Nokea
A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.
- A. Stage III pressure ulcer
- B. Sutured surgical incision
- C. Casted bone fracture
- D. Laceration sealed with adhesive
- E. Open burn area
Correct Answer: A, E
Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring. Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.
You may also like to solve these questions
A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.
- A. Warm the enema prior to instillation
- B. Position the client on the left side with the right leg flexed forward
- C. Lubricate the rectal tube or nozzle
- D. Slowly insert the rectal tube about 2 inches
- E. Hang the enema container 24 inches above the client's anus
Correct Answer: A, B, C
Rationale: The correct steps for administering a cleansing enema are to warm the enema prior to instillation to prevent discomfort, position the client on the left side with the right leg flexed forward to facilitate the flow of the solution, and lubricate the rectal tube or nozzle to ease insertion. Warming the enema helps relax the colon, the left side position helps the solution flow toward the rectum, and lubrication minimizes discomfort and potential injury. Other choices are incorrect: slowly inserting the rectal tube 2 inches is too shallow, hanging the enema container 24 inches above the client's anus may be too high causing a rapid flow and potential injury.
An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is unlawfully restrained against their will. In this scenario, the nurse administering a sedative without the client's consent is considered an act of restraint, which restricts the client's freedom to leave. This action constitutes false imprisonment as the client is being detained without proper legal authority.
A: Assault involves the threat of harm or unwanted physical contact, which is not present in this situation.
C: Negligence refers to a failure to provide proper care or fulfill duties, which is not the case here.
D: Breach of confidentiality involves disclosing private information without consent, which is not relevant in this scenario.
In summary, the nurse committed false imprisonment by restricting the client's freedom of movement without legal justification.
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect?
- A. Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds.
- B. Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver.
- C. Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity.
- D. Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. The 1st-pass effect refers to the metabolism of a drug in the liver before it reaches systemic circulation.
2. Medications administered orally undergo first-pass metabolism in the liver, leading to potential inactivation.
3. Administering such meds through nonenteral routes (e.g., intravenous) bypasses the liver, avoiding inactivation.
4. Choice A discusses receptor activity, not related to the first-pass effect.
5. Choice C refers to drug elimination rate, not specific to the first-pass effect.
6. Choice D discusses safety margin and monitoring, not directly related to drug metabolism.
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the medication, which of the following actions is the highest priority?
- A. Teaching the client about the purpose of the medication
- B. Administering the medication to the client at the prescribed time
- C. Identifying the client's medication allergies
- D. Documenting the client's anxiety level
Correct Answer: C
Rationale: The highest priority action before administering any medication is to identify the client's medication allergies to prevent potential adverse reactions. Administering diazepam without knowing the client's allergies could lead to serious complications. Teaching the client about the medication's purpose is important but not as critical as ensuring the client does not have allergies. Administering the medication at the prescribed time is important but comes after ensuring safety. Documenting anxiety level is relevant but not as urgent as identifying allergies.