DAVIS ADVANTAGE CHAPTER 50 QUESTIONS WITH COMPLETE ANSWERS.

DAVIS ADVANTAGE CHAPTER 50
QUESTIONS WITH COMPLETE
ANSWERS.

The nurse is assigned to a patient who is preparing to go to surgery for wound
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debridement. The nurse explains to the patient the purpose of the wound
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debridement, including which of the following? Select all that apply.
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Facilitates healing bb



Removal of tissue for a biopsy
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Removal of necrotic tissuebb bb bb



Reduces the risk of infection
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Reduces the risk of fluid imbalance - ANSWER:
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The nurse is explaining to the student nurse the difference between undermining and
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tunneling. How should the nurse explain the two terms?
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"Undermining is measuring a passageway under the skin surface and tunneling is the
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destruction of tissue extending under the wound edges."
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"Undermining is the measurement of the wound's length from head to toe and
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tunneling is the measurement of the wound's widest point perpendicular to the
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length."
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"Undermining is the destruction of tissue under the wound edges and tunneling is the
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development of a passageway under the skin's surface."
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"Undermining is the development of infection in the wound bed of the wound and
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tunneling is the development of necrotic tissue over the wound." - ANSWER:
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"Undermining is the destruction of tissue under the wound edges and tunneling is the
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development of a passageway under the skin's surface."
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The nurse is caring for a patient at risk for skin breakdown. Which nursing
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interventions are appropriate to implement to minimize the effects of injury? Select all
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that apply.
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Keep the head of the bed less than 60 degrees.
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Use a draw sheet when moving the patient.
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Minimize the amount of time the patient is in one position.
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Firmly massage reddened areas noted on the back, hips, and coccyx.
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Use alcohol-based skin products. - ANSWER:
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Upon admission, the nurse knows that all patients must be assessed using the
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Braden Scale to evaluate the patient's risk for skin breakdown. Which of the following
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areas are included when assessing the patient using the Braden Scale? Select all
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that apply.
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, Activity
Nutrition
Mobility
Body mass index bb bb



Gender - ANSWER: bb bb bb




The nurse is caring for a client who has a large full-thickness burn and is going to the
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operating room to have a burn excision. The nurse notes on the surgical consent that
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an allograft is planned. The tissue for an allograft is from which source?
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The client's own skin
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The skin from a pig bb bb bb bb



The skin from a cadaver
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The skin grown in the lab from a biopsy of the client's own skin - ANSWER: The skin
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from a cadaver
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The nurse is caring for a client in the intensive care unit who is 36 hours post-deep
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partial-thickness burn to the left lower extremity. Which nursing interventions would
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be in place to decrease the development of compartment syndrome?
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Monitor pulses in both burned and unburned extremities every 8 hours.
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Assess pulses hourly in burned and unburned extremities.
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Monitor sodium and potassium levels every 4 hours.
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Maintain the head of the client's bed at 45 degrees. - ANSWER: Assess pulses hourly
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in burned and unburned extremities.
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A client with a major burn injury is at great risk of burn shock. What factor causes this
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type of shock?
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Infection
Massive fluid shift bb bb



Loss of blood bb bb



Organ dysfunction - ANSWER: Massive fluid shift
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The nursing student is observing in the burn unit. The student would expect to see
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which infection control measures implemented in the burn unit? Select all that apply.
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Contact precautions for all client interactions
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Use of antibiotic-coated intravenous and central line catheters
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Use of betadine hand scrub by nursing staff before and after caring for clients
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Changing Foley catheters every 72 hours bb bb bb bb bb




Use of disposable equipment such as blood pressure cuffs and stethoscopes -
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ANSWER: Contact precautions for all client interactions
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Use of antibiotic-coated intravenous and central line catheters
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