you an order for your client 50mg of hydroxyzine (Vistaril) PO. Available are 10mg tablets of hydralazine. How many tablets are you going to give?
None. They are two different drugs (hydroxyzine is an antihistamine drug while hydralazine is a vasodilator)