Final Exam: NR224/ NR 224 Fundamentals – Skills Final Exam Comprehensive Review| Guide with Verified Answers| 2023/2024 New Update| 100% Correct
... [Show More] |Chamberlain
QUESTION
A nurse educator is reviewing the wound healing process with a group of nurses. Which of the following should be included in the information regarding what wounds heal by secondary intention? (Select all that apply) A. Stage III pressure injury
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area
Answer: A. Stage III pressure injury
E. Open burn area
QUESTION
A nurse is caring for patients with a variety of wounds. Which wound will most likely heal by primary intention?
Cut in the skin from a kitchen knife
Excoriated perianal area
Abrasion of the skin
Pressure ulcer
Answer:
QUESTION
Cut in the skin from a kitchen knife
QUESTION
A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good. " Upon assessment, you note an elevated temperature. What other indication would indicate the wound is infected?
A. it has no odor.
B. a culture is negative.
C. the edges reveal the presence of fluid.
D. it shows purulent drainage coming from the incision site.
Answer: D. it shows purulent drainage coming from the incision site.
QUESTION
Systems involved in mobility
Answer: Musculoskeletal & Neurological
QUESTION
Respiratory immobility interventions
Answer: -Deep breathing and coughing
-Incentive spirometer
-Positioning changes
-Oxygen therapy
-Chest physiotherapy (Chest PT)
-Suctioning
-Hydration (oral or IV fluids)
QUESTION
Cardiovascular immobility interventions
Answer: -Anti-embolitic Stockings (TED
hose)
-Change position q2hr
-Anticoagulants (heparin, Lovenox, etc. )
-Dangle patient when sitting or prior to standing
QUESTION
Musculoskeletal immobility interventions
Answer: -Active and passive ROM
-Isometric exercises
-Physical therapy
-Braces & supports to prevent foot drop and contractures
-Use of assistive devices
-Positioning
QUESTION
Integumentary immobility interventions
Answer: -Frequent skin assessments
-Turn client q2hr
-Use therapeutic bed or mattress
-Use of corrective devices
-Use of supportive devices
-Monitor diet and fluid intake
-Skin care; keep client clean and dry
QUESTION
URINARY/KIDNEY/RENAL immobility interventions
Answer: -Positioning of client
-I/O
-Hydration status
-Potential for alternative nutrition
QUESTION
The effects of immobility on the cardiac system include which of the following? (Select all that apply)
A. Thrombus formation
B. Increased cardiac workload
C. Weak peripheral pulses
D. Irregular heartbeat
E. Orthostatic hypotension
Answer: A. Thrombus formation
B. Increased cardiac workload
E. Orthostatic hypotension
QUESTION
A client has been on bed rest for 5 days. Which of the findings during assessment indicate a complication of immobility?
A. Decreased peristalsis
B. Decreased heart rate
C. Increased blood pressure
D. Increased urinary output
Answer: A. Decreased peristalsis
QUESTION
A nurse is caring for a client who has been sitting in a chair for 2 hours. Which of the following complications is the greatest risk to the client?
A. Muscle atrophy B. Fecal impaction C. Pressure injury
D. Pneumonia
Answer: C. Pressure injury
QUESTION
Principles of body mechanics
Answer: -Use arm & leg muscles to lift
- Have Item/client close to you
-Feet shoulder width apart and bed at knees
-Contract/tighten abdominal & gluteal muscles
-Push, pull or roll items if able instead of lifting
-DO NOT twist at waist or hips- move feet instead [Show Less]