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Worksheetswounds, musculoskeletal and airways!!
Total questions: 15
Worksheet time: 8mins
Check all that apply to proper client teaching regarding oxygen via nasal cannula use.
avoid the use of candles near the oxygen source
apply petroleum jelly around and inside the nares
remove the nasal cannula during mealtimes
check the position of the cannula frequently
post "no smoking " signs in prominent location
You are caring for a patient who is having difficulty breathing. The client is lying in bed and already recieving O2 therapy via nc. What nursing intervention is priority?
increase the o2 flow to 4L/min
promote removal of pulmonary secretions
obtain a specimen for arterial blood gases
assist the client to fowler's postion
A nurse assesses a pressure sore to the heel which has full-thickness tissue loss of the epidermis, dermis and subcutaneous tissue. This sore will be staged as a ..
unstageable
stage III
stage IV
Stage II
While assessing a wound, the nurse notices the edges are irregular, and cannot be brought together. The nurse must pack the wound to allow tissue to grown in. The incision is healing by ...
necrosis
second intention
first intention
third intention
check all that apply to the reconstruction phase of wound healing
occurs when the wound begins to heal and lasts about 21 days after injury
as new tissue begins to grow and fill in the wound, it looks red and semitransparent (granulation tissue)
this phase occurs when the wound is fresh and includes hemostasis and phagocytosis
the new tissue bleeds easy if abraded
what is a stasis ulcer?
an ulcer that develops when venous flow is sluggish, generally in the le's, allowing deoxygenated blood to pool in the veins
a decubitus ulcer
occurs when external pressure is exerted on soft tissues, especially over bony prominences, for a prolonged period of time
a bed sore
bloody drainage from a wound will be documented as:
serosanguineous
sanguineous
purulent
serous
A patient with a leg fx is waiting to have surgery. To align the bone ends and prevent severe muscle spasm until surgery can be performed, the nurse should immobilize the patient using
an immobilizer
a cast
skin traction
skeletal traction
check all that apply to proper crutch use
when walking upstairs with crutches, you should place the affected leg on the step, then move up the unaffected leg and the crutches
when walking down the stairs, place the crutches and affected leg on the downward step, then bring down the unaffected leg
keep the affected foot slightly forward, rather than bending the knee and holding the foot behind the crutches
crutches fit correctly when there are 3 fingerbreadths between the axillary pad and the patient's axilla, as the patient is standing with the crutch tips 4-6 inches to side of the heel
bear weight on the hands and wrists, not the axilla/axillary pads
Check all that apply to safety walker use:
A correctly-fit walker will come up the patient's hip joint
when the patient grips the handles, their elbows should be bent at a 30-degree angle
ensure the patient stands between the back legs of the walker
if one leg is weak, instruct the patient to move affected leg forward with the walker, then move the unaffected leg forward
If a nurse notes that the cuff of a tracheostomy tube has become deflated, which of the following actions should the nurse take first?
inflate the cuff
nothing
check most recent ABG results
Listen to breath sounds
what is the normal pH of range of arterial blood gases
7.45-7.95
7.35-7.45
6.9-7.35
22-26
which of the following pH indicates alkalosis in ABG's
7.43
7.47
7.34
7.2
Which of the following should be included in the plan of care for a COPD patient being seen by home health?
Use a shower chair
alternate activity with rest periods
provide diet high in carbs
encourage small frequent meals
Assess the use of accessory muscles with respiratory effort
Check all nursing responsibilites that apply to dressing changes:
You must keep a good "sterile conscience"
assess the wound during the dressing change: measure L x W x D, inspect for granulation tissue as well as yellow/black tissue, location and length of any sinus tracts
assess the type of drainage on the old dressing for color and amount
remove your gloves and wash hands before applying new dressing
apply the new dressing following orders for the new dressing. write date, time and your initials on the new dressing
