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Fundamental 2 test 3
Terms in this set (50)
1. Place pad under the infected hand.
2. Open sterile irrigation basin and solution.
3, Pour irrigating solution in basin.
4. Don sterile gloves to apply dressing.
5. Irrigate keeping the syringe tip 1 inch from the wound surface.
6. Pat wound dry and redress.
7. Document procedure.
The nurse irrigating an infected wound of the hand would: (Prioritize the steps.
An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse is, "Do not use antidiarrheal medication for longer than _____ hours without calling back for an appointment."
the medication with a large amount of fluid
An elderly patient who routinely takes the bulk-forming laxative psyllium (Metamucil) is counseled by the home health nurse that in order to prevent constipation and possible fecal impaction, this patient should be sure to take:
An elderly resident in a long-term care facility has experienced constant diarrhea for 3 days and is now exhibiting signs and symptoms of dehydration. The nurse initiates an intervention to offer small amounts of ________ frequently.
A nurse caring for a patient with a stage I pressure ulcer would most appropriately select a(n) _____ dressing
occlude air and promote breakdown of necrotic tissue.
A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:
Non distended, soft with active bowel sounds
A nurse has performed abdominal assessments on four patients. After reviewing the findings, the nurse is least concerned about problems with bowel elimination for the patient with abdomen _____ bowel sounds in all four quadrants.
Assist the patient in a supine position
A nurse is ambulating a patient in the hall a few days after abdominal surgery and the patient says, "I think something just let go." The initial intervention by the nurse should be to:
restlessness, rising pulse, and falling blood pressure
A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by _____ blood pressure.
A nurse is caring for a patient who had bowel surgery 3 days ago and is now beginning to have a well-functioning ostomy. The ostomy drainage bag should be emptied whenever it is:
cleanse patients from the rectum to the urinary meatus
A nurse is instructing one of the facility's unlicensed assistive personnel (UAP) in ways to prevent health care-associated infections. The nurse recognizes that further instruction is warranted when the UAP states, "I will:
A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measures to assist with bowel elimination if the patient has not had a bowel movement within how many days?
Use of enema
A nurse is reinforcing teaching with a patient who will begin a bowel training program. An intervention this program does not include is:
supine with the head tilted toward the right eye.
A nurse performing a right eye irrigation will position the patient:
A nurse removing wound staples would engage the staple puller and squeeze the handles completely and:
A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a(n):
From each of the four sides toward the wound
A patient is due for a wound dressing change for a horizontal lower abdominal incision. In which direction should the nurse pull to remove the tape from the old dressing?
repeated enemas may cause electrolyte imbalance.
A patient scheduled for bowel surgery has an order to receive enemas until clear. The nurse is aware that no more than three enemas should be given because:
A patient who has started antibiotic therapy is having diarrhea as a side effect of the medication. The nurse should encourage the patient to eat:
A patient who is badly constipated has just received an oil-retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?
uses one alcohol wipe to clean both the spout and the plug.
A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:
A patient with a colostomy asks about foods that can be eaten that will reduce odor in the ostomy drainage bag. The most informative response by the nurse is to say that ostomy odor can be decreased with the intake of:
No answers were there instructor says about a quarter inch
A patient with a new colostomy should have the hole in the faceplate cut to allow _____ inch around the stoma.
Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use:
prepare a new sterile field if it becomes wet during the procedure.
The nurse adding sterile liquids to a sterile field should:
The nurse caring for a patient with lactose intolerance would anticipate the need to offer interventions for:
Add normal saline to loosen it
The nurse changing a wet-to-damp normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:
allows drainage to seep through the barrier and be absorbed on the other side.
The nurse chooses a nonadherent dressing to apply to a wound because the nonadherent dressing:
drawing the wound edges together by negative pressure.
The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:
The nurse clarifies that the first stage of wound healing is:
laceration with edges that do not approximate.
The nurse gives an example of a wound that heals by second (secondary) intention as a:
Presence of occult blood
The nurse has assessed that a patient's stool has changed from brown to dark black and sticky. The nurse suspects:
Frothy and foul smelling
The nurse has documented that a patient has had two episodes of steatorrhea, which means that the character of the stool is:
Whole kernel corn, tomatoes, and shrimp.
The nurse instructs a patient with a new colostomy against eating food that may cause an obstruction. These foods include:
increased serosanguineous drainage from the wound.
The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
The nurse is aware that the only necrotic wound for which debridement is not recommended is a pressure ulcer located on the:
What about your colostomy scares you?
The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, "I am so scared." The nurse's most supportive response would be:
point out the possible break in surgical asepsis and provide another set of sterile gloves and a fresh sterile field.
The nurse is helping the physician perform a sterile procedure at the bedside. Halfway through the procedure, the nurse believes the physician has contaminated the sterile field. The nurse should:
in a circular motion around the wound circling to the outside.
The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:
The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by _____ intention.
The nurse performing a surgical scrub is aware that the average time for the scrub is _____ minutes.
atrophy of the villi in the small intestine., decreased absorption of fats and vitamin B12., decreased motility in the large intestine.
The nurse points out that age-related changes in the intestinal tract are relatively insignificant. The changes include:
the hands are kept lower than the elbows during the surgical scrub.
The nurse recognizes a break in aseptic technique when:
atherosclerosis., diminished lung function., slow metabolism
The nurse reminds the 85-year-old patient that his healing will be slower because of age- related changes such as:
absorb food substances from the bloodstream.
The nurse reminds the patient that digestion of food is a complex process with much of the food breaking down in intestines. The small intestine functions to:
The nurse warns the patient that one of the patient's habits has caused the reduction of functional hemoglobin, which limits the hemoglobin's oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit:
colostomy is an opening into the colon, whereas an ileostomy is an opening at the ileum.
The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that a(n):
The patient with the new colostomy is concerned about how to control diarrhea of the effluent. The nurse suggests that diarrhea can be controlled by the intake of:
500 to 1000
There is an order to administer a cleansing enema to an adult patient before bowel surgery. The nurse will fill the enema bag with how many milliliters of fluid for this procedure?
vessels have dilated and allowed plasma to leak into the wound site.
When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:
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