NUR 111 Final Exam Review A

Negative pressure wound therapy (wound vac) is being used to treat a non-healing, chronic wound. What should be included in this client's nursing care plan?

• Change the dressing daily.

• Empty the canister on the machine once per day.

• Measure and record the amount of drainage every shift as output.

• Disconnect the wound vac each night between 2200 and 0700.

What intervention should be included in a plan of care to prevent pressure injury development in health care settings?

• Do not turn; use pressure-relieving support surface.

• Implement a turning schedule every 2 hours.

• Change position at least once each shift.

• Use donut cushions for heels and elbows.

A nurse is caring for a client who has a right femur fracture that is currently in traction. When the nurse is completing her head to toe assessment on the client, which nursing assessment findings should be reported to the health care provider? Select all that apply.

• Numbness and tingling to the right leg

• Dorsalis pedis pulses +2 bilaterally

• Capillary refill of 4 seconds on the right foot

• Edema and coolness to the right calf

• Pink color and warmth to the right leg

A nurse is caring for a client who has a surgical incision at the midline abdominal region. After removal of the dressing, the nurse notes drainage from the incision. Which description of wound drainage is indicative of a possible infection?

• Purulent

• Serous

• Sanguinous

• Serosanguinous

When a nurse self-reports making a medication error, which professional value is demonstrated?

• Human Dignity

• Social Justice

• Advocacy

• Integrity

Which of the following body systems can a nurse assess by the use of palpation?

• Heart sounds, lung sounds, blood pressure

• Tissue density, gait, reflexes

• Vision, hearing, cranial nerves

• Temperature, turgor, moisture

The nurse is evaluating client outcomes and discovers there has been no progress toward meeting any of the outcomes for mobility. How should the nurse best respond to this situation?

• Replace the client's individualized plan of care with a clinical pathway.

• Continue the current plan of care with the hope that the client will achieve the outcomes.

• Modify the plan of care to better reflect the client's current functional ability.

• Terminate the plan of care since it does not now accurately reflect the client's abilities.

What pertinent information should be shared in a change-of-shift report among nurses?

• Medical insurance coverage

• Abnormal assessment findings

• Preferred religion

• Previous nurse's complaints

A father runs into the emergency room with his infant son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of impaired gas exchange is what level of priority diagnosis?

• No priority

• Low priority

• Medium priority

• High priority

Tags

NGSS.HS-LS1-7

The nurse pinches the skin under the clavicle and it tents longer than 3 seconds. What conclusion should the nurse determine from this assessment?

• The skin has normal turgor.

• The skin is less elastic with aging.

• The client is dehydrated.

• The client is overhydrated.