Mobility and Immobility Skin Integrity and Wound Care PDF

Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Chapter 45: Mobility and Immobility Potter et al: Canadian Fundamentals of Nursing, 6th Edition MULTIPLE CHOICE 1. A patient has been on prolonged bed rest, and the nurse is observing f...

Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Chapter 45: Mobility and Immobility Potter et al: Canadian Fundamentals of Nursing, 6th Edition MULTIPLE CHOICE 1. A patient has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. While assessing the patient, the nurse is alert to which of the following signs? a. Increased blood pressure. b. Decreased heart rate. c. Increased urinary output. d. Decreased peristalsis. ANS: D Immobility disrupts the normal functioning of the gastrointestinal system, which results in decreased appetite and slowed peristalsis. In the immobilized patient, circulating fluid volume decreases, blood pools in the lower extremities, and autonomic response decreases. These factors result in decreased venous return, followed by a decrease in cardiac output, which is reflected by a decline in blood pressure. Recumbency increases cardiac workload and results in an increased pulse rate. Fluid intake can diminish with immobility, and this, combined with other causes, such as fever, increases the risk of dehydration. Urinary output may decline on or about the fifth or sixth day after immobilization, and the urine is often highly concentrated. DIF: Remember REF: 1249 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 2. A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA; also known as stroke). In planning care for this patient, the nurse would do which of the following? a. Encourage an even gait when walking in place. b. Assess the extremities for unilateral swelling and muscle atrophy. c. Encourage holding the breath frequently to hyperinflate the lungs. d. Teach the use of a two-point crutch technique for ambulation. ANS: B Because edema moves to dependent body regions, assessment of the immobilized patient should include observation of the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis. The patient who has suffered a CVA with left-sided paralysis may not be capable of an even gait. Having the patient hold his or her breath frequently is not an appropriate nursing intervention. To prevent stasis of pulmonary secretions, the patient’s position should be changed every 2 hours, and fluid intake should be increased to 2000 mL, if not contraindicated. The patient should deep breathe and cough every 1 to 2 hours to promote chest expansion. Two-point crutch technique would not be appropriate for the patient with left-sided paralysis. The patient would be more likely to ambulate safely with a walker or a cane. If crutches are used, the patient should use a three-point support. DIF: Analyze REF: 1272 (Skill 45-1) 485 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter OBJ: Assess for correct and impaired body alignment and mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 3. When a patient with impaired physical mobility is in the recumbent position, what angle of lateral position is recommended? a. 15 degrees. b. 30 degrees. c. 45 degrees. d. 90 degrees. ANS: B When a patient with impaired physical mobility is in the recumbent position, the 30-degree lateral position reduces pressure from the sacral area and reduces the risk of skin breakdown. For a patient in the recumbent position with impaired physical mobility, the correct angle for a patient in the recumbent position with impaired physical mobility is not 15, 45, or 90 degrees. DIF: Apply REF: 1265 (Box 45-7)| 1272 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 4. The patient has sequential compression stockings in place. The nurse evaluates that the stockings have been implemented appropriately by the new staff nurse when the nurse observes what? a. Intermittent pressure is set at 40 mm Hg. b. Initial measurement is made around the patient’s calves. c. Stockings are wrapped directly over the leg from ankle to knee. d. Stockings are removed every hour during application. ANS: A Inflation pressure averages 40 mm Hg. Initial measurement is made around the largest part of the patient’s thigh. A protective stockinette is placed over the patient’s leg. Then the stocking is wrapped around the leg, starting at the ankle, with the opening over the patella. Stockings are not removed every hour. For optimal results, sequential compression or intermittent pneumatic compression devices are used as soon as possible and maintained until the patient becomes fully ambulatory. The stockings should be removed periodically to assess the condition of the patient’s skin. DIF: Apply REF: 1268 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Evaluate MSC: NCLEX: Physiological Integrity 5. The patient with torticollis would exhibit a. Exaggeration of the lumbar spine curvature. b. Increased convexity of the thoracic spine. c. Abnormal anteroposterior and lateral curvature of the spine. d. Contracture of the sternocleidomastoid muscle with a head incline. ANS: D 486 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted. Lordosis is an exaggeration of the lumbar spine curvature. Kyphosis is an increased convexity in the curvature of the thoracic spine. Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine. DIF: Understand REF: 1248 (Table 45-1) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse expects to maintain the patient’s legs in abduction after total hip replacement surgery with the use of which of the following? a. Foot boot. b. Wedge pillow. c. Trochanter roll. d. Sandbag. ANS: B A wedge pillow is a triangular pillow made of heavy foam used to maintain the legs in abduction after total hip replacement surgery. A foot boot maintains feet in dorsiflexion. A trochanter roll prevents external rotation of the hips. Sandbags can be used to shape body contours and immobilize an extremity. DIF: Apply REF: 1271 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is getting up for the first time after a period of bed rest. What is the initial nursing action? a. Assess respiratory function. b. Obtain a baseline blood pressure. c. Assist the patient to sit at the edge of the bed. d. Ask the patient if he or she feels lightheaded. ANS: B When getting a patient up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure. Assessing the patient’s respiratory function is not the nurse’s first intervention when getting a patient up for the first time after prolonged bed rest. After the nurse assesses the patient’s blood pressure, the nurse can assist the patient to a sitting position at the side of the bed. After the patient is in the sitting position at the side of the bed, the nurse should ask the patient if he or she feels lightheaded. DIF: Apply REF: 1261| 1272 (Skill 45-1) OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 8. Immobilized patients frequently have hypercalcemia, which increases their risk for what? a. Osteoporosis. b. Renal calculi. c. Pressure ulcers. d. Thrombus formation. 487 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter ANS: B Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Osteoporosis is caused by accelerated bone loss. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. DIF: Remember REF: 1252 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 9. Patients on bed rest or otherwise immobile are at risk for what condition? a. Increased metabolic rate. b. Increased diarrhea (peristalsis). c. Altered metabolic function. d. Increased appetite. ANS: C Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins (nutritional function); causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. DIF: Remember REF: 1250 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 10. In caring for a patient who is immobile, what is important for the nurse to understand? a. The effects of immobility are the same for everyone. b. Immobility helps maintain sleep-wake patterns. c. Changes in role and self-concept may lead to depression. d. Immobile patients are often eager to help in their own care. ANS: C Many immobilized patients become depressed because of changes in role and self-concept. Every patient responds to immobility differently. Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient’s depression, causing withdrawal. Many withdrawn patients do not want to participate in their own care. DIF: Understand REF: 1252 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: NCLEX: Psychosocial Integrity 11. Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware of which of the following? a. Breaks in skin integrity are easy to heal. 488 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter b. Preventing a pressure ulcer is more expensive than treating one. c. A 30-degree lateral position is recommended d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue. ANS: C Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. A 30-degree lateral position is recommended for patients at risk for pressure ulcers. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation. DIF: Understand REF: 1265 (Box 45-7)| 1272 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient who has suffered a stroke. As part of her ongoing care, what should the nurse do? a. Encourage the patient to perform as many self-care activities as possible. b. Provide a complete bed bath to promote patient comfort. c. Place the patient on bed rest to prevent fatigue. d. Understand that the patient will not eat because energy needs are decreased. ANS: A Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient’s immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition. DIF: Apply REF: 1247| 1253 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. The nurse is assessing the way the patient walks. The manner of walking is known as what? a. Activity tolerance. b. Body alignment. c. Range of motion. d. Gait. ANS: D The term gait describes a particular manner or style of walking. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Body alignment refers to the position of the joints, tendons, ligaments, and muscles while the person is standing, sitting, and lying. Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse. DIF: Remember REF: 1254-1259 OBJ: Assess for correct and impaired body alignment and mobility. 489 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter TOP: Assessment MSC: NCLEX: Physiological Integrity 14. When assessing the body alignment of a patient while he or she is standing, the nurse is aware of which of the following? a. When observed posteriorly, the hips and shoulders form an S pattern. b. When observed laterally, the spinal curves align in a reversed S pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out. ANS: B When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed S pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward. DIF: Understand REF: 1259 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is evaluating the body alignment of a patient in the sitting position. In this position, how is the body aligned? a. The body weight is directly on the buttocks only. b. Both feet are supported on the floor with ankles flexed. c. The edge of the seat is in contact with the popliteal space. d. The arms hang comfortably at the sides. ANS: B Both feet are supported on the floor, and the ankles are comfortably flexed. With patients of short stature, a footstool is used to ensure that the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 2.5- to 5.0-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient’s forearms are supported on the armrest, in the lap, or on a table in front of the chair. DIF: Understand REF: 1259| 1260 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is assessing body alignment for a patient who is immobilized. What must the nurse do? a. Place the patient in the supine position. b. Remove the pillow from under the patient’s head. c. Insert positioning supports to help the patient. d. Place the patient in a lateral position. ANS: D For a patient who is immobilized or bedridden, body alignment is assessed with the patient in the lateral position, not supine. The nurse should remove all positioning support from the bed, except for the pillow under the patient’s head. DIF: Apply REF: 1260 490 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter OBJ: Assess for correct and impaired body alignment and mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment. When the respiratory system is assessed, what should the nurse do? a. Assess the patient at least every 4 hours. b. Inspect chest wall movements during the expiratory cycle only. c. Auscultate the entire lung region to assess lung sounds. d. Focus auscultation on the upper lung fields. ANS: C The nurse auscultates the entire lung region to identify diminished breath sounds, crackles, or wheezes. A respiratory assessment is performed at least every 2 hours for patients with restricted activity. The nurse inspects chest wall movements during the full inspiratory-expiratory cycle. Auscultation is focused on the dependent lung fields because pulmonary secretions tend to collect in these lower regions. DIF: Apply REF: 1260 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs). Because of this, what action does the nurse take? a. Make sure that elastic stockings are not removed. b. Measure the calf circumference of both legs. c. Dorsiflex the foot while assessing for patient discomfort. d. Measure both ankles to determine size. ANS: B The nurse measures bilateral calf circumference and records it daily as an assessment for deep vein thrombosis (DVT). Homans’s sign, or calf pain on dorsiflexion of the foot, should not be assessed in patients when a DVT is suspected; it is no longer considered a reliable indicator in assessing for DVT, and it is present in other conditions. The patient’s elastic stockings or sequential compression devices, or both, should be removed every 8 hours and the calves observed for redness, warmth, and tenderness. Bilateral calf (not ankle) circumferences should be measured daily to detect unilateral increases that may be an early indication of thrombosis. DIF: Apply REF: 1261 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 19. A patient is admitted to the medical unit after a CVA. There is evidence of left-sided hemiparesis, and the nurse will be following up on range-of-motion (ROM) and other exercises performed in physiotherapy. Which of the following principles of ROM exercises does the nurse correctly teach the patient and family members? a. Flex the joint to the point of discomfort. b. Work from proximal to distal joints. c. Move the joints quickly. d. Provide support to the extremity. ANS: D 491 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter While the patient is performing ROM exercises, support should be provided to the extremity. The joint should be flexed to the point of resistance, not to the point of discomfort. When performing ROM exercises, the patient should begin at distal joints and work toward proximal joints. Joints should be moved slowly through the ROM. Quick movement could cause injury. DIF: Apply REF: 1282-1284 OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 20. The nurse is caring for an older patient with the diagnosis of urinary tract infection (UTI). The patient is confused and agitated. It is important for the nurse to realize that confusion in older people is which of the following? a. Not a normal expectation. b. Purely psychological in origin. c. Not a common manifestation with UTIs. d. Acceptable and needs no further assessment. ANS: A Acute confusion in older persons is not normal; a thorough nursing assessment is the priority. Abrupt changes in personality often have a physiological cause such as surgery, a medication reaction, a pulmonary embolus, or an acute infection. For example, the primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion. Identifying confusion is an important component of the nurse’s assessment. DIF: Understand REF: 1262 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: NCLEX: Psychosocial Integrity 21. In preparing to create a nursing diagnosis for a patient who is immobile, what is important for the nurse to understand? a. Physiological issues should be the major focus. b. Psychosocial issues should be the major focus. c. Developmental issues should be the major focus. d. All dimensions are important to health. ANS: D Often the physiological dimension is the major focus of nursing care for patients with impaired mobility. Thus the psychosocial and developmental dimensions are neglected. However, all dimensions are important in health. DIF: Understand REF: 1263 OBJ: Formulate appropriate nursing Diagnosis for impaired mobility. TOP: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. Many patients who experience an alteration in mobility have one or more nursing diagnoses. For whom would the nurse would use the diagnosis of Impaired physical mobility? a. A patient who is not completely immobile. 492 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter b. A patient who is completely immobile. c. A patient who is at risk for multisystem problems. d. A patient who is at risk for single-system involvement. ANS: A The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems. DIF: Apply REF: 1263 OBJ: Formulate appropriate nursing Diagnosis for impaired mobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. This diagnosis means that the nurse should do what? a. Encourage the patient to perform self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM exercises. d. Assist the patient with comfort measures. ANS: D The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and better able to move. Pain must be controlled before the patient will be willing to initiate movement. The diagnosis of Reluctance to initiate movement necessitates interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM exercises. This cannot be accomplished until comfort is achieved. DIF: Apply REF: 1263 OBJ: Formulate appropriate nursing Diagnosis for impaired mobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. In developing an individualized plan of care for a patient, what is important for the nurse to do? a. Set goals that are a little beyond the capabilities of the patient. b. Use his or her judgement and not be swayed by family desires. c. Establish goals that are measurable and realistic. d. Explain that without taking alignment risks, there can be no progress. ANS: C The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility. DIF: Apply REF: 1264 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 493 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter 25. When the nurse creates a plan of care for a patient who is experiencing alterations in mobility, which of the following is true? a. The nurse cannot delegate interventions to nursing assistive personnel. b. The nurse is solely responsible for modifying activities of daily living (ADLs). c. The nurse consults other health care team members to help plan therapy. d. The nurse consults wound care specialists only when wounds are apparent. ANS: C The nurse should collaborate with other health care team members such as physiotherapists or occupational therapists when considering mobility needs. Nurses often delegate some interventions to unregulated care providers. Unregulated care providers may perform such tasks as turning and positioning patients, applying elastic stockings, and helping patient use the incentive spirometer. Occupational therapists are a resource for planning ADLs that patients need to modify or relearn. It is especially important in priority setting to account for potential complications. Many times, actual problems such as pressure ulcers are addressed only after they develop. They should be addressed before they develop. DIF: Apply REF: 1282 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment 26. The patient is being admitted to the neurological unit with the diagnosis of stroke. When should the nurse should begin discharge planning? a. At the time of admission. b. The day before the patient is to be discharged. c. As soon as the patient’s discharge destination is known. d. When outpatient therapy will no longer be needed. ANS: A Discharge planning begins when a patient enters the health care system. In anticipation of the patient’s discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient’s needs will be met at home. Referrals to home care or outpatient therapy are often needed. DIF: Apply REF: 1264 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. Of the following nursing goals, which is the most appropriate for a patient who has had a total hip replacement? a. The patient will walk 305 m (1000 feet), using her walker, by the time of discharge. b. The patient will ambulate by the time of discharge. c. The patient will ambulate briskly on the treadmill by the time of discharge. d. The nurse will assist the patient to ambulate in the hall. ANS: A 494 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter A goal of walking 305 m (1000 feet) with the use of her walker by the time of discharge is individualized, realistic, and measurable. “The patient will ambulate by the time of discharge” is not measurable because it does not specify the distance. Even though the patient will ambulate, this does not quantify how far. “Ambulating briskly on a treadmill” is not realistic for this patient. The last option focuses on the nurse, not the patient, and is not measurable. DIF: Analyze REF: 1264 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Assessment MSC: NCLEX: Health Promotion and Maintenance 28. Prevention of plantar flexion through the use of pillows to support the lower legs and elevate the toes is a priority intervention for which patient? a. A 54-year-old with a diagnosis of osteoarthritis in all lower extremity joints. b. A 25-year-old with a fractured pelvis as a result of a motorcycle accident. c. A 78-year-old who has experienced left-sided paralysis caused by a CVA. d. A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof. ANS: C The patient who has suffered a CVA with resulting left-sided paralysis (hemiplegia) is at risk for footdrop. Neither the 54-year-old patient with osteoarthritis in all lower extremity joints nor the 25-year-old patient with a fractured pelvis as a result of a motorcycle accident would have damage to the nerve necessary to cause footdrop. There is little chance that the 15-year-old patient who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof will ever be capable of mobility. DIF: Analyze REF: 1251| 1252 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 29. The patient is immobilized after undergoing hip replacement surgery. Which of the following would place the patient at risk for hemorrhage? a. Thick, tenacious pulmonary secretions. b. Low-molecular-weight heparin doses to prevent DVT. c. Sequential compression devices wrapped around the legs to prevent DVT formation. d. Elastic stockings (thromboembolic disease [TED] hose) to promote venous return. ANS: B Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT. Because bleeding is a potential side effect of these medications, the nurse must assess the patient continually for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration, but not of bleeding. Sequential compression devices consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return, and they also do not usually cause bleeding. 495 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter DIF: Analyze REF: 1265 (Box 45-7)| 1269 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 30. The nurse needs to transfer the patient from the bed to the chair. What should the nurse remember? a. To avoid using a transfer or gait belt around the patient’s waist before transfer. b. Not to allow the patient to help in any way because resistance can lead to injury. c. To assess for the need of a mechanical lift and help. d. To ensure that the patient has stockings on the feet for transfer. ANS: C Careful assessment of the patient’s ability to assist in the positioning technique to be used is extremely important. The use of a mechanical lift should be considered. The nurse’s role in assisting the patient to a sitting position is to guide and instruct. If the patient can bear weight and move to a sitting position independently, he or she should be allowed to do so, and the nurse may offer assistance. A transfer belt maintains stability of the patient during transfer and reduces risk for falls. The nurse must ensure that the patient has stable nonskid shoes on the feet. DIF: Apply REF: 1281 OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment 31. The nurse is caring for a patient with a spinal cord injury and notices that the patient’s hips have a tendency to rotate externally when the patient is supine. To help prevent injury secondary to this rotation, what can the nurse use? a. A trochanter roll. b. The trapeze bar. c. Hand rolls. d. Hand-wrist splints. ANS: A A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. Hand-wrist splints are individually moulded for the patient to maintain proper alignment of the thumb and the wrist. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises. DIF: Remember REF: 1281 OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Physiological Integrity 32. The patient is unable to move himself and needs to be pulled up in bed. For this repositioning to be done safely, what must the nurse understand? a. The procedure can be done by one person if the bed is in the flat position. 496 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter b. Side rails should be in the up position to prevent the patient from falling out. c. The pillow should be placed under the patient’s head and shoulders. d. Assistive devices or additional nurses should be used. ANS: D This is not a one-person task. Helping a patient move up in bed without help from other coworkers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. When a patient is pulled up in bed, the bed should be flat or in the Trendelenburg position (when tolerated) for gravity assistance, and the side rails should be down. The pillow should be removed from under the patient’s head and shoulders and placed at the head of the bed to keep the patient’s head from striking against the head of the bed. DIF: Understand REF: 1272-1280 (Skill 45-1) OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment 33. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient’s toes. What is one strategy that the nurse could use? a. A foot cradle. b. A trochanter roll. c. The trapeze bar. d. Hand rolls. ANS: A A foot cradle may be used for patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient’s toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises. DIF: Apply REF: 1275 (Skill 45-1) OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Physiological Integrity 34. In applying for a job on a nursing unit that requires frequent patient positioning, of what should the nurse should be aware? a. That nurses are at low risk for back injury. b. That nurses are especially at risk for upper back injuries. c. That nurses should be aware of agency policies. d. That nurses should not need to use assistive devices. ANS: C 497 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Therefore, the nurse should be aware of agency policies and protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to perform these activities themselves. DIF: Understand REF: 1247 OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment 35. When the nurse is preparing a plan of care for an immobilized patient, what should the nurse keep in mind? a. To use established expected outcomes to evaluate the patient’s response to care. b. To display an air of professional superiority when interventions are not successful. c. Never to vary from interventions that have been successful for other patients. d. To use only objective data in determining whether interventions have been successful. ANS: A The nurse should use established expected outcomes to evaluate the patient’s response to care. The nurse should use creativity when designing new interventions to improve the patient’s mobility status and should display humility when identifying the interventions that were not successful. The nurse should ask whether the patient’s expectations of care are being met and use objective data to determine the success of interventions. DIF: Apply REF: 1295 (Figure 45-22) OBJ: Evaluate the nursing care plan for maintaining body alignment and mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 36. It has been determined that each of the following patients is at risk for falling. Which one requires the nurse’s priority for ambulation? a. A 16-year-old with a sprained ankle being discharged from the emergency department. b. A 54-year-old who has taken the initial dose of an antihypertensive medication. c. A 45-year-old postoperative patient up for the first time since knee surgery. d. An 81-year-old who is asthmatic and had a hip replaced 18 months ago. ANS: C Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Although all of the options represent a potential risk for falling, the postoperative patient has both prolonged immobility and physical injury (surgery) and so is at greatest risk. The 16-year-old with a sprained ankle being discharged from the emergency department, the 54-year-old who has taken the initial dose of an antihypertensive medication, and the 81-year-old who is asthmatic and had a hip replaced 18 months ago do not receive priority for ambulation. DIF: Analyze REF: 1251 OBJ: Develop individualized nursing care plans for patients with impaired mobility. 498 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter TOP: Implementation MSC: NCLEX: Physiological Integrity 37. The nurse needs to reposition a 136.1 kg (300-pound) patient. Which of the following strategies is most likely to prevent back injury? a. Turn the patient alone using the lift pad and applying pillows. b. Put the bed in the Trendelenburg position and pull from the head of the bed. c. Assess and obtain the number of people needed to help. d. Bend at the waist and pull the lift pad, using the arms. ANS: C The nurse must assess and determine the number of people needed; to prevent injury, the task should not be started until it can be completed safely. The nurse should assess the situation and not turn the patient alone if this cannot be done safely. The nurse’s trunk should be erect and the knees bent, so that multiple muscle groups (not just the arms) work together in a coordinated manner. This is not a one-person task: the nurse must not pull from the head of the bed. DIF: Analyze REF: 1273 (Skill 45-1) OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment 38. The nurse is caring for a patient who has had a stroke that caused total paralysis of the right side. To help maintain joint function and to prevent contractures, passive ROM exercises will be initiated. When should therapy begin? a. After the acute phase of the disease has passed. b. As soon as the ability to move is lost. c. Once the patient enters the rehabilitation unit. d. No ROM exercise is needed. ANS: B Passive ROM exercises should begin as soon as the patient’s ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehabilitation unit, and contractures could form by then. ROM exercise is certainly needed by this patient. DIF: Understand REF: 1254| 1284 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 39. The nurse is admitting a patient who has had a stroke. The physician writes orders for “ROM as needed.” What does the nurse understand about this situation? a. The nurse will have to move all the patient’s extremities. b. The patient is unable to move his extremities. c. Further assessment of the patient is needed. d. The patient needs to restrict his mobility as much as possible. ANS: C 499 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Further assessment of the patient is needed. Some patients are able to move some joints actively, whereas the nurse must help other joints with passive movement. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as the patient’s health and mobility allow. DIF: Understand REF: 1253 (Figure 45-5) OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 40. While performing passive ROM exercises, the nurse stands at the side of the bed closest to the joint being exercised and does what else? a. Forces the joint just a bit beyond the point of resistance. b. Moves the joint until the patient complains of pain. c. Repeats each movement twice. d. Carries out movements slowly and smoothly. ANS: D The nurse carries out movements slowly and smoothly, just to the point of resistance. ROM exercises should not cause pain. A joint should never be forced beyond its capacity. Each movement needs to be repeated five times during the session. DIF: Apply REF: 1284 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 41. Two nurses are standing on opposite sides of the bed to move the patient up in bed with a drawsheet. Which of the following describes the correct position for the nurses in order to safely position the patient? a. The nurses should face the patient. b. The nurses should face the direction of movement. c. The nurses should face each other. d. The nurses should face opposite the direction of movement. ANS: B Facing the direction of movement ensures proper balance and prevents twisting of the nurses’ bodies while moving the patient. Facing the patient, facing each other, and facing opposite the direction of movement are not the correct positions for the nurses to take. DIF: Apply REF: 1274 (Skill 45-1) OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Physiological Integrity 42. The patient has suffered a spinal cord injury and needs to be repositioned through the log-rolling technique to keep the spinal column in straight alignment. Which of the following is the proper technique for nurses to perform log-rolling? a. Obtaining assistance from at least two or three other people. b. Having the patient reach for the opposite side rail when turning. c. Moving the top part of the patient’s torso, then the bottom part. d. Not using pillows after turning because the softness causes misalignment. ANS: A 500 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter At least three to four people are needed to perform this skill safely. The patient crosses arms on the chest to prevent injury to the arms. The patient should be moved as one unit in a smooth, continuous motion on the count of three. The nurses gently let the patient as a unit lean back toward pillows for support. DIF: Apply REF: 1274| 1279 (Skill 45-1) OBJ: Describe essential techniques when assisting with active and passive range-of-motion (ROM) exercises, assisting a patient to move up in bed, repositioning a patient, assisting a patient to a sitting position, and transferring a patient from a bed to a chair or from a bed to a stretcher. TOP: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Correct body alignment reduces strain on musculoskeletal structures and contributes to balance. Balance control is attained by which of the following? (Select all that apply.) a. Keeping the body’s centre of gravity high. b. Maintaining a wide base of support. c. Keeping the body’s centre of gravity low. d. Maintaining correct body posture. e. Maintaining immobility to prevent falls. ANS: B, C, D Without balance control, the centre of gravity is displaced, thus creating risk for falls and injuries. Balance is enhanced by keeping the body’s centre of gravity low (not high) with a wide base of support and by maintaining correct body posture. Prolonged immobility leads to impaired balance. DIF: Understand REF: 1247 OBJ: Discuss physiological and pathological influences on body alignment and joint mobility. TOP: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient with the nursing diagnosis of Impaired physical mobility. The nurse needs to be alert for which of the following potential complications? (Select all that apply.) a. Pulmonary emboli. b. Pneumonia. c. Impaired skin integrity. d. Somnolence. e. Increased socialization. ANS: A, B, C Immobility leads to complications such as pulmonary emboli or pneumonia. Other possible complications include impaired skin integrity. Insomnia and social isolation are more common than somnolence or increased socialization. DIF: Apply REF: 1263 OBJ: Formulate appropriate nursing Diagnosis for impaired mobility. TOP: Implementation MSC: NCLEX: Health Promotion and Maintenance 501 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter 3. The nurse is caring for a patient who has had a recent stroke and is paralyzed on his left side. He has no respiratory or cardiac issues, but he cannot walk. He becomes extremely frustrated when he cannot button his shirt and cannot feed himself because he was left-handed. He has shown no signs of dysphagia, but he has been eating very little and has lost 0.9 kg (2 pounds). He asks the nurse, “How can I go home like this? I’m not getting better. I can’t ask my wife to take care of me like a baby.” Of the following list of health care team members, which member would the nurse need to consult? (Select all that apply.) a. Physiotherapy. b. Occupational therapy. c. Respiratory therapy. d. Cardiac rehabilitation. e. Psychology services. ANS: A, B, E Physiotherapists are a resource for planning ROM or strengthening exercises, and occupational therapists are a resource for planning ADLs that patients need to modify or relearn. Referral to a mental health advanced practice nurse, a licensed social worker, or a physiologist to assist with coping or other psychosocial issues is also wise. Because the patient exhibits good cardiac and respiratory function, respiratory therapy and cardiac rehabilitation probably are not needed at this time. DIF: Apply REF: 1264 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment 502 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Chapter 46: Skin Integrity and Wound Care Potter et al: Canadian Fundamentals of Nursing, 6th Edition MULTIPLE CHOICE 1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure injuries. The nurse recognizes that the risk factors that predispose a patient to pressure injury development include which of the following? a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain. ANS: B Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not among the predisposing factors. DIF: Remember REF: 1291| 1292 OBJ: Discuss the risk factors that contribute to pressure injury formation. TOP: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. What is the major element involved in the development of a pressure injury? a. Pressure. b. Resistance. c. Stress. d. Weight. ANS: A Pressure is the main element that causes pressure injury. Three pressure-related factors contribute to pressure injury development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure injury. DIF: Remember REF: 1290 OBJ: Discuss the risk factors that contribute to pressure injury formation. TOP: Assessment MSC: NCLEX: Physiological Integrity 3. Which nursing observation would indicate that the patient was at risk for pressure injury formation? a. The patient ate two thirds of breakfast. 503 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient’s capillary refill is less than 2 seconds. ANS: B The presence and duration of moisture on the skin increase the risk of pressure injury formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, which causes maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits. DIF: Understand REF: 1292 OBJ: Discuss the risk factors that contribute to pressure injury formation. TOP: Implementation MSC: NCLEX: Physiological Integrity 4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage 3 pressure injury. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this pressure injury? a. Stage 1 pressure injury. b. Healing stage 2 pressure injury. c. Healing stage 3 pressure injury. d. Stage 3 pressure injury. ANS: C When a pressure injury has been staged and is beginning to heal, the pressure injury keeps the same stage and is labelled with the words “healing stage.” Once a pressure injury has been staged, the stage endures even as the pressure injury heals. This pressure injury was labelled a stage 3; it cannot return to a previous stage such as stage 1 or 2. This pressure injury is healing, so it is no longer labelled just stage 3. DIF: Remember REF: 1299 OBJ: Recognize the stages of pressure injury. TOP: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open pressure injury without slough on the right heel of the patient. How would this pressure injury be staged? a. Stage 1. b. Stage 2. c. Stage 3. d. Stage 4. ANS: B 504 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter This would be a stage 2 pressure injury because it manifests as partial-thickness skin loss involving epidermis, dermis, or both. The pressure injury is superficial and appears clinically as an abrasion, blister, or shallow crater. In a stage 1 injury, skin is intact with nonblanchable redness over a bony prominence. With a stage 3 pressure injury, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage 4 involves full-thickness tissue loss with exposed bone, tendon, or muscle. DIF: Remember REF: 1299-1301 (Table 46-3) OBJ: Recognize the stages of pressure injury. TOP: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging a pressure injury on this patient? a. Cotton-tipped applicator. b. Disposable measuring tape. c. Sterile gloves. d. Halogen light. ANS: D When a patient with darkly pigmented skin undergoes a skin assessment, proper lighting is essential to accurately complete the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used. DIF: Apply REF: 1291 (Box 46-2) OBJ: Recognize the stages of pressure injury. TOP: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient with a stage 4 pressure injury. The nurse recalls that a pressure injury takes time to heal and that the healing process is an example of which of the following? a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention. ANS: C Pressure injuries are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate; hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodelling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed; and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. In tertiary intention, a wound is left open for several days, and then the wound edges are approximated; wound closure is delayed until risk of infection is resolved. 505 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter DIF: Understand REF: 1302| 1303 OBJ: Discuss the normal process of wound healing. TOP: Planning MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in how long? a. 4 days. b. 2 days. c. 1 day. d. 7 days. ANS: A A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry. DIF: Remember REF: 1303 OBJ: Discuss the normal process of wound healing. TOP: Planning MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a patient who is undergoing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar. b. Slough. c. Granulation. d. Purulent drainage. ANS: C Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and must be resolved for the wound to heal. DIF: Understand REF: 1303 OBJ: Discuss the normal process of wound healing. TOP: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient who has undergone a laparoscopic appendectomy. The nurse recalls that this type of wound heals by which process? a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention. ANS: D 506 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. In tertiary intention, a wound is left open for several days, and then the wound edges are approximated; wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn, a pressure injury, or a laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. DIF: Remember REF: 1301-1303 OBJ: Describe the differences between wounds that heal by primary and secondary intention. TOP: Planning MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by which process? a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention. ANS: B A wound involving loss of tissue such as a burn or a pressure injury or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. In tertiary intention, a wound is left open for several days, and then the wound edges are approximated; wound closure is delayed until the risk of infection is resolved. DIF: Remember REF: 1301-1303 OBJ: Describe the differences between wounds that heal by primary and secondary intention. TOP: Planning MSC: NCLEX: Physiological Integrity 12. Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Severe scarring. ANS: D A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, loss of function is often permanent. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter colour than normal skin. 507 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter DIF: Understand REF: 1301-1303 OBJ: Describe the differences between wounds that heal by primary and secondary intention. TOP: Assessment MSC: NCLEX: Physiological Integrity 13. The nurse is caring for a patient who has undergone a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in colour. ANS: D A hematoma is a localized collection of blood underneath the tissues. It appears as swelling; a change in colour, sensation, or warmth; or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain. DIF: Understand REF: 1306| 1308 OBJ: Describe the complications of wound healing. TOP: Assessment MSC: NCLEX: Physiological Integrity 14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way. b. Protrusion of visceral organs through a wound opening. c. Chronic drainage of fluid through the incision site. d. Drainage that is malodorous and purulent. ANS: A Dehiscence is a development in which a wound fails to heal properly and the layers of skin and tissue separate. It often involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Affected patients often report feeling as though something has given way. In evisceration, vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is malodorous and purulent. DIF: Understand REF: 1309 OBJ: Describe the complications of wound healing. TOP: Assessment MSC: NCLEX: Physiological Integrity 15. A patient has developed a pressure injury. What laboratory data would be important to gather? a. Serum albumin level. b. Creatine kinase level. c. Vitamin E level. d. Potassium level. ANS: A 508 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Normal wound healing necessitates proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin level because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarctions and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing. DIF: Understand REF: 1292 OBJ: Explain the factors that impede or promote wound healing. TOP: Assessment MSC: NCLEX: Physiological Integrity 16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? a. Muscular strength assessment. b. Sleep assessment. c. Pulse oximetry assessment. d. Sensation assessment. ANS: C Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, also does not provide any data with regard to wound healing. DIF: Apply REF: 1292 OBJ: Explain the factors that impede or promote wound healing. TOP: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse is caring for a patient with a healing stage 3 pressure injury. Upon entering the room, the nurse notices an odour and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b. Notify the charge nurse about the change in status and the potential for infection. c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d. Notify the wound care nurse about the change in status and the potential for 509 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter infection. ANS: A The patient is showing signs and symptoms associated with infection in the wound. It is serious and necessitates treatment but is not a life-threatening emergency, for which care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs such as temperature, and laboratory results such as the most recent complete blood cell count or white blood cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient’s status and on any new orders. DIF: Apply REF: 1306| 1307 OBJ: Explain the factors that impede or promote wound healing. TOP: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is collaborating with the dietitian in treatment of a patient with a stage 3 pressure injury. After the collaboration, the nurse orders a meal plan that includes increased levels of what? a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E. ANS: C Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing. DIF: Apply REF: 1317 OBJ: Explain the factors that impede or promote wound healing. TOP: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is completing an assessment on an individual who has a stage 4 pressure injury. The wound is malodorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. “I think I will be ready to go home early next week.” b. “I am so weak and tired; I want to feel better.” c. “I am ready for my bath and linen change as soon as possible.” d. “I am hoping there will be something good for dinner tonight.” ANS: C 510 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter The patient’s psychological response to any wound is part of the nurse’s assessment. Body image changes can influence self-concept. Factors that affect the patient’s perception of the wound include the presence of scars, drains, odour from drainage, and temporary or permanent prosthetic devices. The wound is malodorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. Statements about wanting to feel better, going home, and wondering what is for dinner could be interpreted as positive statements that indicate progress along the health journey. DIF: Analyze REF: 1292| 1293 OBJ: Explain the factors that impede or promote wound healing. TOP: Implementation MSC: NCLEX: Psychosocial Integrity 20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step? a. Inspecting the wound for bleeding. b. Inspecting the wound for foreign bodies. c. Determining the size of the wound. d. Determining the need for a tetanus antitoxin injection. ANS: A After determining that a patient’s condition is stable, the nurse should inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. The nurse should first address any bleeding issues. Then the nurse inspects the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, the nurse should determine the need for a tetanus vaccination. DIF: Apply REF: 1308| 1309 OBJ: Describe the differences in nursing care for acute and chronic wounds. TOP: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies. ANS: B Because removal of dressings is painful, it often helps to give the patient an analgesic at least 30 minutes before the wound is exposed and the dressing is changed. The sequence of the next events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure. DIF: Apply REF: 1319 (Skill 46-3)| 1326 OBJ: Describe the differences in nursing care for acute and chronic wounds. TOP: Implementation MSC: NCLEX: Physiological Integrity 511 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter 22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse’s next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing. ANS: B Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate drain blockage, and the nurse must notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present. DIF: Apply REF: 1307 OBJ: Describe the differences in nursing care for acute and chronic wounds. TOP: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse is caring for a patient who has a stage 4 pressure injury and is awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress. b. Nonpowered redistribution air mattress. c. Low-air-loss therapy unit. d. Lateral rotation. ANS: B A static air mattress, or nonpowered redistribution mattress, is utilized for the patient at high risk for skin breakdown, as in this scenario. A low-air-loss therapy unit is utilized for stage 4 pressure injury and when prevention or treatment of skin breakdown is needed. If the patient has a stage 3 or stage 4 pressure injury or a postoperative myocutaneous flap, the low-air-loss therapy unit would be an appropriate selection. A standard mattress is utilized for an individual who does not have actual or potential altered or impaired skin integrity. Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility. DIF: Understand REF: 1313 OBJ: Describe the differences in nursing care for acute and chronic wounds. TOP: Assessment MSC: NCLEX: Physiological Integrity 24. The nurse is caring for a patient with a pressure injury on the left hip. The pressure injury is black. The nurse recognizes that the next step in caring for this patient includes which of the following? a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage. ANS: C 512 Test Bank for Canadian Fundamentals of Nursing 6th Edition by Potter Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tiss