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Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)

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No clinical judgment is needed to administer the AUDIT, which is a written questionnaire that is given to patients for self-administration and scored based on patient answers. Making appropriate refe... rrals, patient teaching, and obtaining a patient history all require critical thinking and RN education and scope of practice. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment OTHER 1. A patient is admitted to the emergency department for treatment of a possible opioid overdose. Rank the nursing activities in the correct order from first activity to last activity. (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Initiate IV access. b. Take a health history. c. Obtain a toxicology screen. d. Administer naloxone (Narcan). e. Provide respiratory support with a bag-valve mask. ANS: E, A, D, C, B Maintenance of the airway is the first priority for patients with possible depressant overdose. Opioid antagonists are given before toxicology testing is done because reversal of the opioid will prevent respiratory arrest. However, this will require IV access. The toxicology report will help guide further treatment for possible multiple substance ingestions. The health history will guide care after the initial emergency treatment phase. Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 89 DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 90 Chapter 11: Inflammation and Healing Test Bank MULTIPLE CHOICE 1. The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours. ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic ther [Show More]

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