Good Sunday Evening 3294. As promised I have had a chance to review the Exam. Th

Question

Good Sunday Evening 3294. As promised I have had a chance to review the Exam. There are some themes that I think are important to review. What I have done is put together a list of 7 questions. I gave you the correct answer and the most commonly chosen incorrect answer for this Exam. To complete the assignment, you must tell me why the answer is right and why the answer is wrong. You must cite the source you used for that information and create a reference page.

1. A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention? X Minimal scar tissue C Scarring that may be severe

2. A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing? X Resting energy expenditure (REE) C Basal metabolic rate (BMR)

3. The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? X Ileum C Duodenum

4. A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? C Drapes the urinary drainage tubing with no dependent loops X Washes the drainage tube toward the meatus with soap and water

5. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? C Decreased pain sensation and increased risk of skin impairment X High risk for skin infection and low saliva pH level

6. The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing? X The site is approximated. C The site has a mass, bluish in color.

7. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? C Assessment X Implementation

Explanation / Answer

1. The scarring can be severe

Scars are areas of fibrous tissue (fibrosis) that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound (e.g., after accident, disease, or surgery) results in some degree of scarring. Hypertrophic scars occur when the body overproduces collagen, which causes the scar to be raised above the surrounding skin. Hypertrophic scars take the form of a red raised lump on the skin. They usually occur within 4 to 8 weeks following wound infection or wound closure with excess tension and/or other traumatic skin injuries.

2. Basal metabolic rate

The basal metabolic rate (BMR) is the energy needed to maintain life-sustaining activities for a specific period of time at rest. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in rela-tion to kilocalories.

3. ileum

The gastrointestinal tract includes your mouth, stomach, small intestines and large intestines. Approximately 92 to 97 percent of the nutrients consumed, which includes carbohydrates, protein, fat, fluid, vitamins and minerals, are absorbed through the GI tract. Digestion and absorption of foods begins in your mouth and extends down through your colon, and each area is responsible for breaking down foods with a variety of enzymes and absorbing nutrients.

4. Drapes the urinary drainage tubing with no dependent loops

for more explanation, refer to website - https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html

5.Decreased pain sensation and increased risk of skin impairment

Assess site of skin impairment and determine etiology. Determine that skin impairment involves skin damage only. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain.Monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.Individualize plan according to client's skin condition, needs, and preferences.Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.Evaluate for use of specialty mattresses, beds, or devices as appropriate

6. All patients with wounds will have their wounds appropriately assessed by nursing staff within 24hours of recognition with timely referrals to stomal therapy where appropriate.

Considerations for assessment

Wound Bed

Wound Measurement

Wound Edges

Healthy wound edges present as advancing pink epithelium growing over mature granulated tissue.

7. Assessment

Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

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