Ch 48 + 31

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

A. Necrotic tissue
B. Wound drainage
C. Drainage on the dressing
D. Wound after it has first been cleaned with normal saline

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

A. Allow the area to be exposed to air until all drainage has stopped
B. Place several cold packs over the area, protecting the skin around the wound
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

Which description best fits that of serous drainage from a wound?

A. Fresh bleeding
B. Thick and yellow
C. Clear, watery plasma
D. Beige to brown and foul smelling

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Serous fluid generally is serum and presents as light red, almost clear fluid.

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

A. Binder
B. Ice bag
C. Elastic bandage
D. Absorptive diaper

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

A. Keeping the buttocks exposed to air at all times
B. Using a large absorbent diaper, changing when saturated
C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment
D. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.

Which of the following describes a hydrocolloid dressing?

A. A seaweed derivative that is highly absorptive
B. Premoistened gauze placed over a granulating wound
C. A debriding enzyme that is used to remove necrotic tissue
D. A dressing that forms a gel that interacts with the wound surface

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

A. Collection of wound drainage
B. Reduction of abdominal swelling
C. Reduction of stress on the abdominal incision
D. Stimulation of peristalsis (return of bowel function) from direct pressure

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

When is an application of a warm compress indicated? (Select all that apply.)

A. To relieve edema
B. For a patient who is shivering
C. To improve blood flow to an injured part
D. To protect bony prominences from pressure ulcers

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C.
Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

What is the removal of devitalized tissue from a wound called?

A. Debridement
B. Pressure reduction
C. Negative pressure wound therapy
D. Sanitization

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A.
Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

What does the Braden Scale evaluate?

A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown
C. The amount of repositioning that the patient can tolerate
D. The factors that place the patient at risk for poor healing

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient’s pressure ulcer?

A. Stage II
B. Stage IV
C. Unstageable
D. Suspected deep tissue damage

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days.

A. True
B. False

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.

Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms.

A. True
B. False

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
This is the correct definition of healing by primary intention.

Which of the following may indicate internal hemorrhage? (Select all that apply.)

A. Distention or swelling of the affected body part
B. An elevated white blood cell count
C. A decreased blood pressure and increased pulse
D. A change in the type and amount of drainage from a surgical drain

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D.
The nurse can detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock such as a decreased blood pressure, increased pulse, and cool, clammy skin. An elevated white blood cell count would be an indication of infection.

Which of the following patients has the least risk for developing a wound infection?

A. An 80-year-old man who has a burn
B. A 17-year-old patient who has a metal fragment lodged in his thigh
C. A 30-year-old female who had an episiotomy after childbirth
D. A patient receiving chemotherapy who has a surgical incision
E. A patient with peripheral vascular disease and an ulcer on the heel

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The chances of wound infection are greater when the wound contains dead or necrotic tissue (as with a burn), there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced or the patient is immunocompromised.

When teaching a patient about wound healing, the nurse should tell the patient:

A. Inadequate nutrition delays wound healing and increases risk of infection.
B. Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible.
C. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing.
D. Fat tissue heals more readily because there is less vascularization.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—delays tissue repair and increases risk for infection. Both full-thickness wounds and partial-thickness wounds heal more efficiently in a moist, protected environment. Long-term steroid therapy may diminish the inflammatory response and reduce the healing potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which decreases transport of nutrients and cellular elements required for healing.

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient’s knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed?

A. These are expected findings for this postoperative time period.
B. The patient is becoming dependent upon pain medication.
C. The nurse should observe the patient more closely for wound dehiscence.
D. The patient is demonstrating signs of a postoperative wound infection.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, an elevated white blood cell count, and the edges of the wound may appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.

The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence?

A. The nurse should be alert for an increase in serosanguineous drainage from the wound.
B. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery.
C. The nurse should administer cough suppressant to prevent wound dehiscence.
D. The condition is an emergency that requires surgical repair.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence most commonly occurs before collagen formation (3 to 11 days after injury). To prevent dehiscence, place a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. Evisceration is an emergency that requires surgical repair. Dehiscence does not necessarily indicate surgery is necessary.

The nurse reports a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient:

A. has a drain.
B. is at greater risk for infection.
C. is at greater risk for wound dehiscence.
D. is healing naturally.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
Healing by secondary intention indicates the patient has a wound where there is tissue loss and the wound edges are not well-approximated. There is greater opportunity for development of infection without the protective epidermal barrier and longer healing time.

A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient’s history indicates obesity with a BMI of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for:

A. Developing a blood clot.
B. Developing a fistula.
C. Wound dehiscence.
D. Hemorrhage.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
This patient is at risk for poor wound healing due to the chronic illness of diabetes, being obese (BMI >30), and smoking. Fatty tissue has a poor blood supply for healing and smoking increases the patient’s likelihood of coughing. The nurse should observe for an increase in serosanguineous drainage, an indication of potential dehiscence. The nurse should teach the patient to splint the abdomen with a pillow when coughing as a sudden strain on the incision could lead to dehiscence.

Match the description to the correct term: Thick, yellow, green, tan, or brown.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.

Match the description to the correct term: Clear, watery plasma.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.

Match the description to the correct term: Bright red: indicates active bleeding.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.

Match the description to the correct term: Pale, red, watery.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.

The patient asks the nurse what the purpose is for his Hemovac drain. The nurse’s best response is:

A. “To reduce the need for frequent dressing changes”
B. “To provide constant suction to remove and collect drainage from your wound to help it heal”
C. “To have a more accurate method of determining fluid loss and whether your fluids need to be increased”
D. “To prevent infection and crust formation at the wound site”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
The correct response would be “To provide constant suction to remove and collect drainage from your wound to help it heal.” Although a Hemovac drain will collect drainage, the Hemovac drain is used to provide constant low-pressure suction to remove and collect drainage from the wound bed to allow the tissues to come together to heal. Measuring the amount of drainage is used to determine when the drain may be removed.

A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required?

A. “I should empty the drain when it is one-half to two-thirds full.”
B. “I should keep a record of how much drainage I empty.”
C. “If drainage suddenly stops, it means the drain is ready to be removed.”
D. “The bulb of the drain should remain compressed.”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
If drainage suddenly stops, the drainage tubing may have a blockage. Notify the health care provider. The drain reservoir should be emptied every 8 hours or less if the reservoir becomes one-half to two-thirds full. The patient should keep a record of the drain’s output in 24 hours to aid in determining whether the amount is decreasing as expected and when the drain may be removed. The reservoir should remain compressed to provide a constant low suction.

When should wound drainage be cultured?

A. When there is a change in color, amount, or odor of drainage
B. If the patient complains of pain
C. When the drain is removed
D. If the nurse empties the drainage evacuator without applying sterile gloves

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Wound drainage should be cultured when infection is suspected, as indicated by the drainage appearing to be purulent, a change in the amount or color of the wound drainage, or when a foul odor of the drainage is noted. It is appropriate for the nurse to wear clean gloves to empty the drainage evacuator.

The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient:

A. opens the plug on the port for emptying the drainage reservoir and drains the contents into the measuring container.
B. presses downward until the bottom and top of the Hemovac are in contact to reestablish the vacuum.
C. holds the surfaces of the Hemovac together with one hand, cleans the opening and plug with an alcohol swab with the other hand, and immediately replaces the plug.
D. empties the Hemovac drain, replaces the plug, and records the amount of drainage.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
The patient must reestablish the vacuum for the Hemovac to be effective. To re-establish the vacuum, the patient needs to press the bottom and the top of the Hemovac together.

Because a patient has a Penrose drain, the nurse inspects the patient’s skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this?

A. Because drainage can be irritating to the skin and may cause skin breakdown
B. Because a Penrose drain has to be frequently compressed to create a constant low-pressure suction
C. To prevent the tubing from migrating into the wound
D. To advance the tube as the wound heals

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
A Penrose drain does not have a collection device. Therefore, the nurse should inspect the skin and change the dressings as needed to prevent skin breakdown. A Penrose drain does not have a reservoir to compress. A safety pin is inserted through a Penrose drain to prevent the tubing from migrating into the wound. Although a Penrose drain may be advanced as the wound heals, this is not the rationale for the nurse’s inspection and changing of the drainage sponges.

Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)?

A. Emptying a closed drainage container
B. Measuring the amount of drainage
C. Assessment of wound drainage
D. Reporting the amount on the patient’s intake and output record

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Assessment of wound drainage and maintenance of drains and the drainage system require the critical thinking and knowledge application unique to a nurse and therefore are inappropriate to delegate to NAP.

***NAPs CANNOT ASSESS***

The patient complains “It feels like the drain is pulling on my surgical site.” What is the nurse’s best action?

A. Secure the drain above the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain above the insertion site when ambulating, sitting, and lying.
B. Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site.
C. Instruct the patient that this is the normal sensation of having a drain and inquire if the patient would like pain medication.
D. Have the patient lie down and advance the drain further into the patient until the sensation is relieved and drainage is noted in tubing; secure a new dressing over insertion site of drain.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
To avoid pulling at the insertion site, the nurse should be sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement. To facilitate drainage, the nurse should secure the drain below the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain below the insertion site when ambulating, sitting, and lying. An order would be required to administer pain medication. The nurse should not advance the tube into the patient as this would introduce microorganisms.

Which of the following are functions of dressings? (Select all that apply.)

A. To promote hemostasis
B. To keep the wound bed dry
C. Wound debridement
D. To prevent contamination
E. To increase circulation

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D.
Dressings provide several functions, which include debridement, maintaining a moist wound environment, protecting from outside contamination and further injury, preventing the spread of microorganisms, increased patient comfort, and promoting hemostasis by control of bleeding. Dressings are unable to increase circulation.

Which of the following patients would be expected to benefit from a moist-to-dry dressing? (Select all that apply.)

A. A 24-year-old patient with an open and infected wound from a spider bite
B. A 7-year-old with abrasions on the knees
C. A 50-year-old with a postoperative knee-replacement incision
D. A 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater-type wound

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, D.
Moist-to-dry dressings are best used with necrotic, infected wounds requiring debridement. Moist dressings are often used for helping to heal full-thickness wounds that look like craters. Dry woven gauze dressings are most often used for abrasions and postoperative incisions when minimal drainage is anticipated.

The nurse is observing the patient’s wife perform the moist-to-dry dressing change. Which actions, if made by the patient’s wife, indicate that further instruction is needed? (Select all that apply.)

A. Premedicates for pain
B. Packs wound tightly
C. Leaves contact or primary dressing dripping moist
D. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: B, C.
Inner gauze should be moist to absorb drainage and adhere to debris. The wound should be loosely packed to facilitate wicking of drainage into the absorbent outer layer of the dressing. The wound should never be over packed because this can cause wound trauma when the dressing is removed. Premedicating for pain will help provide comfort during the dressing change. If dressing sticks on a moist-to-dry dressing, the wife should gently free the dressing and alert the patient of discomfort. The wife was correct in not wetting the dressing as a moist-to-dry dressing should debride the wound.

A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to complain of pain. What measures may be taken? (Select all that apply.)

A. Switch to the white polyvinyl alcohol (PVA) soft foam.
B. Decrease the pressure setting.
C. Administer pain medication.
D. Switch to the black polyurethane (PU) foam.
E. Keep the suction in the “off” position.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, B, C.
Patients may experience more pain with the black foam because of excessive wound contraction. For this reason, they may need to be switched to the PVA soft foam. Administering pain medication can help alleviate pain, and decreasing the pressure setting may also help reduce pain.

During a sterile dressing change, when are the gloves changed?

A. After the old dressing is removed and before creating a sterile field
B. After the old dressing is removed and before cleansing the wound
C. After the old dressing is removed, after cleansing the wound, and before applying a new dressing
D. It is unnecessary to change gloves for chronic wounds.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
Gloves are discarded after removing the old dressing. If required, a sterile field is then prepared, new sterile gloves are applied, and the wound is cleansed. It is unnecessary to change the gloves frequently unless they are accidentally contaminated. Gloves are changed after removing the old dressing and before cleaning the wound to reduce transmission of cross-contamination microorganisms. The same gloves may then be worn for applying a new dressing. Clean gloves may be worn rather than sterile gloves with chronic wounds (check facility policy).

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient?

A. “If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care facility.”
B. “Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing.”
C. “This type of dressing requires frequent changing because they do not stay in place.”
D. “You probably are applying it incorrectly, or perhaps you are just too anxious about having to perform the dressing change.”
E. “There are many options on the market. Why don’t you try to use a non-adhesive-backed transparent dressing instead?”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1 to 1.5 inches or 2.5 to 3.75 cm) margin, and the skin should be dried thoroughly before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is an unexpected outcome. Blaming the patient is non-therapeutic.

A patient asks the nurse why the Montgomery ties are being used instead of regular tape. The nurse’s best response is:

A. “Because Montgomery ties are nonallergenic.”
B. “Montgomery ties can be tied tighter, providing a more secure dressing and greater support of the wound.”
C. “It allows the wound to breathe.”
D. “Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes.”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
Frequent removal of tape for dressing changes is irritating to the skin. Montgomery straps are wide tapes with holes to use with ties that secure dressings and facilitate changes without removing the tape each time. Some patients are allergic to adhesive. These patients often benefit from paper or nonallergenic tape. Transparent dressings allow the wound to “breathe.”

How can the nurse determine that negative pressure is being achieved with a wound V.A.C.?

A. The nurse can inquire about the patient’s pain level. If there is a reported decrease in the level of pain, then the wound is constricting and negative pressure is being achieved.
B. The nurse can ensure that there is no whistling noise at the wound site and that the wound V.A.C. has not triggered its alarm.
C. The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure.
D. The nurse can ensure that the foam is in contact with the entire wound base, margins, and tunneled and undermined areas.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The nurse should inspect the wound V.A.C. system to verify that negative pressure is being achieved: verify that the display screen reads THERAPY ON; be sure the clamps are open and tubing is patent; identify air leaks by listening with a stethoscope or by moving hand around edges of the wound while applying light pressure; and if a leak is present, use strips of transparent film to patch areas around the edges of the wound. Negative pressure is achieved when an airtight seal is achieved. The wound V.A.C. will sound an alarm if the canister is improperly engaged or if the unit is tilted beyond 45 degrees.

Which of the following is a correct sequence for changing a gauze dressing?

A. Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing.
B. Remove old dressing, discard gloves, apply new gloves, and apply new dressing.
C. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, and cover with thicker woven pad (e.g., ABD pad).
D. Create sterile field, remove old dressing, discard gloves and perform hand hygiene, apply new gloves, clean wound, blot dry, apply new dressing.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
The nurse should remove the old dressing, inspect the wound, dispose of gloves and soiled dressings, and perform hand hygiene. The nurse then creates a sterile field and applies new sterile gloves and cleans the wound from least contaminated (the surgical incision) to the most contaminated (the drain). The nurse dries the area in the same manner and puts on the new dressing.

A patient has a 4-day-old postoperative incision. Which would be a normal finding when changing the dressing?

A. Small amount of serous drainage
B. Moderate amount of sanguineous drainage
C. Small amount of serosanguineous drainage
D. Small amount of purulent drainage

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
A small amount of serous drainage is normal postoperatively. A moderate amount of sanguineous drainage would indicate bleeding. Purulent drainage would indicate infection.

Which of the following are common sites for the development of pressure ulcers? (Select all that apply.)

A. Sternum
B. Heels
C. Sacrum
D. Lateral malleoli
E. Trochanters
F. Ischial tuberosities

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: B, C, D, E, F.
Common sites for the development of pressure ulcers include the sacrum, heels, elbows, lateral malleoli, trochanters, and ischial tuberosities. (Helpful, I know.)

Identify contributing factors to pressure ulcer formation. (Select all that apply.)

A. Malnutrition
B. Middle age
C. Decreased sensory perception/mobility
D. Anemia
E. Excessive sweating
F. Ethnic background

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D, E.
Three pressure-related forces contribute to the development of a pressure ulcer: intensity of pressure (how much pressure is applied), duration of pressure (how long the pressure is applied), and tissue tolerance (the ability of the tissue to redistribute the weight). Having decreased mobility or decreased ability to perceive the need to shift one’s weight or change position places an individual at risk for pressure ulcer development. Three extrinsic factors, shear, friction, and moisture, make the tissues less tolerant of pressure. Other factors important in pressure ulcer development include poor nutrition, advanced age, medical conditions that support poor tissue perfusion (low blood pressure, smoking, elevated temperature, anemia), and psychosocial status, in particular stress-induced cortisol secretion.

Identify prevention strategies for pressure ulcers. (Select all that apply.)

A. Use a moisture barrier ointment, applied after each incontinent episode.
B. Reposition patient at least every 4 hours; use a written schedule.
C. When the patient is in the side-lying position in bed, use the 30-degree lateral position.
D. Place patient on a pressure-reducing support surface.
E. Maintain the head of the bed at 45 degrees.
F. Massage reddened bony prominences.
G. Oral supplements should be instituted if the patient is found to be undernourished.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D, G.
Patients should be repositioned every 2 hours to reduce the duration and intensity of pressure. The 30-degree lateral position avoids direct contact of the trochanter with the support surface. Placing the patient on a pressure-reducing support surface reduces the amount of pressure exerted against the tissues. The head of the bed should be maintained at 30 degrees. If the head is elevated more than this, it can increase the potential of the patient to slide toward the foot of the bed and incur a shear injury. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue, and therefore it should be avoided. A moisture barrier ointment protects reddened intact skin from incontinence. There is a strong relationship between poor nutrition and pressure ulcer development. Supplements may provide lacking nutrients.

The nurse is observing the patient’s wife perform treatment of her husband’s pressure ulcer. Which action, if made by the patient’s wife, indicates that further instruction is needed?

A. She premedicates the patient for pain before beginning the dressing change.
B. She performs hand hygiene and removes the old dressing and begins to clean the ulcer with soap and water.
C. While wearing gloves, she rinses the ulcer with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze.
D. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. She covers the gently packed wound with dry 4 x 4 gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
To avoid transfer of microorganisms, the caretaker should apply nonsterile gloves to remove the old dressing and discard the gloves and old dressing materials in a plastic bag. She should perform hand hygiene and apply new gloves before beginning to cleanse the wound. She should use the ordered solution, most generally normal saline, because soap can be very drying to tissues and may leave a residue.

A family member calls the nurse to ask for advice regarding their mother who has developed a “bedsore” on her right heel. The family member describes the pressure ulcer as “a blister that has now popped and you can see redness.” Based on this description, at what stage would the nurse classify this pressure ulcer?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A stage II pressure ulcer can be described as an abrasion, a blister, or shallow crater with skin loss involving the epidermis and/or dermis. A stage I pressure ulcer appears as an area of color change (e.g., persistent redness) on intact skin. A stage III pressure ulcer presents clinically as a deep crater. A stage IV pressure ulcer involves bone, muscle, or supporting structures.

Which of the following is an example of healing by secondary intention? (Select all that apply.)

A. A full-thickness pressure ulcer
B. A surgical incision
C. A dog bite
D. A burn

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D.
Healing by secondary intention often accompanies traumatic open wounds with tissue loss or wounds with a high microorganism count. Examples of wounds that heal by secondary intention are pressure ulcers, a dog bite, a severe laceration, or a burn. Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. Examples of healing by primary intention are a surgical incision, an abrasion, or a skin tear.

It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.)

A. Yellow-tinged drainage
B. Temperature 100.3°F (37.94°C)
C. Increased complaints of pain at wound site
D. White blood cell count 13,000 mm3 (elevated)
E. Wound edges of pink to normal skin color
F. Foul odor noted from previous dressing

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, B, C, D, F.
The patient has a fever, tenderness, and pain at the wound site and an elevated white blood cell count (normal 5,000 to 10,000 per mm3). Wound edges that appear red and inflamed indicate infection. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.

Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.)

A. A BMI (body mass index) of 35 (elevated)
B. Fasting blood glucose of 215 mg/dl (elevated)
C. A serum albumin of 2.9 g/dl (decreased)
D. A hemoglobin of 10.0 g per dL (decreased)
E. A white blood cell count of 7000 per mm3 (normal)

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, B, C, D.
A BMI over 30 indicates obesity, which is a factor that may impair wound healing because fatty tissue has a poor blood supply. Elevated blood glucose indicates diabetes, which is a chronic disease that leads to poor tissue perfusion. A serum albumin below 3.5 indicates malnutrition. Adequate nutrition plays a significant role in wound healing. Hemoglobin below 12 g per dL indicates anemia and a decreased oxygen-carrying capacity necessary for tissue growth. The normal white blood cell count is 5,000 to 10,000 mm3. If the white blood cell count were elevated, this would indicate infection, which also is a factor that impairs wound healing.

Identify the functions of dressings. (Select all that apply.)

A. Maintaining a moist environment
B. Preventing shear
C. Control of bleeding and drainage
D. Removing surface bacteria
E. Protection from outside contaminants and further tissue injury
F. Increased patient comfort

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, E, F.
Dressings serve several functions, including maintaining a moist environment conducive to wound healing; protecting the wound from outside contaminants, further tissue injury, and transfer of microorganisms; maintaining hemostasis by controlling bleeding with pressure dressings; managing drainage to prevent excoriation of skin; and increased patient comfort. Cleaning the wound removes surface bacteria.

Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.)

A. Tape should be pulled parallel to the skin in a direction away from the incision.
B. If dressing is over a hairy area, remove tape in the direction of hair growth.
C. While wearing clean gloves, remove the dressing layers all at one time and discard.
D. Use caution to avoid tension on any drains that are present.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: B, D.
Tape should be pulled parallel to the skin, in a direction toward the dressing to avoid pulling on the suture line. If the dressing is over a hairy area, remove in the direction of hair growth. With clean gloves, remove dressings one layer at a time, observing appearance and drainage. Use caution to avoid tension on any drains that are present.

Which of the following is a method of wound debridement?

A. Gauze dressing
B. Transparent dressing
C. Moist-to-dry dressing
D. Hemovac drain

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Necrotic tissue may be loosened and possibly removed by the use of moist-to-dry dressings. Transparent dressings are used for partial-thickness wounds with minimal wound exudate. Dry gauze dressings are used for wounds that will heal by primary intention with little drainage such as a closed surgical incision. A Hemovac drain is used to collect drainage, but not for wound debridement.

The nurse is teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should the nurse include in the teaching? (Select all that apply.)

A. Turning patients at least every 2 hours
B. Rubbing reddened bony prominences
C. Use of pillow bridging when needed
D. Positioning the patient in the 30-degree lateral position
E. Using a turn sheet to reposition patients
F. Decreasing patients’ fluid intake to decrease the incidence of incontinence

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D, E.
There are several strategies to prevent the development of pressure ulcers. Patients should be repositioned at least every 2 hours to reduce the duration and intensity of pressure. The use of pillow bridging will prevent direct contact between bony prominences. Using a turning sheet to reposition patients prevents dragging along the sheets (friction). Maintaining the head of the bed at 30 degrees decreases the potential for the patient to slide toward the foot of the bed and incur a shear injury. The 30-degree lateral position should prevent positioning directly over the bony prominence. Avoid massaging reddened bony prominences because this may cause skin breakdown. Incontinence should be managed by methods other than withholding fluids. Dehydration can also negatively affect tissue integrity.

How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?

A. By turning the suction on
B. By keeping the drain lower than the insertion site
C. By compressing the drain reservoir
D. By “milking” the tubing

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Compressing the surface of the Hemovac drain or the bulb of the Jackson-Pratt drain and quickly reinserting the cap re-establishes the vacuum. Suction is never used with a Jackson-Pratt drain.

A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?

A. Dispose of gloves and soiled dressings in waterproof bag. Perform hand hygiene. Create a sterile field with individually wrapped sterile supplies on the over-bed table. Pour necessary prescribed solution into sterile basin. Apply sterile gloves.
B. Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom. Cleanse around drain by using a circular stroke starting near the drain and moving outward.
C. Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.
D. Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze) around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or Surgipad).

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The nurse should clean from the least-contaminated area to the most-contaminated because this avoids introducing microorganisms from surrounding skin into the incision. The nurse should clean the incision first in a direction of top to bottom and then clean the drain site.

A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?

A. Hypoallergenic tape
B. Paper tape
C. Adhesive tape
D. Montgomery ties

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
Frequent removal of tape for dressing changes is irritating to the skin. These dressings should be secured with Montgomery ties . Montgomery ties are wide tapes with holes to use with ties that secure dressings and facilitate changes without removing the tape each time.

Why does a wound bed need to stay moist?

A. To support healing by enabling granulation tissue to grow
B. To prevent excessive fluid loss from the body
C. To determine if the area has reactive hyperemia
D. To decrease patient discomfort

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Granulation tissue is the healthy, red, fleshy projection of moist tissue that indicates healing. If the wound bed were dry, this process would be impaired. Open wounds frequently have fluid loss as drainage. Replacing this loss is relevant to the patient’s overall hydration.

A nurse is applying a wound V.A.C. dressing independently for the first time. What action, if made by the nurse, indicates that further instruction is needed in performing this procedure?

A. The nurse turns the V.A.C. unit off, applies clean gloves, disconnects the tubes to drain fluids into the canister, and tightens the clamp on the canister tube.
B. With dressing tube unclamped, the nurse instills 10 to 30 mL of normal saline into the tubing to soak the foam underneath. The nurse gently pulls the transparent film horizontally and removes the old V.A.C. dressing, noting drainage. The nurse discards the dressing, removes gloves, and performs hand hygiene.
C. The nurse applies new gloves, irrigates the wound with normal saline, and then gently blots it dry. The nurse measures the wound, removes and discards gloves, and applies a new pair of gloves. The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas.
D. The nurse applies the tubing to the foam in the wound, applies a skin protectant to skin around the wound, and applies the transparent dressing, covering 3 to 5 cm (1.2 to 2 inches) of surrounding healthy tissue. The nurse secures the tubing to the transparent dressing and connects the tubing from the dressing to the tubing from the canister and V.A.C. unit. The nurse makes sure the tubing clamps are open, turns the wound V.A.C. unit on, and sets the pressure at 125 mm Hg.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The nurse should use sterile scissors to cut the foam to fit the size and shape of the wound, including tunnels and undermined areas. The nurse should place the foam in the wound, being sure that the foam is in contact with the entire wound base and margins and tunneled and undermined areas. This maintains negative pressure to the entire wound. The edges of the foam dressing must be in direct contact with the patient’s skin.

The nurse may use clean gloves for changing the dressing on which of the following?

A. Chronic pressure ulcer
B. Surgical wound
C. Sterile gloves should always be used for dressing changes performed by nurses.
D. Sterile gloves should always be used for dressing changes performed in the hospital setting.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Clean gloves and clean technique are acceptable only for the care of chronic wounds. Sterile technique or a no-touch technique with sterile forceps may be used when changing the dressing of a new surgical wound. Sterile gloves or nonsterile gloves may be worn with chronic wounds. Research has noted an absence of difference in wound infection rates when using sterile gloves or clean gloves, and there is a lowered cost for dressing supplies. Gloves should be changed, however, to avoid cross-contamination of microorganisms. The type of wound should determine whether clean or sterile technique is used, not who performs the dressing change or the setting.

The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states the patient has a hematoma on the right knee. The nurse knows to expect to see:

A. A shallow wound with loss of the epidermis and partial loss of the dermis.
B. A localized collection of blood underneath the tissues that often takes on a bluish discoloration.
C. A deep wound extending into the dermis.
D. An area of skin that has been scraped away.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A hematoma is a localized collection of blood underneath the tissues that often takes on a bluish discoloration. A shallow wound with loss of the epidermis and partial loss of the dermis is a partial thickness wound. A deep wound extending into the dermis is a full-thickness wound.
An area of skin that has been scraped is an abrasion.

When is a surgical wound at greatest risk for hemorrhage?

A. During the first 24 to 48 hours after surgery.
B. Two to three days after surgery.
C. Four to five days after surgery.
D. Five to seven days after surgery.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
The greatest risk of hemorrhage is during the first 24 to 48 hours after surgery or injury, indicating inadequate hemostasis. The nurse should monitor for decreased blood pressure and increased pulse rate and observe dressing and underneath the patient for any bloody drainage.

The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection:

A. during the first 24 to 48 hours after injury.
B. two to three days after injury.
C. Up to five days after injury.
D. five to seven days after injury.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.

A patient with lung cancer received radiation therapy to reduce the size of the tumor prior to a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient’s chest cavity and an opening on the patient’s back. The nurse is aware the patient is at increased risk for:

A. edema
B. hemorrhage
C. nerve damage with decreased sensation
D. fluid and electrolyte imbalance

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
The patient has a fistula, an abnormal passage between two organs or between an organ and the outside of the body. Most fistulas form as a result of poor wound healing or as a complication of disease, such as in this case cancer and radiation exposure in this case. The patient is at an increased risk for fluid and electrolyte imbalances from fluid loss through the fistula. Chronic drainage of fluids through a fistula can also predispose a person to skin breakdown.

The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?

A. “The old dressing may be removed while wearing clean gloves. Remove in direction of hair growth and toward the center. Remove disposable gloves pulling them inside out over the soiled dressing and dispose of properly.”
B. “You will need to apply new gloves after you open your supplies and before you clean the wound. Make sure the area around the wound is dry before applying a new transparent dressing.”
C. “You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling.”
D. “When the dressing change is completed, be sure to wash your hands. A transparent dressing is beneficial because it maintains a moist environment aiding wound healing, allows you to examine the wound without having to remove the dressing, and conforms well to body contours.”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Gloves are not discarded until the new dressing has been applied. The transparent film should be placed smoothly over the wound without stretching because wrinkles can provide a tunnel for drainage.

The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse’s best action at this time?

A. Apply sterile gloves and push the intestines back into the wound.
B. Instruct the patient to avoid looking at the wound.
C. Apply sterile saline-soaked towels to the area.
D. Assess the wound to determine the extent of evisceration.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
When evisceration occurs, the nurse places sterile towels soaked in sterile saline over the extruding tissues. The patient should be allowed nothing by mouth (NPO), observed for signs and symptoms of shock, and prepared for emergency surgery.

Which of the following may indicate an increased risk for wound dehiscence?

A. It is within the first 24 to 48 hours after surgery.
B. The patient holds a pillow over the abdomen whenever coughing.
C. There is a small amount of serous drainage noted on the dressing.
D. There is an increase in serosanguineous drainage from the wound.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
When there is an increase in serosanguineous drainage from a wound, the nurse should be alert for the potential for dehiscence. Dehiscence most commonly occurs before collagen formation (3 to 11 days after injury or surgery). Risk for hemorrhage is greatest during the first 24 to 48 hours following surgery. Placing a pillow or folded thin blanket over the abdomen provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. This is done to prevent wound dehiscence.

Which of the following patients is at greatest risk for developing a wound infection?

A. A diabetic obese patient who smokes.
B. An adolescent who takes steroids for asthma.
C. An alcoholic.
D. An elderly patient.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
The diabetic patient has the most risk factors for developing a wound infection. Other risk factors include: having a chronic disease, being obese, and smoking. Although taking steroids is one risk factor, this patient has fewer risk factors than the patient who has a chronic disease, is obese, and smokes. The same is true of the other patients.

The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding? (Select all that apply.)

A. The nurse instructs the NAP to empty the drain every 8-12 hours or when it is 2/3 full and document the amount as output on the intake and output record.
B. The nurse expects the Jackson-Pratt drain to be used when there is a large amount of drainage (500 mL).
C. The nurse ensures the drainage device appears deflated after it is emptied.
D. The nurse pins the Jackson-Pratt drain above the wound.
E. The nurse instructs the NAP to determine and report what type of drainage is present in the JP drain.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C.
The drainage device should be emptied every 8-12 hours or sooner if one-half to two-thirds full. To function properly the drainage device should be compressed. Determining the type of drainage present is the responsibility of the nurse.

During a home health visit a nurse talks with a patient and his family caregiver about the patient’s medications. The patient has hypertension and renal disease. Which of the following findings places him at risk for an adverse drug event? (Select all that apply.)

A.Taking two medications for hypertension
B.Taking a total of eight different medications during the day.
C.Having one physician who reviews all medications
D.Patient’s health history
E.Involvement of the caregiver in assisting with medication administration

Answers: B, D.
The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.

The nurse is having difficulty reading a physician’s order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take?

A. Call a pharmacist to interpret the order
B. Call the physician to have the order clarified
C. Consult the unit manager to help interpret the order
D. Ask the unit secretary to interpret the physician’s handwriting

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
You must have the right documentation and clarify all orders with the prescriber before administering medications.

The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her?

A. 2 mL
B. 5 mL
C. 16 mL
D. 30 mL

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient’s ear when administering the medication?

A. Outward
B. Back
C. Upward and back
D. Upward and outward

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.

A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer?

A. ½ tablet
B. 1 tablet
C. 1 ½ tablets
D. 2 tablets

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
Using dimensional analysis:
Tablets = 1tablet/250 mg× 500 mg = 500/250 = 2 tablets.

A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, “I don’t remember my child having that medication before.” What is the nurse’s next action?

A. Give the medications
B. Identify the patient using two patient identifiers
C. Withhold the medications and verify the medication orders
D. Provide medication education to the mother to help her better understand her child’s medications

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: C.
Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse?

A. Set up the follow-up appointments with the physician for the patient.
B. Ensure that someone will provide housekeeping for the patient at home.
C. Ensure that the home care agency is aware of medication and health teaching needs.
D. Make sure that the patient’s family knows how to safely bathe him or her and provide mouth care.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: C.
A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.

A nursing student takes a patient’s antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient?

A. Only the patient’s physician can give this information.
B. The student provides the name of the medication and a description of its desired effect.
C. Information about medications is confidential and cannot be shared.
D. He has to speak with his assigned nurse about this.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
Patients need to know information about their medications so they can take them correctly and safely.

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s next best course of action?

A. Ask the prescriber to change the order
B. Crush the pill with a mortar and pestle
C. Hide the capsule in a piece of solid food (lol!)
D. Open the capsule and sprinkle it over pudding

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: A.
Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.

The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse’s next action?

A. Ask the patient’s reason for refusal
B. Explain that she must take the medication
C. Take the medication away and chart the patient’s refusal
D. Tell the patient that her physician knows what is best for her

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: A.
When patients refuse a medication, first ask why they are refusing it.

The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to:

A. Hospital policy.
B. The prescriber’s orders.
C. The type of medication ordered.
D. The patient’s size and muscle mass.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
The order from the prescriber needs to indicate the route of administration.

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse:

A. Continues to let the IV run.
B. Applies a warm compress to the infiltrated site.
C. Stops the administration of the medication and follows agency policy.
D. Should not worry about this because vesicant filtration is not a problem.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: C.
When an IV medication infiltrates, stop giving the medication and follow agency policy.

If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects:

A. Sepsis.
B. Phlebitis.
C. Infiltration.
D. Fluid overload.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
Redness, warmth, and tenderness at the IV site are signs of phlebitis.

After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to:

A. Follow ISMP guidelines for safe medication abbreviations.
B. Explain to the physician that the order needs to be given to a registered nurse.
C. Write down the order on the patient’s order sheet and read it back to the physician.
D. Ensure that the six rights of medication administration are followed when giving the medication.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
Nursing students cannot take orders.

A nurse accidently gives a patient a medication at the wrong time. The nurse’s first priority is to:

A. Complete an occurrence report.
B. Notify the health care provider.
C. Inform the charge nurse of the error.
D. Assess the patient for adverse effects.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
Patient safety and assessing the patient are priorities when a medication error occurs.

A patient is taking albuterol through a pressurized metered dose inhaler (pMDI) that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the
pMDI last?
__________ days

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Correct Responses: “16, Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days., 16, Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days.”

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. …

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. Client admitted 2 days ago with congestive …

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? 1. Administering digestive enzymes before meals as prescribed 2. Providing small, frequent meals 3. …

The nurse helps a client to cough and deep breathe after surgery. It is desirable for the client to assume which position? Side-lying Prone Supine with one pillow High Fowler’s High Fowler’s- high Fowler’s is the best position to deep …

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