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54 Cards in this Set
- Front
- Back
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A wound with full thickness tissue loss, possibility of visible subcutaneous fat, but no visible bone, tendon or muscle is categorized as: a) Unstageable b) Stage IV c) Stage III d) Suspected deep tissue injury |
c) Stage III |
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The Braden Scale is a: a) Scale designed to predict pressure sore risk b) Scale designed to assess how severe a wound infection is c) Scale designed to give the most accurate weight measurement d) Scale designed to assess the effectiveness of a given wound treatment |
a) Scale designed to predict pressure sore risk |
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Granulation tissue is defined as: a) Black or brown necrotic tissue b) Yellowish, stringy, infected tissue attached to the wound base c) Purple, damaged, bleeding tissue d) Red, moist tissue composed of new blood vessels |
d) Red, moist tissue composed of new blood vessels |
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All of the following apply to secondary intention wounds EXCEPT: a) Wound edges are not approximated b) Examples are pressure ulcers and surgical wounds that have tissue loss c) Wound heals through granulation tissue formation, wound contraction, and epitheliazation d) Wound is contaminated and requires observation for signs of inflammation |
d) Wound is contaminated and requires observation for signs of inflammation |
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Which of the following is a description of purulent drainage: a) Pale, red, watery: mixture of clear and red fluid b) Thick, yellow, green, tan, or brown c) Bright red, indicates active bleeding d) Clear, watery plasma |
b) Thick, yellow, green, tan, or brown |
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Where do you collect a wound specimen from: a) Send down the gauze with the drainage on it after an old dressing is removed b) Swipe the skin around the outside of the wound c) In the wound bed of the open wound d) A blood test is required |
c) In the wound bed of the open wound |
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A total separation of wound layers, usually accompanied by protrusion of internal organs through the wound open is defined as: a) Dehiscence b) Fistula c) Infection d) Evisceration |
d) Evisceration |
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Which type of bed has surfaces that change load distribution properties when powered and when client is in contact with the surface: a) Non-powdered beds b) Air-fluidized beds c) Low-air-loss beds d) Lateral rotation beds |
b) Air-fluidized beds |
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When irrigating a wound, utilize a 35 mL syringe with a 19-gauge angiocatheter to deliver fluid pressure between: a) 4-15 psi b) 200-250 psi c) 75 psi d) 100-120 psi |
a) 4-15 psi |
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The purpose of a dressing is to: a) Protect a wound from microorganism contamination b) Promote healing through abosrbing drainage and supporting autolytic debridement c) Provide a moist environment for the wound bed d) All of the above |
d) All of the above |
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Indications and contraindications of WHICH class of wound care dressings include: "should not be used on draining wounds. Solid sheets should not be used on infected wounds" a) Hydrogels b) Foams c) Antimicrobials d) Hydrophilic fibers |
a) Hydrogels |
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The following are critical points in packing a wound EXCEPT: a) Packing should be level with the top of the wound b) Pack gauze in tightly to prevent exudate from forming c) Pack any sinus tracts to prevent pooling of exudate d) Ensure the entire wound surface is in contact with the packing |
b) Pack gauze in tightly to prevent exudate from forming |
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Nutrition is fundamental to wound healing in that it impacts cellular integrity and tissue repair. Which of the following are clinically significant of serious malnutrition: a) Serum albumin is less than 3.5 mg/100 mL b) Total lymphocyte count is less than 1800/mm3 c) Body weight has decreased more than 15% d) All of the above |
d) All of the above |
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What is the purpose of debridement: a) Rid the ulcer of a source of infection b) Visualization of the wound bed c) Provide a clean base for healing d) All of the above |
d) All of the above |
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Synthetic dressings over a wound allow the eschar and fibrinous slough within the wound to be self-digested by the action of enzymes that are present in wound fluids, best describes: a) Mechanical debridement b) Surgical debridement c) Autolytic debridement d) Biological debridement |
c) Autolytic debridement |
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Which of the following is NOT recommended when a nurse notes deepening of an ulcer, combined with increased drainage: a) Notify healtch care professionals for possible change in pressure ulcer status b) Do nothing, as this is an expected finding c) Obtain additional consults (i.e. wound care specialist) d) Obtain necessary wound cultures |
b) Do nothing, as this is an expected finding |
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The definition of undermining is: a) The loss of underlying tissue (subcutaneous and muscle) to a greater extent than the skin, giving the skin a shelf like appearance b) A wound that has "tunnel-like" openings extending away from the wound bed c) A wound that is healing appropriately d) A wound that is receiving VAC therapy |
a) The loss of underlying tissue (subcutaneous and muscle) to a greater extent than the skin, giving the skin a shelf like appearance |
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The following are nursing interventions for Friction and Shear EXCEPT: a) Reposition client by using a drawsheet to lift the client off the surface b) Provide a trapeze to facilitate movement c) Position client at a 30-degrees lateral turn and limit head elevation to 30 degrees d) Assess client need for incontinence management |
d) Assess client need for incontinence management |
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The following are ways to prevent skin breakdown EXCEPT: a) Perform frequent skin assessments b) When cleaning the skin, avoid soaps and hot water c) Allow some moisture to remain on the skin after cleaning d) Use moisturizer or skin barriers to keep the epidermis well-lubricated but not oversaturated |
c) Allow some moisture to remain on the skin after cleaning |
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Which of the following, while officially an indication for enteral feeding, is controversial due to the belief that negative effects outweigh potential benefits a) Upper GI tract cancers b) Inflammatory bowel disease c) Dementia d) Cerebrovascular accident |
c) Dementia |
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During discontinuation of a NG tube - which step is the most important in avoiding aspiration of stomach contents in to the lungs? a) Turning off the suction b) Pinching the tube as it is pulled out c) Having suction on "high-continuous" as the tube is pulled out d) Flushing the tube with sterile water prior to removal |
a) Turning off the suction |
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Which of the following formulas contain predigested nutrients that are easier for a partially dysfunctional gastrointestinal tract to absorb: a) Specialty formulas b) Polymeric formulas c) Modular formulas d) Elemental formulas |
d) Elemental formulas |
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The pH of pleural fluid from the tracheobronchial tree is generally: a) Higher than 6 b) Between 1 and 4 c) Sits exactly at 5 d) Never goes over 2 |
a) Higher than 6 |
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The most accurate non radiological method of determining nasograstric tube placement is: a) X-ray b) Auscultation c) Fluroscopy d) pH testing |
d) pH testing |
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Which of the followin are risk factors for tube occlusion a) Insufficient tube irrigation b) Sedimentation of formula c) Reaction of incompatible medications d) All of the above |
d) All of the above |
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Using your prioritizing skills, assess which patient concern relating to the nasogastric tube needs to be addressed first: a) Distention/pain in the abdomen b) Sore throat caused by dry/irritated mucuous membranes c) Signs of pulmonary aspiration d) Irritation of the skin around the nares |
c) Signs of pulmonary aspiration |
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Which is the MOST IMPORTANT reason for using normal saline for irrigating a nasogastric tube: a) Minimizes the loss of electrolytes from the stomach fluids b) Limits bacterial growth in the tube c) Is a better lubricant than sterile water d) Is less likely to cause a crystallized build up on the sides of the tube |
a) Minimizes the loss of electrolytes from the stomach fluids |
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A client who is receiving enteral feeds should have their bed in what position? a) Reverse fowlers b) HOB at 30 degrees c) Supine d) They should be on a tilt table at 90 degrees |
b) HOB at 30 degrees |
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Determining the length of tubing prior to inserting a nasogastric tube involves measuring from the tip of the nose to the tip of the earlove to the xiphoid process. How uch longer would be required if inserting the tube past the stomach to the duodenum or jejunum? a) 20-30 cm b) 50-70 cm c) no change in distance d) 1-5 cm |
a) 20-30 cm |
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Why is auscultation no longer considered a reliable method of testing placement? a) Research has shown that the stethoscope is consistently placed in the wrong spot on the abdomen b) Instilling air causes a dangerous build up of pressure in the stomach c) A tube sitting in the lungs/pharynx can give off a similar sound to a tube sitting in the stomach d) Instilling air is an infection risk |
c) A tube sitting in the lungs/pharynx can give off a similar sound to a tube sitting in the stomach |
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What position should the client be in when inserting a nasogastric tube into the intesting a) Left side b) Right side c) Reverse Fowlers d) Supine |
b) Right side |
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When initiating enteral feeds, how often will the nurse increase the hourly rate a) every 5-10 min b) every 1-2 hours c) every 12-24 hours d) every 1-2 weeks |
c) every 12-24 hours |
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What volume of urine does the adult bladder normally hold? |
500 mL |
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Which of the following "factors influencing urination" is described as initially triggering the general adaptation syndrome as well as often in an altered state of fluid balance due to the disease process of preoperative fasting a) Psychological factors b) Disease conditions c) Fluid balance d) Surgical procedures |
d) Surgical procedures |
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Which "common alteration in urinary elimination" is defined as "marked accumulation of urine in the bladder as a result of the bladder's inability to empty?" a) Urinary retention b) Urinary diversion c) Nocturia d) Urinary incontinence |
a) Urinary retention |
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When focusing on altered urinary processes in odler adults, which of the following is NOT correct: a) Physiological changes in the lower urinary tract occur in continent as well as incontinent older adults b) Dilute urine discourages bacterial growth, therefore encourage increased fluid intake c) Restriction of fluid 2 hours before sleep may decerase incidences of nocturia d) Treating asymptomatic bacteriuria is highly recommended |
d) Treating asymptomatic bacteriuria is highly recommended |
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Which of the following is NOT a common cause of urinary hesitancy: a) Diabetes Mellitus b) Hypotonic bladder c) Urethral stricture d) Anxiety |
a) Diabetes mellitus |
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Which of the following is NOT a characteristic of urine which you would assess for: a) Colour b) Viscosity c) Clarity d) Odour |
b) Viscosity |
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Which of the following urine collection types can be collected during normal voiding into a clean specimen cup? a) Clean-voided or mid-stream specimen into a sterile specimen cup b) Sterile specimen c) Random specimen for routine urinalysis d) Time urine specimens |
c) Random specimen for routine urinalysis |
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Which of the following common urine tests is described as "the weight or degree of concentration of a substance compared with an equal amount of water" a) Urinalysis b) Urine culture c) Glucose testing d) Specific gravity |
d) Specific gravity |
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Which of the following substances are NOT commonly found to irritate the bladder mucosa: a) Tobacco b) Sugar c) Alcohol d) Citrus fruits/juices |
b) Sugar |
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Ensuring than an in-dwelling catheter drainage bag is lower than the bladder prevents: a) Urine flowing back in to the bladder which will likely cause an infection b) Urinary retention c) Reflux incontinence d) Urinary incontinence |
a) Urine flowing back into the bladder which will likely cause an infection |
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The normal adult urine output is: a) 1000 mL/day b) 1500-1600 mL/day c) 3000-32000 mL/day d) 4000 mL/day |
b) 1500-1600 mL/day |
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Which of the following is the MOST IMPORTANT goal of bladder training: a) To incraese the size of the bladder b) To decrease the frequency of intermittent catheterization c) To increase gradually, the interval between voids and to decrease voiding frequency during waking/sleeping hours d) To increase pelvic floor muscle stability, therby decreasing the risk of bladder prolapse |
c) To incraese gradually, the interval between voids and to decrease voiding frequency during waking/sleeping hours |
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What is the MOST IMPORTANT benefit of intermittent catheterization over indwelling catheterization a) Patient comfort - most patients find repeated insertion less uncomfortable than the catheter remaining in b) An indwelling catheter remains in the bladder for an extended period, increasing the risk of infection c) Nursing workload - an indwelling cathter requires a geater amount of nursing duties d) Long term bladder function can be compromised with an indwelling catheter |
d) Long term bladder function can be compromised with an indwelling catheter |
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Which of the following is NOT something that a client doing intermittent self-catheterization needs to know: a) Structure of the urinary tract b) Clean versus sterile technique c) Importance of adequate fluid intake d) How to inflate the balloon on the foley catheter |
D) How to inflate the balloon on the Foley catheter |
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When inserting an indwelling catheter, how much normal saline do you use to fill the balloon? a) Test balloon first and fill until stretched out to maximum fullness b) The balloon is filled with sterile water not normal saline c) It will say on the side of the syringe d) Minimum of 20 cc |
b) The balloon is filled with sterile water not normal saline |
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When inserting an indwelling catheter, what is the PRIMARY purpose of inserting the catheter another 2.5-5 cm after you get urine return? a) To ensure the foley will not be expelled with a bladder spasm b) To ensure the foley is in the urethra and not the vagina c) To ensure the tip of the catheter (where the balloon is) is past the urethral sphincter and that the balloon will not inflate in the urethra d) To ensure that the foley will drain all of the urine sitting in the bladder |
c) To ensure the tip of the catheter is past the urethral sphincter and that the balloon will not inflate in the urethra |
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What do we ideally want the gastric aspirate to be? |
pH under 4 |
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How long do you turn suction off for after medication administration? |
30 minutes |
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How much formula is added to the feeding bag at a time? |
4 hours supply at a time |
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If a feeding tube becomes blocked, what meds/enzymes are ordered to aid in unblocking the tube? |
Sodium bicarbonate or pancreatic enzymes |
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What does the nurse do when a tube becomes dislodged in an established tract? |
- Stop feeds - Insert foley or red rubber catheter to maintain passage - Call physician |
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How much of the catheter should you lubricate for insertion of a male? |
12-14 cm |
