NUR 227 Exam 1, Questions with Correct Answers 100% Already Graded A+ Excel

NUR 227 Exam 1, Questions with Correct Answers 100% Already Graded A+ Excel When removing the initial surgical dressing by order of the surgeon, the nurse assesses a moderate amount of watery pinkish-red bleeding at the site. The nurse accurately documents this drainage as: Sanguinous Serosanguinous Purulent Serous - CORRECT ANSWER-Serosanguinous Stage the pressure ulcer: -Full thickness tissue loss. -Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. -Slough may be present but does not obscure the depth of tissue loss. Stage II Stage III Stage I Stage IV - CORRECT ANSWER-Stage III The nurse is assessing a skin tear in an elderly patient that occurred from removal of tape that was applied to the skin. The edges of the wound are uneven and only the epidermis is involved. The nurse best classifies this wound as a(n): Puncture Wound Contusion Laceration Wound Penetrating Wound - CORRECT ANSWER-Laceration Wound A surgical wound that has become infected is edematous with purulent drainage and debris. The nurse knows it must heal by: Primary Intention Tertiary Intention Surgical Closure Secondary Intention - CORRECT ANSWER-Tertiary Intention Steroids and NSAIDs can interfere with wound healing by: Causing excessive bleeding Suppressing the inflammatory process Decreasing the oxygen carrying capacity of the blood cells Decreasing venous return - CORRECT ANSWER-Suppressing the inflammatory process The medical team orders a wound culture and antibiotic therapy on your newly admitted patient. Which of the following sequence of nursing interventions is correct? Obtain skin culture and then administer antibiotic therapy 6 hours from skin culture collection. Start antibiotic therapy and then immediately collect culture. Administer antibiotic therapy and then in 1 hour obtain skin culture. Obtain skin culture and then administer antibiotic therapy. - CORRECT ANSWER-Obtain skin culture and then administer antibiotic therapy. A patient states they are having intense itching between their fingers with brown linear lines presenting. Based on your nursing knowledge this best describes what condition? Scabies Eczema Impetigo Psoriasis - CORRECT ANSWER-Scabies A client is being admitted for the treatment of acute cellulitis of the thigh. The client asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include: A skin infection into the subcutaneous tissue and dermis. An epidermal and lymphatic infection caused by Staphylococcus. An inflammation of the epidermis only. An acute superficial infection of the lymphatics and dermis. - CORRECT ANSWER-A skin infection into the subcutaneous tissue and dermis. ________ are small, clear, fluid-filled blisters 10 mm in diameter and are commonly characteristic of herpes infections, acute allergic contact dermatitis, and some autoimmune blistering disorders. Plaques Papules Bullae Vesicles - CORRECT ANSWER-Vesicles ______ are hypertrophic scars that extend beyond the original wound margin. Keloids Ulcers Eschar Scabs - CORRECT ANSWER-Keloids As a knowledgeable nurse, you know that the following are part of the five rights except: Right drug Right Route Right room Right Person - CORRECT ANSWER-Right room When performing an assessment about medication, the drug history should include: Select all that apply Indication for the medication Does the client take OTC medications? Last physical therapy appointment Last set of vital signs - CORRECT ANSWER-Indication for the medication Does the client take OTC medications? Last set of vital signs Which of the following muscles is a possible site (by anatomical landmark standards) for IM injections? Shoulder Vastus Lateralis Outer edge of hip Vastus Gluteus - CORRECT ANSWER-Vastus Lateralis The nurse receives the preoperative blood work report for a female patient who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon? INR, 1.1 Hemoglobin, 12.2 Creatinine, 4.2 Albumin, 3.5 - CORRECT ANSWER-Creatinine, 4.2 The client's ability to take PO medications will be hindered by: Lifestyle Dysphagia Age Dental Caries - CORRECT ANSWER-Dysphagia The nurse is caring for a drowsy patient who returned from the PACU 10 minutes ago. Post-op orders include: IV of D5 NS with 20 meq KCL at 100 ml/hour, vital signs q1h, incentive spirometer q1h and continuous pulse oximetry. While taking the patient's vital signs, the nurse observes that the O2 sat has dropped to 91%. What is the next best nursing action?