NUR 330 Exam #4 NCLEX Questions

Where do you usually find a pressure ulcer?
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Where do you usually find a pressure ulcer?
Over a bony prominence
What are four predisposing factors for pressure ulcers?
limited mobility
poor nutrition
comorbidities
aging skin
What is the pathophysiology of a pressure ulcer creation?
The external pressure is greater than the capillary pressure and clamps the capillaries shut. This causes ischemia and tissue damage
Where are the 5 most common places to get a pressure ulcer? (hint: 3 on the back, 2 on the sides)
Back: Sacrum, Heels, Ischial Tuberosity
Sides: Greater Trochanter, Lateral Malleoli
what are four ways you can prevent stress ulcers?
-patient repositioning schedule
-keep head of bed at lowest safe elevation to prevent shear (<30 degrees)
-using pressure-reducing surfaces
-assessing nutrition/providing supplementation
How often should people who are bed ridden be respositioned to prevent pressure ulcers?
every 2 hours
what is ideal for wound cleansing?
saline
if the wound takes longer than this amount of time to heal on its own, you should consider antibiotics.
2 weeks
3 other names for pressure ulcers
decubitus ulcers
bedsores
pressure sores
Image: 3 other names for pressure ulcers
what two reasons would you see a pressure sore in a younger patient (<65)?
severe illness
neurologic impairment
This stage of pressure ulcer has intact skin with non-blanching redness?1This stage of pressure ulcer has shallow, open ulceration with a red-pink wound bed?2This stage ulcer has a full-thickness tissue loss with visible subcutaneous fat?3This stage ulcer has full thickness tissue loss with exposed muscle and bone?4This stage of ulcer is full-thickness tissue loss with base covered by slough?Unstageable4 methods of debridement (removal of necrotic tissue)?sharp mechanical enzymatic autolyticWhat is sharp debridement?Sharp: sterile scalpel or scissors are used to remove necrotic tissue or infected areasWhat is mechanical debridement? (4)Includes wet-to-dry dressings, hydrotherapy, wound irrigation, whirlpool bathsWhen should you use enzymatic debridement?Long-term care of patients who cannot tolerate sharp debridementwhy do we use saline to clean wounds instead of antiseptic agents?antiseptic agensts destroy granulation tissuedressings that maintain a moist wound environment facilitate healing and can be used for _____ debridementautolyticWhat is the advantage of using a hydrogel dressing? what stage(s) of ulcer(s) can it be used on?reduces pain and rehydrates wound also easy to apply and remove stages 2,3,4what is the advantage of transparent film dressing? what stages of ulcers can it be used on?allows for wound observation does not require secondary dressing (ex tape, wrap) 1,2what is the advantage of hydrocolloid dressing? what stages of ulcers can it be used on?facilitates autolytic debridement me be applied over alginate may be used under compression products 1-4what are those side effects of bacteremia again?hypotension fever tachycardia altered mental statusIf there is no improvement of the pressure ulcer after 14 days of treatment, what should you do?Topical Antibiotics with dressings and wound cleaningIf there is no improvement of the pressure ulcer after 2-4 weeks of treatment, what should you do?Obtain tissue culture and consider osteomyelitispurulentincluding yellow, gray and green discharge - always appears milky and with an especially thick consistency. Usually a sign of infectionserousclear, watery plasma. If excessive it may indicate the presence of bacteria.sanguinous drainageThis drainage refers to actual blood, a normal occurrence during the very initial stages of almost any wound type.serosanguineous drainagethin, watery drainage that is blood-tinged. May be yellow in color. The pinker the color the more blood present which indicates capillary damage.1. You are assigned four patients on your nursing unit. Which patient is at most risk for pressure ulcers? A) A 72 year old female weighing 82lbs with stress incontinence and dementia. B) A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities. C) A 6 month old with the flu. D) An ambulatory 88 year old with dementia who is admitted with shingles.A) A 72 year old female weighing 82lbs with stress incontinence and dementia.2. A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at greatest risk? A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bonesC. Thinning of the skin, with loss of elasticity3. As a home care nurse, you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming? A. Exercise the extremities actively and passively. B. Turn and reposition the patient every 2 hours. C. Keep the skin moist and layer the sacral area with extra sheet layers. D. Use pillows to elevated bony prominences.C. Keep the skin moist and layer the sacral area with extra sheet layers.4. The home health registered nurse is reinforcing instructions to the family about how to prevent pressure ulcers for their family member who is bedridden. Which measure should the RN discuss? A) Lift the client when turning to prevent sliding B) Massage directly over reddened sites C) Change client's position every 4 hours D) Place pillows under both kneesA) Lift the client when turning to prevent sliding5. A nurse is using the Braden scale to assess a patient's risk for pressure ulcer formation. Upon assessment, the patient's sensory perception appears to be slightly limited, is occasionally moist, mobility is slightly limited, and walks occasionally. Nutrition is adequate and friction is a potential problem. What is this patient's risk? A) High B) Very High C) Mild D) ModerateC) Mild6. The home health RN is assessing an older client for a pressure ulcer. Which finding should the RN observe the area for a Stage 1 pressure ulcer? A) Superficial skin breakdown and flaking B) Deep, pink, red, or mottled skin C) Subcutaneous damage or necrosis D) Skin that blanches pink when pressedB) Deep, pink, red, or mottled skin7. The RN is assessing the skin of an older client. Which finding should the nurse document as consistent with the normal aging process? A) Decreased elasticity B) Tough and leathery texture C) Shiny and edematous D) Excessive hair growth on the headA) Decreased elasticity8. An older client who is a resident in a long term facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin B) Localized dry skin on the lower extremities C) Red flush over entire skin surface D) Rashes in the axillary, groin, and skin fold regionsD) Rashes in the axillary, groin, and skin fold regions9. Which patient position would simultaneously relieve pressure from the sacrum and the trochanter? (Lippincott Williams & Wilkins, 2015) A) Supine B) 30-degree lateral position C) 90-degree side-lying position D) Sitting uprightB) 30-degree lateral position10. On a full body admission assessment, you note the patient has a stage 3 pressure ulcer. How would you document the appearance of the wound? A. Area is red and does not blanch. B. Full-thickness skin loss to dermis and subcutaneous tissues. C. Partial thickness of dermis with shallow open ulcer. D. Full thickness with bone and tendon visible.B. Full-thickness skin loss to dermis and subcutaneous tissues.What should the nurse teach the client to do to prevent stress incontinence? Select all that apply. A) Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises. B) Avoid dietary irritants (e.g., caffeine, alcoholic beverages). C) Not to laugh when in social gatherings. D) Carry an extra incontinence pad when away from home E) Obtain a fluid intake of 500 mL/ day.A Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises. B Avoid dietary irritants (e.g., caffeine, alcoholic beverages). Rationale: Laughing may be a part of one's socialization, so it should not be discouraged. In non-restricted clients, a fluid intake of at least 2 to 3 L/ day is encouraged; clients with stress incontinence may reduce their fluid intake to avoid incontinence at the risk of developing dehydration and urinary tract infections. Establishing a voiding schedule would be more effective in the prevention of stress incontinence rather than carrying incontinence pads. Dietary irritants and natural diuretics, such as caffeine and alcoholic beverages, may increase stress incontinence. Kegel exercises strengthen the sphincter and structural supports of the bladder.2. The primary goal of nursing care for a client with stress incontinence is to: A) Help the client adjust to the frequent episodes of incontinence. B) Eliminate all episodes of incontinence. C) Prevent the development of urinary tract infections. D)Decrease the number of incontinence episodes.D)Decrease the number of incontinence episodes. Rationale: The primary goal of nursing care is to decrease the number of incontinence episodes and the amount of urine expressed in an episode. Behavioral interventions (e.g., diet and exercise) and medications are the nonsurgical management methods used to treat stress incontinence. Without surgical intervention, it may not be possible to eliminate all episodes of incontinence. Helping the client adjust to the incontinence is not treating the problem. Clients with stress incontinence are not prone to the development of urinary tract infection.3. The nurse is developing a teaching plan for a client with stress incontinence. Which of the following instructions should be included? A) Avoid activities that are stressful and upsetting. B) Avoid caffeine and alcohol. C) Do not wear a girdle. D)Limit physical exertion.B) Avoid caffeine and alcohol. Rationale: Clients with stress incontinence are encouraged to avoid substances, such as caffeine and alcohol, that are bladder irritants. Emotional stressors do not cause stress incontinence. It is most commonly caused by relaxed pelvic musculature. Wearing girdles is not contraindicated. Although clients may want to limit physical exertion to avoid incontinence episodes, they should be encouraged to seek treatment instead of limiting their activities.4. A client has urge incontinence. When obtaining the health history, the nurse should ask if the client has: A) Inability to empty the bladder. B) Loss of urine when coughing. C) Involuntary urination with minimal warning. D) Frequent dribbling of urine.C) Involuntary urination with minimal warning. Rationale: A characteristic of urge incontinence is involuntary urination with little or no warning. The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress incontinence. Frequent dribbling of urine is common in male clients after some types of prostate surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.5. Which of the following interventions would be most appropriate for a client who has urge incontinence? A) Have the client urinate on a timed schedule. B) Provide a bedside commode. C) Administer prophylactic antibiotics. D) Teach the client intermittent self-catheterization technique. E) Have the client urinate on a timed scheduleA) Have the client urinate on a timed schedule. Rationale: Instructing the client to void at regularly scheduled intervals can help decrease the frequency of incontinence episodes. Providing a bedside commode does not decrease the number of incontinence episodes and does not help the client who leads an active lifestyle. Infections are not a common cause of urge incontinence, so antibiotics are not an appropriate treatment. Intermittent self-catheterization is appropriate for overflow or reflux incontinence, but not urge incontinence, because it does not treat the underlying cause.6. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? A) The bladder distends and its capacity increases. B) Older adults ignore the need to void. C) Urine becomes more concentrated. D) The amount of urine retained after voiding increases.D) The amount of urine retained after voiding increases. Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3).7. During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. A) Perineal skin irritation B) Fluid intake of less than 1,500 mL/day C) History of antihistamine intake D) History of frequent urinary tract infections E) A fecal impactionA) Perineal skin irritation B) Fluid intake of less than 1,500 mL/day D) History of frequent urinary tract infections E) A fecal impaction Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3).8. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? A) Leaves the catheter in place and gets a new sterile catheter. B) Leaves the catheter in place and asks another nurse to attempt the procedure. C) Removes the catheter and redirects it to the urinary meatus. D) Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatusA) Leaves the catheter in place and gets a new sterile catheter. Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus9. Urinary incontinence is not a normal part of aging. An intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include: A) Bladder training B) Habit training C) Prompted voiding D) Fluid restrictionD) Fluid restriction Rationale: Fluids would be encouraged, to allow the kidneys to be flushed and urine to be formed. Bladder training requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable, rather than according to an urge. Habit training is also referred to timed or scheduled voiding. There is no attempt to motivate the client to delay voiding if the urge occurs. Prompted voiding supplements habit training by encouraging the client to try to use the toilet and reminding the client when to void.10. The goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. Which of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? A) Having the client drink up to 2000 mL per day B) Encouraging the client to eat foods that increase the acid in the urine C) Routine hygienic care D) Changing indwelling catheters every 72 hours.D) Changing indwelling catheters every 72 hours. Rationale: Retention catheters are removed after their purpose is achieved; routine changing of the catheter or drainage system is not recommended. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Eating foods that increase the acid in urine helps to reduce the risk of urinary tract infections and stone formation. Hygiene care related to catheters is set by hospital policy.Loss of urine with cough, sneeze, or exertion a. Stress incontinence b. Urge incontinence c. Overflow incontinence d. Functional incontinenceAWhat type of incontinence is most common in men? a. Mixed b. Urge c. Stress d. FunctionalBThis type of incontinence is seen commonly in patients with Alzheimer's, Parkinson's and severe arthritis. a. Functional b. Overflow c. Stress d. FunctionalAIncontinence is most commonly associated with elderly ________.femalesThe parasympathetic NS promotes bladder _________ while the sympathetic NS promotes bladder ____________. a. filling, voiding b. voiding, fillingBFalse incontinence is also known as ___________ incontinence, and is secondary to incomplete emptying due to impaired detrusor contractility (neurogenic bladder) or bladder outlet obstruction a. Functional b. Overflow c. Stress d. ExtraurthralBWhat type of incontinence is most common in women? a. Mixed b. Urge c. Stress d. FunctionalCRisk of incontinence increases in both genders with what risk factor? a. Obesity b. Advancing age c. Type of delivery d. ParityBThe most common cause of female stress incontinence is: a. Intrinsic sphincter deficiency b. Urinary retention c. Detrusor overactivity d. Urethral hypermobilityDThe most common cause of male stress incontinence is: a. Radiation b. Prostate surgery c. Urethral hypermobility d. Urinary retentionBInvoluntary loss of urine accompanied by or immediately preceded by sudden urge a. Stress incontinence b. Unconscious incontinence c. Overflow incontinence d. Urge incontinenceDSymptoms of urgency +/- urge incontinence is called:Overactive bladder (OAB)What test is helpful in distinguishing the mechanism of leakage? a. Cystoscopy b. Urodynamics c. Uroflometry d. Pad TestingBThe nurse writes a dx of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply. A.Monitor the clients hemoglobin and hematocrit B.Move the client to a room near the nurses desk C.Limit the clients dietary intake of green vegetables D.Assess the client for numbness and tingling E.Allow for rest periods during the day for the clientA,B,D,EThe client was dx with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client? A.Take Imodium, and anti diarrheal, OTC for diarrhea B.Limit exercise for several weeks until a tolerance is achieved C.The stools may be very dark, and this can mask blood D.Eat only red meats and organ meats for proteinCThe nurse is admitting a 24 year old American American female client with a dx of rule-out anemia. The client has a hx of gastric bypass surgery for obesity 4 years ago. Current assessment findings include height 5'5, wt. 75 kg, P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed? A.Vitamin B12 deficiency B.Folic acid deficiency C.Iron deficiency D.Sickle cell anemiaAThe nurse and AP are caring for clients on a medical unit. Which task should the nurse delegate to the AP? A.Check on the bowel movements of a client dx with melena B.Take vital signs if a client who received blood the day before C.Evaluate the dietary intake of a client who has been noncompliant with eating D.Shave the client dx with severs hemolytic anemiaBThe client is being admitted with Folic acid deficiency anemia. Which would be the most appropriate referral? A.Alcoholics anonymous B.Leukemia society of America C.A hematologist D.A social workerAThe charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse? A.The client dx with iron-deficiency anemia who is prescribed iron supplements B.The client dx with pernicious anemia who is receiving vitamin B12 IM C.The client dx with aplastic anemia who has developed pancytopenia D.The client dx with renal disease who has deficiency of erythropoietinCThe client dx with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first? A.Apply oxygen via nasal cannula B.Get a wheelchair for the client C.Assess the clients lung fields D.Assist the client when ambulating in the hallBThe nurse is discharging a client dx with anemia. Which discharge instruction should the nurse teach? A.Take prescribed iron until it is completely gone B.Monitor P and BP at local pharmacy weekly C.Have complete blood count checked at the HCP's office D.Perform isometric exercise three times a weekCThe nurse writes a client problem of "activity intolerance" for a client dx with anemia. Which intervention should the nurse implement? A.Pace activities according to tolerance B.Provide supplements high in iron and vitamins C.Administer packed red blood cells D.Monitor vital signs q4hAA patient has compliants of pain around one eye and it radiates to the temple and forehead. What headache is the patient experiencing? A. Cluster B. Sinus C. Migraine D. TensionA. ClusterThe patient is experiencing nausea, vision changes, and pain in his head. What headache is the patient experiencing? A. Cluster B. Sinus C. Migraine D. TensionC. MigraineA patient experiences a severe migraine. What treatment is first line for the patient? A. Turn of the lights B. Triptan C. A glass of water D. OxygenB. TriptanA patient experiences a pain in his head that feels like a band squeezing the head. What treatment would be given to the patient to relieve the pain? Select all that apply A. Ibuprofen B. Muscle relaxant C. Massage D. Heparin E. SumatriptanA,B,CA patient experiences a seizure without any cause. What type of seizure is the patient experiencing? A. Myoclonic B. Secondary C. Primary D. Atonic E. Tonic-ClonicC. PrimaryA patient that has a history of seizures for 10 years is admitted into the ER after experiencing a seizure. During his seizure he was stiffening and jerking. What type of seizure did the patient most likely experience? A. Atonic B. Myoclonic C. Focial D. Tonic-ClonicD. Tonic- ClonicA child at the park is playing when suddenly he pauses for a couple seconds just blinking into space then the child continues playing. What seizure did the child most likely experience ? A. Focal B. Complex C. Absence D. GeneralizedC. AbsenceA patient experiences multiple seizure back to back with jerking and stiffening. What treatment should be given to the patient? A. Benzos B. Oxygen C. IV lorazepam D. IV NSC. IV lorazepam