NUR 204/ NUR204 Exam 2 (NEW 2026/ 2027 Update) Leadership and Management VERSION 2| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Fortis

NUR 204/ NUR204 Exam 2 (NEW 2026/ 2027 Update) Leadership and Management VERSION 2| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Fortis Q: Nurse prepares to administer a med to a 6-mo infant. Nurse monitors closely for signs of drug toxicity based on knowledge that, compared to adults, infants have... Answer Immature hepatic and renal function Q: Nurse reviews info about a drug that is best absorbed in an acidic environment. When giving this drug to a 1 y/o, the nurse will expect to administer a dose that will be... Answer More than an adult dose Q: Nurse cares for an infant showing signs of drug toxicity to a drug given several hours prior. Nurse checks the dose and confirms the dose is consistent with standard dosing guidelines. What characteristic of the drug likely explains the patient's response? Answer It is highly protein-bound Q: Parent is concerned about giving a child medication bc of lack of knowledgeable about effects of drugs on children. Nurse discussed legislation passed in 2002-03 about pediatric pharmacology. Answer They require drug manufacturers to study pediatric medications use Q: Nurse administers an IV med to an adolescent. When preparing the adolescent for the IV insertion, what action is appropriate by the nurse? Answer Allowing the patient to verbalize concerns about the procedure Q: Provider ordered vitamin D drops to be given to a newborn. Based on drug distribution in infants, nurse understands the infant may need: Answer Lower dose Q: Nurse prepares to administer an oral liquid med to an 11 mo child who is fussy and incorporative. What action will the nurse take to facilitate giving this meds? Answer Using a syringe and allowing the parent to give the med. Q: 2 y/o child will receive several doses of intramuscular meds. The nurse caring for this child will use what intervention to help the child cope with this regimen? Answer Allowing the child to give pretend shots to a doll w an empty syringe. Q: A pre-schooled child has meds rare dehydration and needs a rapid bolus of fluids. To provide atraumatic care and administer fluids most effectively, what action will the nurse take? Answer Use a powdered lidocaine preparation prior to insertion of the IV needle Q: Nurse prepares to administer an intramuscular med to a 4 y/o who starts to cry and screams, I don't want a shot! What is the nurses action? Answer Engage the child in a convo about preschool and fav activities Q: 14 y/o female with type 1 diabetes mellitus that's been well controlled for several years is admitted to the hospital for treatment of severe hyperglycemia. The patients lab values indicate poor glycemic control for the past 3 months. What will the nurse suspect was the cause for the change in diabetic control? Answer Hormonal fluctuations Q: Nurse teaches 15 y/o female and her parents about an antibiotic the adolescent will begin taking. The drug is known to decrease the effectiveness of oral contraceptive pills (OCPs). Nurse will... Answer Tell her privately the med may decrease the effectiveness of OCPs Q: Nurse assists a parents of a 6 mo old infant to administer an oral liquid med. the parent asks why the med can't be given in a bottle of formula to make it taste better. How will the nurse respond? Answer Infant may not always take the entire bottle of formula Q: Patient asks the nurse if an enteric coated tab can be crushed and put in pudding to make it easier to swallow. How will the nurse respond to the patient? Answer Crushing med can lead to possibly toxins med dose Q: Nursing students understanding about Liquid meds Answer I will line up bottom of the med curve w the line in the syringe Q: Patient asks why the provider ordered a transdermal form of a med. how will the nurse respond? Answer Drug levels fluctuate less w the patch Q: When administering topical meds, what's nursing action is important? Answer Wearing gloves Q: Why is a spacer necessary? Answer Distributed med to target tissues Q: Nurse teaches a parent to administer meds using child's G tube. Parent asks why it's necessary to give water after each med. nurse explains the purpose for water is... Answer To ensure all med is infused into the stomach Nurse prepares to administer a rectal suppository antipyretic med. What action by the nurse is correct? Having patient remain in side lying position for 20 mins after the insertion Nurse preforms tuberculin testing on a patient. What nursing action is correct? Use a 25-gauge, 3/8 needle Needle is inserted at a 10-15 degree angle Intradermal injections are given with a 25-27-gauge, 3/8-5/8 long needle. Nurse teaches an overweight patient to administer sub-q heparin. What statement by the patient shows understanding? I should insert the needle and inject the med w/o aspirating for blood 45-90 degree angle Absorption is slower with this route Nurse prepares to administer intramuscular injection to 14-mo old toddler. To help with site selection, the nurses asks the child's parent.. How long has your child been walking? Nurse demonstrated the Z-track injection technique to a nsg student on a patient receiving iron dextran. What statement by the student shows understanding? This is necessary to prevent staining of the patients skin Usually a large bore needle Nurse prepares to start an IV line in a preschool-age child. After applying a eutectic mixture of local anesthetics, what will the nurses do to prepare the child? Give the child equipment to handle and practice on a doll Nurse cares for an elder who receives multiple meds. When monitoring this patient for potential drug toxicity, what labs should the nurse review very closely? Serum creatinine and liver function (LFTs) An older patient reports a 2-3 yr history of upper GU symptoms will begin taking ranitidine (Zantac) to treat this disorder. The patient has completed a health history form. The nurse notes the patient answered no when asked if any meds were being taken. What will the nurse do next? Ask whether the patient uses OTC meds To assist an older, confused patient to adhere to a multi drug regimen, the nurse will recommend.. Bring all meds to each clinic visit Nurse cares for an older patient who's taking 25 mg per day of hydrochlorothiazide. What lab value will the nurse closely monitor in this patient? Serum potassium Nurse cares for an 82 y/o patient who takes dotoxin to treat chronic atrial fibrillation. When caring for this patient, to monitor for drug side effects, the nurse will carefully assess... HR Usual dosages for peds when administering liquid meds... Less than 1 tsp and some are less than 1 mL Recommended devices for measuring small amts of peds liquid oral meds Oral syringe Hollow handled med spoons Marked droppers (only if provided with med) Recommended device for measuring larger amts of liquid meds for peds Measuring cup Syringe caps can present a risk of ASPIRATION and suffocation Administering meds to INFANTS (birth - 1 yr.: Nurse cares for 80 y/o who's taking warfarin. What action is important for the nurse? Initiating fall risk protocol 80 y/o patient is being treated for infection. What antibiotic ordered would cause concern for nurse? Aminoglycoside Excreted in urine and are not usually prescribed for 75+ y/o 75 y/o is readmitted to the hospital to treat recurrent pneumonia. Patient had been discharged with antibiotics 5 days prior. Nurse admitting this patient will take what initial action? Ask patient how many doses for the antibiotic have been taken Nurse performs an admission assess on an 80 y/o who has frequent hospital admissions. Patient appears more disoriented and confused than usual. What action by the nurse is correct? Asking about med doses Elder takes ibuprofen for arthritis pain. Patient tells the nurse the ibuprofen sized GI upset. Nurse will Explore options to help decrease the drug side effdcts Nurse cares for 78 y/o patient who lives alone. Patient will begin a new drug regimen that requires taking multiple drugs at various times per day. Nsg. Intervention = Dev a log to record times drugs will be taken Nurse prepares an 80 y/o for discharge home. Patient will receive several new meds. Patient lives alone but have several fam who stop by every day. What suggestions will the nurse make for this family? Ask pharmacy for non-childproof med bottles Place pulls in organizer container Put water bottles near pulls for convenience Which drug properties are problematic for older patients? Drugs with anticholinergic effects b. Drugs that are highly protein-bound e. Drugs with a narrow therapeutic range Nurse teaches group in the community about drug abuse. What statement by the nurse is correct? Drug addiction is characterized by emotional, mental, and sometimes physical dependence. What must occur to produce withdrawal syndrome? Physical dependence Nurse counsels a patient who wants to stop smoking. The correct statement by this nurse is... You may experience headaches and increased appetite for several months Patient with asthma has been using nicotine transdermal 24- hr patch for 3 weeks to quit smoking. The patient reports having difficulty sleeping. Nurse will.. Suggest 18-hr patch instead. Nurse discusses smoking cessation with a colleague who smokes. What statement indicates a readiness to quit? I want to stop, but I will need help Patient uses Commit lozenge 2 mg to help quit smoking and reports nausea and indigestion. Nurse will instruct the patient to perform... Allow the lozenge to dissolve slowly over 20-30 mins Patient reports seeing colored lights and describes feeling bugs crawling under the skin. Nurse suspects what drug is being abused? Cocaine Patient is chronically irritable and anxious and prone to violet behaviors. Patient has several teeth missing and has dental caries in remaining teeth. Nurse suspects precious chronic use of what drug? Meth Nurse teaches a patient who has completed detoxification for alcohol abuse who will be discharged home with a prescription (Antabuse). What statement by the patient indicated understanding of the teaching? Even topical products containing alcohol can have serious adverse effects while I am taking this drug Patient with a long history of alcohol abuse is admitted to the hospital for detoxification. In addition to meds needed to treat withdrawal symptoms, the nurse will anticipate giving IV.... Thiamine to treat nutritional deficiency Patient in ED w acute alcohol intoxication and reports chronic consumptions of several 6 packs of beer every day for the past year. Nurse anticipates administering what med? Chlordiazepoxide (Librium) A patient who is unconscious arrives in ED with clammy skin and constricted pupils. RR of 8-10 bpm. Paramedics report obvious signs of drug abuse. Nurse suspects this patient overdosed on what substance? Opioid Patient brought to ED after overdosing on lorazepam (Ativan) SEVERAL HRS PRIOR. Patients RR is 6-10 bpm and is unconscious. Nurse prepares to perform what? Give flumazenil (Romazicon) — flumazenil is the antidote for benzodiazepine Activated charcoal is used for Asymptomatic patients who have recently consumed lorazepam (Ativan) RECENTLY Patient w history of opioid abuse will be discharged home w buprenorphine to help prevent relapse. What product will the nurse anticipate the provider to order? Buprenex Nurse teaches a patient who will be discharged with naltrexone (ReVia) after treatment for opioid addiction. The nurse includes what info in teaching the patient? ReVia blocks pleasurable effects of opioids — taken ONCE daily of EVERY OTHER DAY Nurse provides teaching about sedative side effects of a med ordered to given at 8:00 PM daily. Patient works a 7:00 PM - 7:00 AM shift. Nurse explores options including taking the med at 8 AM instead of the evening. What QSEN competency do the nurses actions best demonstrate? Patient-centered care Nurse learns patient can not afford med and enlists the assistance of the social worker and an outside agency to provide meds at a lower cost. What QSEN competency do the nurses actions best demo? Collab and teamwork 5 y/o patient with type 1 diabetes mellitus has repeated hospitalizations for episodes of hyperglycemia r/t poor control. Parents say they can't keep track of everything. Nurse reviews meds, diet, and symptom management with the parents and draws a daily checklist for the fam. This is an example of the principles outlined in Guiding Principles of Patient Engagement Nurse reviews patients database and learns the patient lives alone, is forgetful, and does not have a routine. The patient will he sent home with 3 new meds to be taken at diff times of the day. Nurse dev a daily med chart and enlists a fam member to put the patients pills in a pill organizer. This is an example of what phase in the nsg process? Implementation — involves edu and patient care to assist them in accomplishing the goals of treatment Patient will be sent home with a metered dose inhaler, and the nurse provides teaching. What is a correctly written goal for this process? Patient will independently admin the med using the metered dose inhaler at then end of the session Nurse develops a teaching plan for an elder who will begin taking anti-HTN drug that causes dizziness and orthostatic hypotension. NSG DX is... Risk for injury r/t side effects of the med An elder must learn to admin a med using a device that requires manual dexterity. Patient becomes frustrated and expresses lack of self-confidence in performing this task. Next, the nurse will... Schedule multiple sessions and practice each step separately A school-aged patient will begin taking a med to be admin 5 mL 3 times a day. Child's parent says, w previous use of the drug, the child repeatedly forgot to bring the med home from school, resulting in missed evening doses. The nurse will recommend... Asking the provider if 7.5 mL may be taken in the am and 7.5 in the pm so that the correct amount is given daily High school student regularly forgets to use a twice-daily inhaled corticosteroid to prevent asthma flares and is repeatedly admitted to the hospital. The child's parents says the child was told that forgetting to take the med causes frequent hospitalizations. Nurse will... Suggest putting the inhaler with the child's toothbrush to use before brushing teeth an adolescent patient who has acne is given a regimen of topical and oral antibiotics that generally clears up lesions yo fewer than 10 within 6-8 weeks. At 2-mo FU, patient has 25+ lesions. Child's parent affirms the child is using the meds as prescribed. What evaluation statement is correct for this patient? Goal of fewer than 10 lesions in 6-8 weeks is not met. When the nurse practices 5 + 5 rights of med admin, what does it ensure? Safe admin of meds H/c provider calls nsg unit to leave a phone order for a PRN antipyretic med for a child. The provider tells the nurse to give PO acetaminophen for a fever greater than 101 F per protocol. Next, the nurse will... Ask the provider to verify how many mg per kg or dose and how frequently to give the med Expired med.. Return to pharmacy to be replaced Nurse prepares to admin chewable tab to a preschooler. Child's parent reports always crushing the tab and mixing it w pudding when at home. Next, the nurse will... Ask pharmacist if the drug may be crushed Nurse cares for a pt who will have surgery that morning. Patient usually takes an anti hypertension med every am. Patient has been NPO since midnight. What action will the next perform? Consult provider and surgeon about giving the med Nurse cares for a patient w asthma. Provider ordered albuterol metered dose inhaler (MDI), 2 puffs q4-6 hr PRN wheezing. Patients last does was 4 hrs ago. Next, the nurse will... Auscultate patients lung sounds Thiazide diuretic treats HTN Reduces volume of fluid in your bloodstream to lower blood pressure Violation of nurses right when administering meds A med preparation area that the unit secretary's desk Excretion of drugs in children are... SLOWER — so it is v important to assess/evaluate drug accumulation Helpful strategies when working with adolescents to promote adherence Allow flexible treatment plan Set up mutually developed drug contract Common reasons for no adherence to drug regiment in elders: Multiple meds Impaired memory Decreased dexterity Elders have slower absorption of oral drugs bc Decreased gastric blood flow Most important subject about elders oral drug metabolism First pass effect Hydrochlorothiazide = eat foods high in potassium: Avocados & mushrooms Strategies to impart new drugS for elder patients: Limit distractions in room when teaching Augment teaching with audio material Use large, dark print on a light background for written material Changes with elders drug distribution: Decreased muscle mass and increase fat Decreased serum albumin Decreased kidney mass Best measure to determine kidney function Estimated GFR Treatments for alcohol toxicity: Thiamine IV IV glucose solution Patient starts disulfiram to help w alcohol use disorder. Edu will include: Importance of taking the med every day Better results when a support group helps with treatment adherence Common food and hygiene products that contain alcohol Disulfiram works by distribution metabolism of alcohol Use of alcohol with disulfiram May cause nausea and vomiting and may even be fatal Decreased level of consciousness A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development? A. Decreased level of consciousness B. Adequate dietary intake C. Shortness of breath D. Muscular pain pressure The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development o fa decubitus ulcer? a. Resistance b. pressure c. weight d. stress fecal incontinence which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. fecal incontinence b. ate two thirds of breakfast c. A raised red rash on the right shin Healing stage III pressure ulcer The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? 1. stage 1 pressure ulcer 2. healing stage II pressure ulcer 3. Healing stage III pressure ulcer 4. Stage III pressure ulcer Stage II The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? 1. Stage 1 2. Stage II 3. Stage III 4. Stave IV Natural Light Which item should the nurse use to first assist in staging an ulcer on the heel of a darkly pigmented skin patient? a. disposable measuring tape b. cotton-tipped applicator c. sterile gloves d. natural light Full thickness wound repair The nurse is caring for a patient with a stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. partial thickness wound repair b. full thickness wound repair c. primary intention d. tertiary intention A patient with appendicitis using a heating pad The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with stage IV pressure ulcer b. a patient with a braden scale score of 18 c. a patient with appendicitis using a heating pad d. a patient with an incision that is approximated granulation The nurse is caring for a patient who is experiencing a full thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. eschar b. slough c. granulation d. purulent drainage Primary intention The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan ? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention Secondary intention The nurse is caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient? a. partial-thickness repair b. secondary intention c. tertiary intention d. primary intention scarring that may be severe Which nursing observation will indicate the patients wound healed by the process of secondary intention? a. minimal loss of tissue function b. permanent dark redness at site c. minimal scar tissue d. scarring that may be severe The incision appears both swollen and bluish color The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing? a. patient reporting,- My incision is hurting b. approximation of the incision edges has occurred c. patient asks, -why has my incision started to itch? d. the incision appears both swollen and bluish color Report by patient that something has given way Which finding will alert the nurse to a potential wound dehiscence? a. protrusion of visceral organs through a wound opening b. chronic drainage of fluid through the incision site c. report by patient that something has given way d. drainage that is odorous and purulent Pealbumin which lab data will be important for the nurse to monitor when a patient develops a pressure ulcer? a. vitamin e b. potassium c. prealbumin d. sodium Pulse oximetry assessment A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing? a. muscular strength assessment b. pulse oximetry assessment c. sensation asessment d. sleep assessment Completing a head-to-toe assessment, including current treatment, vital signs, and lab results Upon entering the room of a patient with a healing stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to? a. completing a head-to-toe assessment, including current treatment, vital signs, and lab results b. notifying the health care provider utilizing situation, background, assessment, and recommendation (SBAR) c. consulting the wound care nurse about the change in status and the potential for infection d. conferring with the charge nurse about the change in status and the potential for infection Protien The nurse is collaborating with the dietician about a patient with stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietician? a. fat b. protien c. vitamin e d. carbohydrates " I really need a bath and linen change right; I feel so awful" The nurse is completing an assessment on a patient who has a stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept? a. "I am so weak and tired. I just want to feel better" b. "I been thinking I will be ready to go home early next week" c. "I really need a bath an linen change right; I feel so awful" d. "I am hoping there will be something good to eat for my dinner tonight" Inspect the wound for bleeding A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. inspect the wound for bleeding b. irrigate the wound to remove foreign bodies c. measure and document the size of the wound d. determine when the patient last had a tetanus antitoxin injection Provide analgesic medications as ordered The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. provide analgesic medications as ordered b. avoid accidently removing the drain c. don sterile gloves d. gather supplies Call the health care provider, a blockage is present in the tubing The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially? a. call the health care provider, a blockage is present in the tubing b. chart the results on the intake and output flow sheet c. do nothing, as long as the evacuator is compressed d. remove the drain; a drain is no longer needed. Air-fluidized The nurse is caring for a patient who has a stage IV pressure ulcer with grafted surgical sites. which specialty bed will the nurse use for this patient? a. low-air-loss b. air-fluidized c. lateral rotation d. standard mattress Surgical debridment of the wound The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient? a. increased monitoring of the wound condition b. documenting the wounds status daily c. surgical debridement of the wound d. increased drainage from wound Irrigate with dakin's solution The nurse caring for a patient with a healing stage III pressure ulcer notes that the wound is clean and granulating. Which health care providers order will the nurse question? a. use a low-air-loss therapy unit b. irrigate with dakins solution c. apply a hydrogel dressing d. consult a dietician pressure points The nurse is completing an assessment of the patients skin integrity. Which assessment is the priority? a. pressure points b. breath sounds c. bowel sounds d. pulse points 20 The nurse is completing a skin risk assessment using the Braden Scale. The pt has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? a. 15 b.17 c.20 d.23 provide analgesic medication as ordered The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patients willingness and ability to increase mobility? a. explain the risks of immobility to the pt b. turn the pt every 3 hours while in bed c. encourage the pt to sit up in the chair d. provide analgesic medication as ordered Impaired skin integrty The nurse is caring for a pt with stage IV pressure ulcer. Which nursing dx should the nurse add to the care plan? a. readiness for enhanced nutrition b. impaired physical mobility c. impaired skin integrity d. chronic pain impaired peripheral tissues perfusion The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? a. imbalanced nutrition: less than body requirements b. impaired peripheral tissues perfusion c. risk for infection d. acute pain Determine the patients risk factors The nurse caring for an immobile patient wants to decrease the risk of formation of pressure ulcers. Which action will the nurse take first? a. offer favorite fluids b. turn the pt every 2 hours c. determine the pt's risk factors d. encourage increased quantities of carbohydrates and fats registered dietician which health care team member will the nurse consult when a pt has received a nursing diagnosis of impaired skin integrity? a. respiratory therapist b. registered dietician c. case manager d. chaplain The patient will remain free of odorous or purulent drainage from the wound When a comatose pt develops a stage II pressure ulcer, the nurse includes the nursing dx of risk for infection to the care plan. Which is the best goal for this pt? a. the pt will state what to look fo rwith regard to an infection. b. the pt family will demonstrate specific care of the wound site c. the pt family members will wash their hands when visiting the pt d. the pt will remain free of odorous or purulent drainage from the wound applying a gauze bandage to secure a nonsterile dressing when caring for a group of pt's, which task can the nurse delegate to the nursing assistive personnel? a. assessing a surgical pt for risk of pressure ulcers b. applying a gauze bandage to secure a nonsterile dressing c. treating a pressure ulcer on the buttocks of a medical patient d. implementing negative pressure wound therapy on a stable pt 1,3,4,5,6,2 the nurse performing a moist-to-dry dressing has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the following steps, starting with the first one? 1. Apply sterile gloves 2. Cover and secure topper dressing 3. Assess wound and surrounding skin 4. moisten gauze with prescribed solution y wring out excess solution and unfold 6. loosely pack until all wound surfaces are in contact with gauze After cleansing thoroughly dry the skin The nurse is caring for a pt at risk for skin impairment. Which initial action should the nurse take to decrease this risk. a. after cleansing thoroughly dry the skin b. request a therapeutic bed and mattress c. pad the bed with absorbent pads d. use products that retain moisture 2 hours or less at any one time a patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the pt to sit in the chair? a. 2 hours or less at any one time b. for a total of less than 3 hours daily c. no longer than 30 mins out of every hour d. until the pt expresses being uncomfortable utilize a transfer device to lift the pt the nurse is caring for a pt who is immobile and is at risk for skin impairment. the plan of care includes turning the pt. which is the best method for repositioning the pt? a. place the pt in a 30-degree supine position b. utilize a transfer device to lift the pt c. elevate the head of the bed 45 degrees d. slide the pt into the new position A stage I As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. which stage of ulcer did the nurse appropriately treat a. a stage I b. a stage II c. a stage III d. a stage IV Offer to explain what they should expect The pt appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take? a. distract the pt with the television b. offer to explain what they should expect c. suggests that the patient- close your eyes d. wait until family is visiting to support the pt Cleanse in a direction from the least contaminated area Which intervention should be included as the nurse cleanses the wound a. allow the solution to flow from the most contaminated to the least contaminated b. scrub vigorously when applying noncytotoxic solution to the skin c. cleanse in a direction from the least contaminated area d. utilize clean gauze and clean gloves to cleanse a site It supports the abdomen Which is the best explanation for the nurse to provide when teaching he pt, the reason for the binder after an open abdominal aortic aneurysm repair? a. it reduces edema at the surgical site b. it secures the dressing in place c. it immobilizes the abdomen d. it supports the abdomen apply ice The nurse is caring for a postoperative pt recovering from a medial meniscus repair of the right knee. which action should the nurse take to assist with pain management? a. monitor vital signs every 15 mins b. check pulses in the right foot c. keep the leg dependent d. apply ice 23 The pt has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? a. 12 b. 13 c. 20 d. 23 place moist sterile gauze over the site contact the surgical team monitor for shock The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (select all that apply) a. place moist sterile gauze over the site b. gently place the organs back c. contact the surgical team d. offer a glass of water e. monitor for shock Hemostasis Maturation Inflammatory Proliferative The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this pt? (Select all that apply) a. hemostasis b. maturation c. inflammatory d. proliferative e. reproduction f. reestablishment of epidermal layers a. "can you easily change your position"? b."Do you have sensitivity to heat or cold"? c. "How often do you need to use the toilets?" e. "Is movement painful?" The nurse is completing a skin assessment on a medical-surgical pt. Which nursing assessment questions should be included in a skin integrity assessment a. "can you easily change your position"? b."Do you have sensitivity to heat or cold"? c. "How often do you need to use the toilets?" d. "What medications do you take?" e. "Is movement painful?" f. "Have you ever fallen?" hyperemia induration blanching temperature of skin The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? a. vision b. hyperemia c. induration d. blanching e. temperature of skin Covered exposed wounds Assess the condition of current dressings Inspect the skin for abrasions and edema Assess the skin at underlying areas for circulatory impairment The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? a. Cover exposed wounds b. Mark the sites of all abrasions c. Assess the condition of current dressings d. Inspect the skin for abrasions and edema e. Cleanse the area with hydrogen peroxide f. Assess the skin at the underlying areas for circulatory impairment Skin is intact with no redness or swelling Non-blanchable erythema is absent No injuries to the skin and tissues are evident Granulation tissue is present The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievements of goals and outcomes? a. The patients expectations are not being met b. Skin is intact with no redness or swelling c. Non-blanchable erythema is absent d. No injuries to the skin and tissues are evident e. Granulation tissue is present Hydrocolloid Absorbs drainage through the use of exudate absorbers in the dressing Gauze Oldest and most common absorbent dressing transparent barrier to external fluids/bacteria but allows wound to breathe hydrogel Very soothing to the patient and do not adhere to the wound bed Calcium alginate Manufactured from seaweed and comes in sheet and rope form