344 Funds exam 2: ATI modules 4-6 and study guide

344 Funds exam on modules 4-6. Includes module 4 ATI medication administration, module 5 ATI clinical judgement, module 6 ATI tissue integrity and gas exchange/oxygenation, as well as information from the teams SI study guide for exam 2.

A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which alteration in tissue integrity?

Dermatitis

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which instructions should be included to the caregiver to prevent further skin breakdown? The caregiver should _____ to take the pressure off the sacral area and prevent the client from sliding down in bed, which can cause shearing and further injury to the skin.

flex the client's knees while in bed

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which instructions by the nurse is related to preventing skin breakdown?

you should shift your weight off your buttocks at intervals throughout the day

A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which statement by the AP indicates an understanding of the teaching?

the skin of older adults is thinner and has less subcutaneous padding over bony prominences

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which dressing type should the nurse use?

a transparent film

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which action should the nurse take before swabbing the wound with a sterile cotton applicator?

clean the wound with 0.9% sodium chloride

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

• a client who has a Braden Scale score of 20

• a client who has a Braden Scale score of 9

• a client who has a Braden Scale score of 12

• a client who has a Braden Scale score of 15

a client who has a Braden Scale score of 9

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. Which dressing type should the nurse anticipate a prescription for to cover the wound?

hydrogel

The nurse should include on the poster that the _____ skin layer is composed of connective tissues with capillaries, blood vessels, and lymph vessels, which sustain and support the epidermis by providing strength, flexibility, and nourishment.

dermis

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which statement by the client indicates an understanding of an alginate dressing?

this type of dressing will need a secondary dressing for reinforcement

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which response by the client indicates an understanding of the information?

i should report pain at my wound site

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. What findings should the nurse expect?

a bright pink incision site that is absent of exudate

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which client statement indicates an understanding of the teaching?

I should increase my protein intake

A nurse is planning care for an older adult client who is bedridden. the nurse should _______ to prevent the client from sliding down in bed, which can cause shearing of the skin, while also relieving pressure to the client's hip.

tilt the client on their side at 30 degrees

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which actions should the nurse take?

cover the client's wound with a sterile saline dressing

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. She includes that pressure injury documentation includes _____

the location, stage, measurements, condition of the wound bed and any drainage present

Which bed position places the client at risk for alterations in skin integrity?

high fowlers position

what are some potential manifestations of sepsis?

increased blood glucose, hypotension, increased WBC count

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which action should the nurse take?

empty and measure the drainage

A nurse is caring for a group of clients. Which client should the nurse identify as having the highest risk for developing alterations in tissue integrity?

a client who is incontinent and is taking a prescribed diuretic

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which complication?

dehiscence

What is an NCSBN model that can assist the nurse with critical thinking and decision making?

The _____ Model was developed to assist nurses in using evidence-based practice to think critically and make decisions.

clinical judgement

_____ is considered a higher order of thinking that is the foundation for clinical decision making. It is a critical component of nursing care and is used in each step of the nursing process to enhance client care.

critical thinking

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?

planning

A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 min ago. Which of the following steps of the nursing process is the nurse performing?

evaluation

A nurse is caring for a client who has been wheezing. The nurse asks an assistive personnel (AP) to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. This is an example of what concept?

wrongful delegation

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which skills should the nurse plan to include in the discussion?

inference, creativity, and inductive reasoning

A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which step of the nursing process is the nurse using?

assessment

A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly license nurse. Which factors should the charge nurse include?

available resources, awareness of the client’s status, and support from other staff

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the client's care requires clinical reasoning when it is complicated by which factors?

complex clinical situations, ongoing client and family concerns

Clients who are _____ have an increased risk for developing alterations in tissue integrity, such as maceration, due to prolonged exposure to moisture.

incontinent

The bulb of a portable wound bulb suction device should be emptied when?

at least every 8 hr or when it is more than half full

Due to their reduced ability to absorb moisture, _____ dressings are used for covering superficial wounds that have minimal exudate.

self adhesive transparent

_____ dressings can be successfully used for debridement of wounds with necrotized tissue and eschars, and causes minimal trauma to the healing wound bed. these dressings work differently than other dressings in that they can provide moisture to or draw moisture away from the wound dependent upon the needs of the wound.

hydrogel

_____ dressings are moistened in normal saline and used for wound packing when continuous debridement is needed.

wet gauze

An _____ dressing is recommended for moderate to high exudative wounds.

alginate

The head of the client's bed should be kept _____ at all times to prevent the client from sliding down in bed, which can cause shearing of the skin, and alleviate pressure from the sacrum.

lower than 30 degrees

The skin consists of three layers, which are the:

epidermis, dermis, and subcutaneous layer

The epidermis contains _____ cells that ingest foreign antigens and package the antigens to be presented to lymphocytes, which then trigger a localized, non-systemic, immune response in the epidermis.

Langerhans (dendritic macrophage)

Expected changes in the skin across its lifespan cause it to be more vulnerable at certain times than others, and place the client at greater risk for developing alterations in tissue integrity. Clients are most at risk _____ in life.

early and late

The _____ layer of the skin contains cells, or melanocytes, that contribute to skin and hair color.

epidermis

The main functions of the _____ are to provide a barrier from injury, infection, and ultraviolet radiation, as well as control fluctuations in body temperature.

skin

The lowest overall score a client can receive on the Braden Scale is a _____, with _____ being the maximum score.

6, 23

The _____ the overall score the client receives on the Braden scale, the greater the risk the client has for alterations in skin and tissue integrity.

lower

The skin plays a role in the synthesis of which vitamin?

vitamin D

Pressure injuries found on the _____ cannot be staged because this tissue does not contain the same layers as the skin.

mucous membranes

By the _____ postoperative day, an incision site should appear bright pink and drainage should have subsided.

7th

The incision site that is in postoperative days _____ may appear red with a small to moderate amount of exudate.

1-4

at which point (in days) should a postoperative incision site appear pale pink?

15 onward

Foods high in which fatty acids aid in wound healing?

omega 3 and 6

Foods high in which vitamins aid in wound healing?

vitamins A and C

To collect a wound culture using a sterile cotton applicator, the nurse should first clean the wound with 0.9% sodium chloride to _____

rinse away any resident bacteria that may be present

_____ is a separation of part or all of the wound edges. This is a common complication after abdominal surgery, where the client experiences a ripping sensation at the wound site.

dehiscence

_____ is the protrusion of internal organs through a surgical incision.

evisceration

A _____ occurs when an accumulation of blood clots underneath the surface of the skin, which can cause increased pressure and compression of blood vessels.

hematoma

A _____ is the abnormal connection from one organ to another, causing a leakage of fluid from the wound site internally. The fluid then drains through the connection to the skin, impairing wound healing.

fistula

An _____ dressing is not self-adhesive and needs a secondary dressing for reinforcement.

alginate

during infancy and early childhood when the skin is immature, _____ develops when the skin is exposed to urine and feces.

dermatitis

Complications of using _____ to close an incision are that they can be difficult to remove due to becoming embedded in the skin.

staples

Staples used to close an incision will need to be removed in _____ days using a staple remover.

7-14

The nurse should listen for a _____ sound when performing chest percussion therapy. This indicates proper technique is being used to loosen the secretions.

hollow

The nurse should perform chest percussion therapy up to _____ times each day.

four

The nurse should expect the client who has left-sided heart failure to have _____ in the lungs. Left-sided heart failure causes the blood to back up into the pulmonary circulation, causing this noise to be heard in the lungs.

crackles

Right-sided heart failure causes blood to back up into the systemic veins, causing _____

peripheral edema

The nurse should identify that _____ is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. A lack of this lubricant can result in atelectasis.

surfactant

Cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min. Cardiac output is calculated by multiplying the client's _____ by the client's _____.

heart rate, stroke volume

_____ is a measurement of the volume of blood pumped out by the left ventricle in 1 min.

cardiac output

_____ is a measurement of the volume of blood pumped out by the left ventricle with each contraction. 

stroke volume

When using the urgent vs. nonurgent approach to client care, the nurse determines that the first client the nurse should see is the client who reports _____. This client might be experiencing hypoxia due to inadequate oxygenation, which requires further intervention by the nurse.

dyspnea

oxygen via nasal cannula can be delivered at concentrations of _____

1 to 6 L/min

A nonrebreather or partial rebreather mask delivers oxygen at concentrations of _____

10 to 15 L/min

A simple face mask delivers oxygen at concentrations of _____

5 to 8 L/min

when caring for a client with a chest tube, the nurse should monitor the client for _____, which can indicate a leak or blockage of the system.

subcutaneous emphysema

when caring for a client with a chest tube, the nurse should identify that continuous bubbling in the water seal chamber indicates that there is _____ in the chest tube system.

an air leak

when caring for a client with a chest tube, the nurse should keep the drainage system at what elevation in order to reduce the risk of drainage flowing back into the client's pleural space?

below the clients chest

when caring for a client with a chest tube, the nurse should not clamp the chest tube tubing because this can cause a _____

tension pneumothorax

The nurse should instruct the client to use the incentive spirometer _____ to promote lung expansion and mobilize secretions.

every hour while awake

The nurse should instruct the client to hold their breath for _____ seconds when using the incentive spirometer to promote lung expansion and mobilize secretions.

3-5

The nurse should instruct the client to use the incentive spirometer _____ times each session to promote lung expansion and mobilize secretions.

10

The greatest risk to a client with a history of asthma that is wheezing is injury from hypoxia; therefore, the first action the nurse should take is to _____, as this will assist the nurse in determining the next intervention.

obtain the client's oxygen saturation

Kussmaul breathing is not an expected breathing pattern. In Kussmaul breathing, respirations are _____

rapid and deep

Cheyne-Stokes breathing is not an expected breathing pattern. In Cheyne-Stokes breathing, the client has _____.

periods of apnea, then deep and rapid breathing, followed by slower breathing

Apnea is not an expected breathing pattern; it is the _____

absence of respirations

The nurse should identify that _____ is an expected finding for a client who has a chronic pulmonary disease, such as COPD.

clubbed fingers

_____ is an irregular breathing pattern that can occur in a client who has fractured ribs following chest trauma.

paradoxical breathing

The nurse should _____ to the client before suctioning their tracheostomy to reduce the risk for hypoxia.

administer 100% oxygen

The nurse should use _____ technique to suction a client's tracheostomy using an open system to reduce the risk for infection.

sterile

The nurse should apply _____ suction when withdrawing the catheter to reduce the risk for hypoxia.

intermittent

when suctioning a clients tracheostomy, the nurse should apply suction for ______ to reduce the risk for hypoxia.

10-15 seconds

The nurse should expect a client who has heart disease and a narrowed valve to have _____.

stenosis

_____ is a narrowing or stiffening of a heart valve that causes backflow of the blood.

stenosis

what is the sequence of transmission of electrical impulses through the heart?

SA node, AV node, bundle of his, right and left bundle branches, purkinje fibers

The _____ are air-filled sacs where the exchange of oxygen and carbon dioxide occurs.

alveoli

The _____ allow air to move in and out of the lungs during ventilation.

trachea and bronchial tubes

The _____ contracts and relaxes to facilitate ventilation.

diaphragm

_____ is caused when electrical impulses start outside of the SA node, causing an irregular heart rate.

atrial fibrillation

A waist circumference of _____ or greater for men and _____ or greater for women increases the risk for heart disease.

40 inches, 35 inches

The _____ is the amount of air that is forcibly expelled after a maximal inspiration.

vital capacity

The _____ is the amount of air inspired and expired with each regular breath.

tidal volume