100% satisfaction guarantee Immediately available after payment Both online and in PDF No strings attached
logo-home
Previously searched by you
Previously searched by you
logo
Fundamentals Exam 2 NCLEX Test Questions & Answers $19.04
Add to cart
Quickly navigate to
Preview
  2.  
  3. Nclex
  4.  
  5. Nclex

Exam (elaborations)

Fundamentals Exam 2 NCLEX Test Questions & Answers
 5 views  0 purchase
  • Course
  • Nclex
  • Institution
  • Nclex

Fundamentals Exam 2 NCLEX Test Questions & Answers-Thirty-six hours after having surgery, a pt has a slightly elevated body temp and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this pt's nursing care plan? a. document th...

[Show more]

Preview 4 out of 38  pages

Document information

  • December 29, 2023
  • 38
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

Subjects

Written for

  • Nclex
  • Nclex

Seller

avatar-seller
ProfMiaKennedy

Reviews received

Content preview

Fundamentals Exam 2 NCLEX Test Questions & Answers Thirty -six hours after having surgery, a pt has a slightly elevated body temp and generalized malaise, as well as pain and redness at the surgical site. Which interventi on is most important to include in this pt's nursing care plan? a. document the findings and monitor the pt b. administer antipyretics, as ordered c. increase the frequency of assessment to every hour and notify the pt's primary care provider d. increase t he frequency of wound care and contact the PCP for an antibiotic order - a. document the findings and monitor the pt A nurse caring patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply a. serous drainage is composed of the clear portion of the blood and serous membranes b. sanguineous drainage is composed of a large number of RBCs and looks like blood c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor e. purulent drainage is thin, cloudy, and watery and may have a must y or foul odor f. serosanguineous drainage can be dark yellow or green depending on the causative organism - a. serous drainage is composed of the clear portion of the blood and serous membranes b. sanguineous drainage is composed of a large number of RBCs and looks like blood c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor A pt who has a large abdominal wound suddenly calls out for help b/c she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. no tify the physician of the situation b. cover the exposed tissue with sterile towels moistened with sterile NSS c. place the pt in low Fowler's position - c. place the pt in low Fowler's position b. cover the exposed tissue with sterile towels moistened wit h sterile NSS a. notify the physician of the situation A pt, age 16, was in an automobile accident and received a would across her nose and cheek. After surgery to repair the wound, the pt says, "I am so ugly now." Based on this statement, what nursing di agnosis would be most appropriate? a. pain b. impaired skin integrity c. disturbed body image d. disturbed thought process - c. disturbed body image A pt is admitted with a non healing surgical wound. Which nursing action is most effective in preventing a wound infection? a. using sterile dressing supplies b. suggesting dietary supplements c. applying antibiotic ointment d. performing careful hand hygiene - d. performing careful hand hygiene A nurse who is changing dressings of post op pts in the hospital documents various phases of wound healing on the pt charts. Which statements accurately describe these stages? Select all that apply a. hemostasis occurs immediately after the initial injury b. a liquid called exudat e is formed during the proliferative phase c. WBCs moe to the wound in the inflammatory phase d. Granulation tissue forms in the inflammatory phase e. during the inflammatory phase, the ppt has generalized body response f. A scar forms during the prolifera tive phase - a. hemostasis occurs immediately after the initial injury c. WBCs moe to the wound in the inflammatory phase e. during the inflammatory phase, the ppt has generalized body response The nurse assesses the wound of a pt who cut himself on the u pper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply a. enhanced healing due to the presence of sugars and proteins b. delayed healing due to d ead tissue present in the wound c. decreased effectiveness of antibiotics against the bacteria d. impaired skin integrity due to over hydration of the fells of the wound e. delayed healing due to cells dehydrating and dying f. decreased effectiveness of th e pt's normal immune process - c. decreased effectiveness of antibiotics against the bacteria f. decreased effectiveness of the pt's normal immune process The nurse is cleaning an open abdominal wound that has unapproximated edges. What are the accurate s teps in this procedure. Select all that apply a. use standard precautions or transmission -based precautions when indicated b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution c. clean the wound in full or half circles beginning on the outside working toward the center d. work outward from the incision in fines that are parallel to it from the dirty area to the clean area e. clean to at least one inch beyond the end of the new dressing if one is being applied f. clean to at least three inches beyond the wound if a new dressing is not being applied - a. use standard precautions or transmission -based precautions when indicated b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution e. clean to at least one inch beyond the end of the new dressing if one is being applied A nurse is developing a plan of care for an 86 YO woman who has bene admitted for right hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for pressure ulcer development for this pt? Select all that apply a. the pt takes time to think about her response to questions b. the pt's age of 86 c. pt reports inability to control urine d. a schedule hip arthroplasty e. lab findings include BUN 12 (elderly normal 8 -23 mg/dL) and creatinine .9 (adult female normal .61 -1 mg/dL) f. pt reports increased pain in right hip when repositioning in bed or chair - b. the pt's age of 86 c. pt reports inability to control urine d. a schedule hip arthroplasty f. pt reports increased pain in right hip when repositioning in bed or chair A nurse is explaining to a pt the anticipated effect of the application of cold to an injured area. What response indicates that the pt understands th e explanation? a. "I can expect to have more discomfort in the area where the cold is applied" b. "I should expect more drainage from the incision after the ice has been in place" c. "I should see less swelling and redness with the cold treatment" d. "My i ncision may bleed more when the ice is first applied" - c. "I should see less swelling and redness with the cold treatment" A nurse is providing pt teaching regarding the use of negative -pressure wound therapy. Which explanation provides the most accurate info to the pt? a. the therapy is used to collect excess blood loss and prevent the formation of a scab b. the therapy will prevent infection, ensuring that the wound heals with less scar tissue c. the therapy provides a moist environment and stimulates b lood flow to the wound d. the therapy irrigates the wound to keep it free from debris and excess wound fluid - c. the therapy provides a moist environment and stimulates blood flow to the wound

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

Guaranteed quality through customer reviews

Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.

Quick and easy check-out

Quick and easy check-out

You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.

Focus on what matters

Focus on what matters

Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!

Frequently asked questions

What do I get when I buy this document?

You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.

Satisfaction guarantee: how does it work?

Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.

Who am I buying these notes from?

Stuvia is a marketplace, so you are not buying this document from us, but from seller ProfMiaKennedy. Stuvia facilitates payment to the seller.

Will I be stuck with a subscription?

No, you only buy these notes for $19.04. You're not tied to anything after your purchase.

Can Stuvia be trusted?

4.6 stars on Google & Trustpilot (+1000 reviews)

53340 documents were sold in the last 30 days

Founded in 2010, the go-to place to buy study notes for 14 years now

Start selling
$19.04
  • (0)
Add to cart
Added