What intervention would be most appropriate for a wound with a beefy red wound bed?
Dressing to keep the wound moist and clean
Removal of devitalized tissue and a sterile dressing
The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist?
"Flo" from the Progressive commercials
Which of the following is considered a “practice” (as opposed to a belief or value)?
Always drinking water after exercise
Emphasis on success
Thinking often about cleanliness
Pressure ulcers are directly caused by which of the following conditions at the site?
Inadequate venous return
Compromised blood flow
A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner?
Use of herbs and roots
Burning of dried plants
Application of oils and poultices
While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?
A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient?
Transparent film dressing
Frequent turn schedule
When performing a spiritual assessment, who is the preferred source of information?
Durable power of attorney
Next of kin
The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, “I feel so light-headed and weak,” as her knees begin to buckle. The nurse’s best action at this time would be to:
Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall.
Grab her under the arms and hold her up as he calls for assistance.
Assist the patient to slide down his leg as he guides her to a seated or lying position.
Instruct the patient to grab the rail in the hallway while he calls for assistance.
What is the primary difference between acute and chronic wounds? Chronic wounds:
Are full-thickness wounds, but acute wounds are superficial.
Are usually infected, whereas acute wounds are contaminated.
Exceed the typical healing time, but acute wounds heal readily.
Result from pressure, but acute wounds result from surgery.
A client has a diagnosis of chronic pain. The physician has prescribed tramadol hydrochloride (Ultram) for the pain. The patient also receives therapeutic touch (TT) from a practitioner three times a week. In this situation, TT is considered to be which of the following?
An alternative modality
A placebo response
A complementary modality
Which of the following describes the difference between dehiscence and evisceration?
With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.
Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.
Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include:
Cognitive and aesthetic needs
Physiological and self-esteem needs
Love and belonging needs
Safety and security needs
A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound “heals a little more” he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?
Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8°F (38.2°C). The nurse would suspect that the patient has what kind of complication?
Formation of granulation tissue
Infection at the site of incision
Hematoma under the skin
Dehiscence of the wound
What is the best rationale to gather data about patients’ use of herbal products?
Patients' medication records must be kept accurate
The nurse practice act requires RNs to monitor all drug dosages
Herbal products need to be evaluated for research purposes
Many herbs are known to interact with medications
While reading a journal article, the nurse asks herself these questions: “What is this about overall? Is it true in whole or in part? Does it matter to my practice?” What is this nurse doing?
Reading the article analytically
Formulating a searchable question
Determining the soundness of the article
Performing a literature review
An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis?
Chronic inflammatory joint disease that must be treated with steroids
Loss of bone density that increases the risk of fracture
Degenerative joint disease that produces pain and decreased function
Acute infection in the bone that must be treated with antibiotics
A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?
Unstageable pressure ulcer
Stage II pressure ulcer
Stage III pressure ulcer
Stage IV pressure ulcer
North American healthcare culture typically reflects which culture?