If a surgical wound was closed with sutures, what is the healing process called?
primary
What is the medical term to describe thick, yellow
... [Show More] drainage?
purulent
Which of the following is correct management of cellulitis?
Use a tight bandage on the affected area
Do not apply heat to the affected area
Use a warm, moist towel on affected area
Use a cold, dry towel on affected area
Use a warm, moist towel on affected area
Which of the following is the best intervention for a patient that experiences pain during a dressing change?
Teach patient nonpharmacological pain control methods
Administer pain medications as indicated per the MAR
Complete the dressing change quickly to decrease amount of time in pain
Educate patient on foods that promote healing
Administer pain medications as indicated per the MAR
Wound healing is negatively impacted by poor nutrition (true/false)
true
What type of injury is a patient at risk for if they are in a high fowler's position (skin layers shift in opposite directions)?
Shearing injury
Friction injury
Pressure injury
Traumatic injury
Shearing injury
How can you help reduce the risk for friction and shear injuries for a patient that is bedridden?
Give a bed bath every other day
Elevate head of the bed to 45 degrees
Slide the patient up in bed by yourself
Use a mechanical lift to reposition the patient every 2 hours
Use a mechanical lift to reposition the patient every 2 hours
A post-op abdominal incision patient just had a bowel movement and noted a sharp pain in his abdomen. The nurse noted his bowel protruding from the incision. What is this called?
Dehiscence
Evisceration
Laceration
Approximation
Evisceration
What is the term to describe when the nurse presses down on an erythematous area of skin and the area becomes white?
Blanching
Warmth
Redness
Non-blanching
Blanching
Which age related change do you expect in the elderly?
Loss of elasticity of the dermal layer
Increased activity of the sebaceous glands
Increased regeneration of healthy skin
Loss of vernix caseosa
Loss of elasticity of the dermal layer
If a patient has HIV and then develops pneumonia, what type of infection is this?
Pathogenic infection
Opportunistic infection
Nosocomical infection
Fungal infection
Opportunistic infection
What is the best intervention to use for a patient just diagnosed with HIV?
Discuss the patient's support system
Call the hospital chaplain
Discuss the legal requirement to talk to partners
Offer to discuss with family for the patient
Discuss the patient's support system
What is a priority intervention for an immunocompromised patient?
Discuss whether this is short term or long term
Take vital signs every 4 hours
Teach patient/family that everyone should get the influenza vaccine yearly
Wash hands before entering patient's room
Wash hands before entering patient's room
What type of immunity is when antibodies are passed from mother to fetus through the placenta?
natural passive immunity
What type of precautions need to be taken for a patient admitted with TB?
airborne precautions
What PPE is required to enter a room if the patient has MRSA?
gown and gloves (not sterile)
What do you expect to see for lab values in a patient with HIV?
Low or high CD4+ T cells?
Low or high CD8+ T cells?
Lower than normal CD4+ T cells & Normal CD8+ T cells
What is the first step if you (the nurse) are stuck by a needle?
Wash/flush the exposed skin with water
What is a primary defense to infection?
Inflammation
Fever
Phagocytosis
Intact skin
Intact skin
If contact precautions are in place, what link in the chain of infection is broken?
Mode of transmission
If a patient recently traveled and developed a fever and cough, what type of isolation should the patient be placed in?
Airborne precautions
It is ok for a patient who is immunocompromised to have fresh flowers in his/her room (true/false)
false
Antiretroviral drugs are used to treat HIV and work by inhibiting viral replication (true/false)
true
A patient with systemic sclerosis (scleroderma) is likely to have what symptoms first?
Joint pain
Wrinkles
Raynaud's phenomenon
Hypertension
Raynaud's phenomenon
An intervention to avoid a Raynaud's flare up is to wear gloves in the winter (true/false)
true
What patient education is expected for a patient with fibromyalgia to help reduce symptoms?
Establish a regular sleep pattern
Do not exercise during a flare up
High intensity interval training (HIIT)
Increase calcium and caffeine intake
Establish a regular sleep pattern
A nurse is teaching a patient with debilitating rheumatoid arthritis about home safety. The following statement is appropriate: "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."(true/false)
true
What do you expect to see with the rheumatoid factor (lab) for a patient experiencing a flare up of her rheumatoid arthritis?
Positive RF
Negative RF
Positive RF
What assessment findings do you expect to see in a patient experiencing Raynaud's phenomenon?
Cold and purple nailbeds
Skin of hands may look white
A patient just had shoulder surgery and has rheumatoid arthritis. What symptoms might prompt the nurse to call the provider immediately?
Patient has gas and mild abdominal discomfort
Patient has a minor headache
Patient is completing physical therapy without her pain medication
Patient has numbness and tingling in her fingers and intense pain that is worsening in her shoulder
Patient has numbness and tingling in her fingers and intense pain that is worsening in her shoulder
What would be most concerning for a patient with SLE?
Butterfly rash
BP of 130/84
Fatigue
Urine output of 20 mL/hour
Urine output of 20 mL/hour
All of the following lab tests may be used to diagnose a connective tissue disease except:
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
Anti-nuclear antibody (ANA)
Rheumatoid Factor (RF)
Thyroid stimulating hormone (TSH)
Thyroid stimulating hormone (TSH)
All of the following are risk factors for osteoarthritis except:
Female
Older age
Obesity
Sports injuries
Vegan diet
Vegan diet
If medication is administered for a patient with rheumatoid arthritis, you would expect all of the following possible outcomes except:
Reduced inflammation
Increased range of motion
Cure the disease
Decreased pain
Increased quality of life
Cure the disease
You would expect to perform the following nursing intervention for a patient with SLE:
Apply topical hydrocortisone
Apply cold therapy to the extremities
Administer antibiotics
Encourage UV light exposure
Apply topical hydrocortisone
What is the goal of medication therapy in a patient with osteoarthritis?
Cure the disease
Improve the immune system
Reduce pain and inflammation
Increase weight loss
Reduce pain and inflammation
What is an appropriate statement by the nurse to complete a psychosocial assessment in a patient with severe rheumatoid arthritis?
Tell me about your medications.
What physical limitations do you have?
How does this impact your role in your family?
What therapies do you currently use?
How does this impact your role in your family?
The priority nursing assessment for a patient that verbalizes the inability to bathe for at least a month
inspection of the client's skin or skin integrity
Signs of adequate perfusion
Bounding pulses, pink fingers, and intact sensation
The priority nursing action for a patient in critical condition and is hypotensive
Maintaining the client's blood pressure
The expected next action of a bedrest patient complains of pain and burning in the right calf
Compare the circumference of one calf to the other
Best nursing intervention to prevent skin breakdown in a patient with impaired mobility
Rotate every 2 hours
This is the level of Maslow's Hierarchy of Needs that shelter belongs to
Safety and security
This is the priority intervention for a patient that speaks only Spanish
Request an interpreter
This is an event that can cause serious injury to a client that should never happen in a hospital
A sentinel event
This is an infectious disease that can be transmitted directly from one person to another
A communicable disease
This is the organization that publishes the National Patient Safety Goals
The Joint Commission
This is a vital sign that may change post operatively that can be related to pain
Blood pressure
This is the most reliable source when assessing pain
The patient
These are nonverbal signs of pain
Increased agitation, decrease attention span, grimacing, and increased heart rate
This is an intervention that should be done first if a patient's oxygen level is at 85%
Raising the head of the bed
This is the type of pain in a patient with an above the knee amputation may complain of distal to the amputation
Neuropathic pain
This is a priority nursing intervention for a patient with acute osteomyelitis
Administer antibiotics
These are all included in the evaluation of the neurovascular status of a patient post of ORIF of a femur fracture
Color, temperature, pulses, and sensation
This is a priority nursing intervention to prevent osteomyelitis
Using proper hand hygiene and strict infection control
This is the priority assessment for a patient with a femur fracture
Assessing pedal pulses
This is when the patient is experiencing acute pain greater than the severity of the fracture, pins and needle sensation, and weak/thready pulse on the affected extremity
Compartment syndrome
These are client education actions to administer eye drops
Instilling drops into the conjuctival sac, washing hands before instilling drops, and not contaminating eye drop cap
This is important patient education to include for a patient with glaucoma
Glaucoma will cause blindness if not treated
This is why glaucoma is irreversible
Once the tissue has necrosed from high pressure, it does not regenerate
This is the best nursing intervention to improve communication with a hearing impaired client
Speaking slowly and clearly while facing the client
This is the diagnosis when a patient complains of blurred vision, thinks his glasses need to be cleaned constantly, but denies any type of eye pain
Cataracts
This is the action the nurse should take to a 3 year old child who is coughing vigorously after aspirating a small object
Encourage the child to continue coughing
Crepitus occurs due to pieces of bone and cartilage floating (true/false)
true
If a patient is re-exposed to HIV, the progression to AIDS may be faster (true/false)
true
A low purine diet for a patient with gout would include the following:
Eat red meat instead of poultry
Limiting fruits
Avoid liver and other organ meats
Drinking only white wine
Avoid liver and other organ meats
It would be appropriate to apply rubbing alcohol to psoriasis plaques (true/false)
false
In a patient with AIDS that developed Pneumocystis Carinii, what is the priority assessment?
Assess pulses
Assess skin
Assess lung sounds
Assess heart sounds
Assess lung sounds
What is the priority action for a patient that states they are experiencing oozing from their wound?
Culture the wound
Apply ointment to the wound
Call the provider to start antibiotics
Inspect the wound and assess the drainage
Inspect the wound and assess the drainage
All of the following decrease the risk of pressure injuries except:
Placing pillows between bony surfaces
Padding hard surfaces
Keeping the head of the bed elevated to 75 degrees
Keeping the head of the bed at 30 degrees or less
Keeping the head of the bed elevated to 75 degrees
What is the term to describe a blood tinged liquid from a wound?
Creamy pus
Serous
Serosanguineous
Purulent exudate
Serosanguineous
The proliferative phase of wound healing occurs at the time of injury and lasts about 3-5 days (true/false)
false
All of the following are opportunistic infections associated with AIDS except:
Pheumocystis Jiroveci Pneumonia
Hodgkin's lymphoma
Candidiasis
Clostridium Difficile
Hodgkin's lymphoma
All of the following are early signs and symptoms of rheumatoid arthritis except:
Anorexia and weight loss
Inflammation in the joints
Bilateral, symmetrical symptoms
Fever
Fever
What lab test would be expected for a patient with SLE complaining of flank pain?
CBC
Creatinine
INR
Sodium
Creatinine
The nurse can break the chain of infection by maintaining integrity of the skin at the portal of entry (true/false)
true
All of the following are potential complications for rheumatoid arthritis except:
Paresthesias
Joint deformity
Fibromyalgia
Dry eye
Fibromyalgia
The nurse should teach a patient with AIDS all of the following about nutrition and hydration except:
Choose foods high in protein
Drink 2-3 L of fluids per day
Eat as many fruits/veggies as you can
Eat high calorie foods
Eat as many fruits/veggies as you can
Which is the first step in collecting a wound culture?
Label the specimen tube
Remove the soiled dressing
Put on non sterile gloves
Irrigate the wound
Put on non sterile gloves
Heat and ice can be used to relieve discomfort in a patient with osteoarthritis (true/false)
true
All of the following statements would require further teaching for a patient with HIV except:
"I need to place my needles in a proper disposable container"
"HIV can spread through touch, so I need to wear gloves in public"
"It is okay to have unprotected sex since my partner does NOT have HIV"
"If I have HIV, that means I have AIDS"
"I need to place my needles in a proper disposable container"
What is the best nonpharmacological intervention to reduce pain and swelling in rheumatoid arthritis joints?
Ice packs for up to an hour
Ice packs for up to 20 minutes
Heat for 20 minutes
High impact exercises
Ice packs for up to 20 minutes
What is the term to describe black, necrotic tissue?
Eschar
Cellulitis
Blanching
Tunneling
Eschar
A patient with rheumatoid arthritis also complains of dry eyes. You would suspect Sjogren's syndrome (true/false)
false
CREST stands for calcinosis, Raynaud's Esophageal dysmotility, Scherodactyly, and Telangiectasia (true/false)
true
How long should you wait to take an oral temperature for a patient that just ate ice chips?
1 minute
30 minutes
You don't need to wait
1 hour
30 minutes
Protein has amino acids that promote wound healing (true/false)
true
All of the following are steps in preparing a sterile field except:
Cover the sterile field once it is set up
Prepare the client before setting up the sterile field
Add items to the sterile field by dropping them gently
Do not turn away from the sterile field
Cover the sterile field once it is set up
All of the following might indicate infection in an HIV patient except:
Purulent drainage
Temp of 101.3
O2 at 97%
Respirations at 22
O2 at 97%
All of the following are interventions to prevent dry skin except:
Using a humidifier during the winter
Drink 3000 mL of water daily
Shower in hot water every day
Avoid tight belts
Shower in hot water every day
Which stage is a wound that is a shallow, open, reddened ulcer with no slough on the anterior region?
Stage 1
Stage 2
Stage 3
Stage 4
Stage 2
All of the following are utilized in the braden scale assessment except:
Nutrition
Sensory perception
Age
Friction and shear
Age
All of the following are nursing interventions to decrease risk of pressure injury except:
Using a hoyer lift for all transfers
Cleansing the skin routinely after soiling occurs
Massaging the client's reddened shoulders and heels
Applying moisturizer to dry areas of skin
Massaging the client's reddened shoulders and heels
You would expect all of the following nonpharmacological pain management for a rheumatoid arthritis patient except:
Adequate rest
Frequent running
Heat for 20-30 minutes
Hot showers
Frequent running
Alcohol can trigger a gout attack (true/false)
true
All of the following should be included when documenting about exudate except:
Odor
Heat
Color
Consistency
Heat
All of the following are patient education for preventing MRSA except:
Wash hands with soap and water before touching infected area
No contact sports until infection is gone
Use antibacterial soap in bath/shower
Use a bath sponge to clean skin
Use a bath sponge to clean skin
The patient complains of fatigue, joint pain, and inability to walk due to pain in the knees. What is the best response?
Just take some ibuprofen, its only arthritis
Do not walk
Tell me more about when your pain started
You will have to lose weight to get rid of the pain
Tell me more about when your pain started
What is the priority nursing intervention for a patient that just had a total hip arthroplasty?
Observe for mental status change
Complete a neurovascular assessment
Cross the patient's legs
Elevate the patient's heels
Complete a neurovascular assessment
Rheumatoid arthritis presents with unilateral joint pain (true/false)
false
What would you expect as a finding in a patient complaining of her leg being hot, red, and painful?
Deep vein thrombosis
Kidney failure
Appendicitis
Pneumonia
Deep vein thrombosis
A pressure injury that is 5 cm by 3 cm with bone and tendon noted at the base would be a stage 4 pressure injury (true/false)
true
A patient moved up in bed by a UAP and nurse and the patient develops an injury to his heel, what caused this injury?
Friction or shearing
Chemical or pressure
Twisting and bending
Pressure or gravity
Friction or shearing
Psoriasis is patches of thick, red skin with silvery scales frequently found on client's elbows and knees (true/false)
true
All of the following can cause pressure ulcers except:
Adequate perfusion
Immobility
Poor nutrition
Ischemia
Adequate perfusion
What is a class symptom seen in a patient with lupus?
Butterfly rash
Herberden's nodes
Chvostek's sign
Ovide's sign
Butterfly rash
The nurse should educate a patient with AIDS to do all of the following to reduce risk of infection except:
Wash hands
Avoid raw fruits/veggies
Avoid crowds
Share toothpaste with family members
Share toothpaste with family members
All of the following are negative lifestyle habits that affect skin integrity except:
Tanning
Regular exercise
Smoking
Tattoos
Regular exercise
It is important to teach your patient with osteoarthritis to take no more than 2000mg of acetaminophen a day (true/false)
false
What should a patient taking ibuprofen watch for as an adverse effect?
Insomnia
Bleeding
Blurred vision
Constipation
Bleeding
Which of the following is the most concerning finding when assessing skin over a bony prominence?
Non blanching
Blanching
Redness
Warmth
Non blanching
What is the term to describe where an abnormal passage occurs connecting 2 body cavities or a cavity and the skin?
Fistula
Infection
Evisceration
Hemorrhage
Fistula
If a patient feels a "popping" sensation in his wound, what is this called?
Laceration
Dehiscence
Approximation
Evisceration
Dehiscence [Show Less]