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Test 5 Concepts
Ch 8,26
| Question | Answer |
|---|---|
| Pressure injury (Pressure ulcer, decubitus ulcer, bedsore) | A wound resulting from pressure, friction, shearing force Develop over a bony prominence or related to a medical device |
| Ischemia | Tissues and capillaries are compressed, resulting in reduced blood flow to the area |
| When moving a patient across the bed rather than pulling or dragging you must do what? | Lift the patient, to avoid shearing force that can result in destruction of the epidermis and dermis. |
| What type of pt are prone to develop pressure injuries? | Elderly, Emaciated(malnourished), Incontinent of bowel or bladder, Immobile, Impaired circulation or chronic metabolic conditions |
| Stage 1 pressure injury | Indicated skin redness, will not turn white (blanch) when gently touched |
| Stage 2 pressure injury | Partial thickness loss and exposed dermis, intact serum filled blistering broken blister that reveal a shallow pink, red ulceration that is moist |
| Stage 3 pressure injury | Full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue |
| Stage 4 pressure injury | Full- thickness skin and tissue loss, only it involves deep tissue necrosis of muscle |
| First intention | Wound is clean with little tissue loss (surgical incision) |
| Second intention | Greater tissue loss and wound edges are irregular, edges can't be brought together (Trauma wound. pressure injury) |
| Third intention | Wound is left open for a time to allow granulation tissue to form (Draining wound) |
| When do you use a wet dressing? | Keep wounds moist |
| When do you use wet to dry dressing? | to remove dead tissue from a wound |
| Dry dressing? | Wound drainage and dead tissue can be removed when you take off the old dressing |
| Culturally competent is ? | is when the nurse is required to make a commitment to consider the cultural background of each patient and to provide appropriate care specific to that individual. |
| Define Culture? | the way of life that distinguishes a particular group of people from other groups. |
| Stereotype? | A person or group is booked at by another person or group through preconceived ideas and fixed impressions |
| Cultural sensitivity? | You provide care to pt and show respect for and incorporate the pt specific cultural beliefs and values into your nursing care. |
| Cultural awareness? | Knowledge of various cultural beliefs and values |
| What crosses Cultural boundaries? | Transcultural nursing |
| Statement verbatim | Clients have the RIGHT to receive care that is considerate of their culture |
| Culturally competent care | Involve the nurse to become familiar with any facet of client culture that may impact his or her care |
| Further teaching is required when a nurse doesn’t know the relations between what ? | Mind body and spirit. |
| As a nurse if you are spirituality concerns for a pt you must know what abut the patient? | Know if the pt practices a religion |
| Client who stopped attending church after death of spouse, What is the nurses goal? | To restore comfort and his relationship with God, ask open ended questions to understand what is going on with him |
| When going through something mentally, what can nurse do | be present, eye contact. |
| Client in er with wound for few days, has been assess, needs surgical closure. What is the nursing diagnosis? | at risk for infection |
| Purulent drainage consists of? | WBC, Debree and bacteria |
| Blue pulse | associated with infection due to pseudomonas |
| Red puss | may contain blood from rupture of small vessel. |
| Blue/ green color is associated with? | infection and pseudomonas bacteria |
| How. would document a Cervical laceration? | tear, separation of skin and tissue where the edges are torn and irregular. |
| A patient is in the pacu after surgery, where would you check for drainage? | Dressing site, underneath pt |
| Sanguineous | Containing blood , red bloody drainage |
| Serous | clear liquid of blood, Clear to pale yellow drainage that looks like serum |
| Purulent | Containing pus, thick yellow or green drainage and sign of infection |
| Bilious | Dark greenish color and is often present after gallbladder surgery |
| Serosanguineous | both blood and clear drainage |
| Seropurulent | clear and pus drainage present |
| What should you do Day 2 post op? | Assist pt in movement, don’t wait to strain on suture incision line. Help pt ambulate to avoid suture stress. |
| Patient teaching, What do you need for healing to take place? | diet ( protein intake) important to have protein for wound healing, restrict diets that are high in fats and carbs |
| Hydrocolloid dressings are used for? | Shallow wounds with MINIMAL drainage |
| Pt has ugly wound, refuses to change dressing what should you do as a nurse? | Respect wishes of pt not wanting to change it himself at that time. |
| What type of irrigation should you use with Necrotic tissue/ Pulsatile? | High pressure laboage for irrigation |
| When dressing an ankle, how should you apply the wrap? | Figure 8 dressing wrap |
| Open fracture of leg with multiple bruises equals what? | Equates compound fracture with multiple contusions |
| Stasis ulcer | Skin wounds, edema, discoloration |
| How do you mark a drainage dressing? | Tracing outline, date, time, initials |
| Abrasions are ? | Superficial will heal quickly if kept free from infection. |
| Clostridia | Infected with bacteria called clostridia, results in a condition called gas gangrene. Occurs due to poor circulation to a body part (Digit/limb) |
| When clostridia is present what should you do/hear? | Press infected area and will heara crackling sound, will access if its gas which is gangrenous. |
| When cleaning wound where should you start? | Start at center and swab outward, to one end, circular motion. |
| Can a CNA assist in observing dressing changes? | Yes, only OBSERVE |
| Inflammatory reaction can increase what? | Increase WBC, increase blood flow to wound |
| What pt would be most critical to nurse? | A pt with pressure sore and hx of diabetes |
| A patient’s J-P drain should be emptied: | every 8 hours, when one-half to two-thirds full. |
| Which one of the following assessment findings makes it impossible to stage a pressure injury? | Eschar |
| The phase of healing during which granulation tissue forms in a wound is the: | reconstruction phase |
| You observe pink drainage from a patient’s wound. You would describe this as: | serosanguineous |
| Your patient has a large abdominal wound with copious drainage and many layers of gauze 4×4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient? | Ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape. |
| A patient returns from surgery with a left shoulder dressing. A 3-inch diameter spot of red drainage is visible on the anterior portion of the dressing. The health-care provider does not want the dressing disturbed for 24 hours. What will you do? | Draw a line on the dressing outlining the drainage, with the date, time, and your initials. |
| A patient has signs of infection in his left shoulder incision—erythema, warmth, and a small amount of purulent drainage. You prepare to report this to the health-care provider. Which information will you have ready when you call? | Vital signs, Appropriate laboratory results Patient’s rating of incisional pain, Description of the wound and drainage, Signs of infection you observe, Name and dosage of antibiotics currently ordered, if any |
| You are caring for a 67-year-old male who had a cerebrovascular accident 3 weeks ago. Which of the following data that you collected will be useful in developing a care plan that will address his pressure ulcer? | Last week he weighed 165.5 pounds, and today he weighs 161.8 pounds. The pressure injury is a stage 3. He is not able to sit up in a chair for longer than 15 minutes at a time. |
| Data continuation when developing care plan for 67 year old male. | He dislikes cheese, beans, chicken, and fish, but loves steak, eggs, all kinds of nuts, and peanut butter He has been on an eggcrate mattress while in the hospital. |
| Which one of the following interventions would you rate as the most important for care of his pressure injury? | Change the wet-to-damp dressing on his right hip wound qid using sterile technique. |
| It is important to understand that as individual members of various ethnic, cultural, and religious groups, we all are different and we all deserve what? | To be treated with respect and dignity. |
| Which of the following organizations has/have worked to promote the patient’s right to culturally competent care in U.S. hospitals? | The Joint Commission |
| Nursing care that involves or combines the elements of more than one culture is called which of the following names? | Transcultural care |
| A patient has expressed the feeling that God has caused his illness. Which of the following would be most important for the nurse to consider when responding to the patient’s feelings? | The nurse must not be judgmental or biased and should respond with compassion. |
| A bedridden patient has a different cultural background and speaks a different primary language than the nurse. In order to provide culturally sensitive care to this patient, the nurse should do which of the following? | Allow the patient time to get his or her thoughts together. Be aware of the patient’s nonverbal body language. |
| The nurse is assisting a patient of the Jewish culture and faith in planning meals for the day. Which of the following might be a concern for the patient? | Green beans with bacon, Pork chops |
| A nurse is admitting a 74-year-old Chinese patient to the hospital who says that he practices traditional Chinese medicine. The nurse understands that traditional Chinese medicine is based on which of these? | Balancing Yin (cold) and Yang (hot) |
| A female nurse is admitting a 24-year-old male Hindu patient to the hospital. The nurse understands that in order to be culturally competent when caring for this patient, she needs to understand anything that might influence his health, including: | perceptions.behavior. expectations, the decision making process. |
| When using an interpreter to communicate with client. Which of the following actions should the nurse use when communicating with client and family members? | Determine client understanding several times during convo, Use lay terms if possible, Do not interrupt the interpreter and family ad they talk |
| Two clients who report following the same religion. Which of the following information should nurse consider when planning care for these clients? | The same religion beliefs can influence individuals differently |
| Nurse enters room of a client who is crying while reading religious book and asks to be alone. What action should the nurse take? | Ensure no visitors or staff enter the room for a short time period |
| Nurse is discussing the plan of care for pt who reports following Islamic practices. Which statement by the nurse indicates culturally responsive care to the client? | "I will ask the client if they want to schedule some time to pray during the day" |
| Nurse is caring for a pt who based on religion values and mandates a blood transfusion is not acceptable treatment. Which response should the nurse make? | "Lets discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution" |
| Nurse is caring for client 2 day potop following appendectomy and type 1 diabetes mellitus. Hgb12g/dL and BMI 17.1 The nurse should recognize that he client has the following risk factors? | Chronic illness, Low hemoglobin, Malnutrition |
| Data from a 5day potop abdominal surgery. Suspects incisional wound infection & prescribes antibiotic, after collecting blood specimen and CNS. Which of the following findings should the nurse expect? | Increase in incisional pain, Fever and chills, Reddened wound edges |
| The nurse educator should include in the information for wound healing by secondary intention? | Stage 3 pressure injury, Open burn area |
| Pt had abdominal surgery 24hr ago suddenly reports pulling sensation and pain on surgical incision. Nurse finds separated with viscera protruding. What actions should the nurse take? | Cover the area with saline soaked sterile dressing, Position the client supine with hips and knees bent |
| Nurse is caring for pt at risk or pressure injury. Which intervention should the nurse use to help maintain integrity of skin? | Keep the head of the bed elevated 30 degrees, Have the client sit on a gel cushion when in a chair. |
| How often do you reposition a client? | At least every 2hrs |
| Nurse is caring for pt who has been sitting in a chair for 1hr. What is the pt a greatest risk for? | Pressure injury |
| Nurse is caring for a pt who is postop. The nurse should do what Interventions to reduce the risk of thrombus development? | Apply elastic stockings, Assist the pt to change position ofetn. |
| Nurse is caring for a client who is o bed rest. What intervention should the nurse plan to implement? | Encourage the pt to perform antiembolic exercises every 2hrs |
Created by:
golds_berry
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