Nursing Assessment and Wound Care

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Questions and Answers

What is the primary goal of providing a high-protein, high-carbohydrate diet to a client?

To manage blood pressure

To reduce the risk of bleeding

To meet metabolic needs and aid in tissue repair (correct)

To promote weight loss

What is the first action the nurse should take if a client is suspected to have a fracture in their leg?

Apply a cold compress to the affected area

Administer pain medication

Conduct a thorough physical assessment

Immobilize the leg and call for emergency help (correct)

What is the correct order of abdominal assessment?

Percussion, palpation, and auscultation

Inspection, palpation, and auscultation

Auscultation, percussion, and palpation (correct)

Palpation, auscultation, and percussion

Why is it important to apply an elastic bandage from the distal area to the proximal area?

To promote venous return Signup and view all the answers

What is the purpose of placing a client in a comfortable position and recording information in their chart?

To provide comprehensive care and document client information Signup and view all the answers

What is the most important factor in assisting a healthcare professional in arriving at a diagnosis or determining a person's needs?

History of present illness Signup and view all the answers

What is a common side effect of nitroglycerin therapy?

Throbbing headache or dizziness Signup and view all the answers

What should the nurse use to assess tactile fremitus, thrills, and vocal vibrations through the chest wall?

Ulnar surface of the hand Signup and view all the answers

What is the purpose of a trochanter roll?

To resist external rotation of the hip Signup and view all the answers

What should the nurse do if a client is experiencing epigastric or back pain?

Recognize the signs of an inflammatory process in the pancreas Signup and view all the answers

Why is it important to avoid massaging a wound with an astringent?

It can further damage the skin Signup and view all the answers

What is the primary purpose of establishing a baseline for blood pressure and pulse rate?

To establish a benchmark for future comparisons Signup and view all the answers

What is a potential complication of insulin administration?

Hypokalemia Signup and view all the answers

What is the correct stage of wound care if a deep crater is clinically observed?

Stage III Signup and view all the answers

When using a walker, what should the client do?

Put all four points of the walker flat on the floor Signup and view all the answers

What is the primary consideration when preparing a client for a test?

Ensure the client does not contaminate the test Signup and view all the answers

What instruction should nurse Tom give to a male client who is having external radiation therapy?

Eat 3 to 4 hours before treatment. Signup and view all the answers

What is the priority nursing diagnosis for a newly admitted female client with agranulocytosis?

Risk for infection Signup and view all the answers

What is the priority action by the nurse if a male client receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism?

Stop the total parenteral nutrition. Signup and view all the answers

What assessment finding reflects a diagnosis of acute pancreatitis?

Severe epigastric pain Signup and view all the answers

What is an important consideration when assisting a female client for immediate surgery?

Assisting the client in removing dentures and nail polish. Signup and view all the answers

What instruction should the nurse give to the client with external radiation therapy to minimize skin irritation?

Protect the irritated skin from sunlight. Signup and view all the answers

What is the priority action by the nurse if the client is experiencing an air embolism while receiving total parenteral nutrition?

Stop the total parenteral nutrition. Signup and view all the answers

What is an important consideration when caring for a client with agranulocytosis?

Monitoring for signs of infection. Signup and view all the answers

Study Notes

Assessment Techniques

The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation.
The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques.
Percussion and palpation can alter natural findings during auscultation.

Skin Care

Massaging with an astringent can further damage the skin.
Auscultation, percussion, and palpation should be performed before the more intrusive techniques to avoid altering natural findings.

Wound Care

Antibiotic cream requires a physician's order.

Venous Return

An elastic bandage should be applied from the distal area to the proximal area to promote venous return.
Starting at the ankle, lower thigh, or knee, the bandage should be applied in this order to promote venous return.

Abdominal Assessment

The nurse uses the ulnar surface, or ball, of the hand to assess tactile fremitus, thrills, and vocal vibrations through the chest wall.

Medication Administration

Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy, but the client usually develops tolerance.
Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia.

Nursing Care

For a client using a walker, the nurse should stand adjacent to the affected side.
The client should put all four points of the walker flat on the floor, put weight on the hand pieces, and then walk into it.

Nutrition

A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection.
Caloric goals may be as high as 5000 calories per day.
Provide high-protein, high-carbohydrate diet.

Vital Signs

Blood pressure and pulse rate are vital signs to monitor for signs of an anaphylactic or hemolytic reaction to the transfusion.

Fracture Care

Immobilize the leg before moving the client if a fracture is suspected.

Nursing Process

Evaluation includes observing the person, asking questions, and comparing the patient's behavioral responses with the expected outcomes.
History of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person's needs.

Orthopedic Care

A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

Radiation Therapy

Protect the irritated skin from sunlight.
Wash the skin over regularly.
Apply lotion or oil to the radiated area when it is red or sore.

Diagnostic Testing

If the test results are contaminated, the results would be invalid.

Deep Tissue Injury

Stage III of deep tissue injury has a clinically evident deep crater.

Nursing Diagnosis

A newly admitted female client with agranulocytosis, the nurse formulates the priority nursing diagnosis as "Risk for infection".

Parenteral Nutrition

If the client suddenly demonstrates signs and symptoms of an air embolism, the priority action by the nurse is to stop the total parenteral nutrition.

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Description

This quiz assesses the reader's knowledge of nursing assessment techniques and wound care procedures. It covers the correct order of examination steps for the abdomen and proper wound care techniques.