NURC 1104 Exam 1 Questions & Answers

NURC 1104 Exam 1 Questions & Answers-Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels? A. Avoid prolonged elevation of ...

NURC 1104 Exam 1 Questions & Answers-Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels? A. Avoid prolonged elevation of the head of the bed B. Order a standard hospital foam mattress C. Consider an alternating pressure support surface D. Place a pillow under the calves - D. Place a pillow under the calves Which of a novice nurse's actions would necessitate intervention when providing care for a patient who is prescribed negative-pressure wound therapy? A. Retaining hair around the wound B. Using a skin barrier around the wound C. Drying around the wound thoroughly D. Filling uneven wound surfaces with a hydrocolloid product - A. Retaining hair around the wound Which patient statement indicates understanding of the disadvantages of using moist applications for wound therapy? A. "It increases body fluid loss." B. "It causes maceration of the skin." C. "It causes increased drying of the skin." D. "It does not penetrate deep into tissues." - B. "It causes maceration of the skin." Which nursing actions are appropriate when removing tape from the patient's skin during wound care? Select all that apply. A. Loosen the ends B. Pull the tape in the direction of hair growth C. Use adhesive remover to loosen the tape D. Apply hard traction to the skin next to the wound E. Gently pull the outer end perpendicular to the skin surface - A, B, C Which factor increases the risk for injury when applying heat therapy to a wound for a patient with a spinal cord injury? A. Thinner layers of skin B. Alteration in nerve pathways C. Rupture and systemic infection D. Decreased peripheral circulation - B. Alteration in nerve pathways Why is maintaining an airtight seal when providing care to a patient who is receiving negativepressure wound therapy important? A. To avoid a wound infection B. To avoid wound desiccation C. To avoid accelerated wound healing D. To avoid discomfort with wound dressing changes - B. To avoid wound desiccation Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to friction and shear? A. Keep the skin dry and free of maceration B. Provide pressure-redistribution surface C. Consult a dietician for nutritional assessment D. Provide a trapeze to facilitate movement in bed - D. Provide a trapeze to facilitate movement in bed Which type of dressing is preferred for dry wounds? A. Hydrogel B. Hydrocolloid C. Calcium alginate D. Debriding enzymes - A. Hydrogel Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown? A. Using a standard surface B. Using a pillow under the calves C. Using an active support surface D. Using a pressure-redistribution seat cushion - A. Using a standard surface Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to moisture? A. Keep the skin dry and free of maceration B. Provide a pressure-redistribution surface C. Consult a dietician for nutritional assessment D. Provide a trapeze to facilitate movement in bed - A. Keep the skin dry and free of maceration Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception? A. Keep the skin dry and free of maceration B. Provide a pressure-redistribution surface C. Consult a dietician for nutritional assessment D. Provide a trapeze to facilitate movement in bed - B. Provide a pressure-redistribution surface Which nursing action during removing tape from the patient's skin during wound care requires which correction? A. Loosening the ends B. Pulling the tape in the direction of hair growth C. Using adhesive remover to loosen the tape D. Applying hard traction to the skin next to the wound - D. Applying hard traction to the skin next to the wound The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient? A. None B. Adherent film C. Composite film D. Calcium alginate - B. Adherent film Which is the most effective intervention for compromised skin integrity? A. Preventing breakdown B. Administering medication C. Implementing wound care D. Monitoring wound healing - A. Preventing breakdown 1. The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350 mg/dL b. who has been on anticoagulants for 10 days c. with a hemoglobin of 8.5 g/dL d. with a heart rate of 100 beats/min and blood pressure of 100/60 ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood. 2. The nurse is reviewing the patient’s arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on assessment of this patient?