chapter 35

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Author:
smatlock
ID:
115823
Filename:
chapter 35
Updated:
2011-11-09 22:21:19
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35 36
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Description:
test 3
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  1. a person has a laceration on the right leg from a fall. the wound is
    open, unintentional & contaminated
  2. a person had a rectal surgery. the person has a
    clean contaminated wound
  3. skin & underlying tissue are pierced. this is
    a penetrating wound
  4. which can cause skin tears
    wearing rings
  5. person has circulatory ulcer. which measure should you question
    hold socks in place with elastic garters
  6. elastic stockings prevent
    prevent blood clots
  7. elastic stocking are applied
    before the person gets out of bed
  8. when applying an elastic bandage
    position the part in good alignment
  9. person with diabetes are at risk for diabetic foot ulcers because of
    nerve and blood vessel damage
  10. A person has diabetes you should check the persons feet every
    day
  11. A person with diabetes needs to wear socks with shoes to prevent
    blisters
  12. a wound is separating this is called
    dehiscene
  13. clear watery drainage from a wound is called
    serous drainage
  14. a dressing does the following except
    support the wound & reduce swelling
  15. to secure a dressing apply tape
    to the top, middle & bottom of the dressing
  16. a person has frequent dressing changes. the nurse will likely have the dressing secured with
    montgomery ties
  17. a person receives a pain-relief drug before dressing change. how long should you wait for the drug to take effect
    30 minutes
  18. to remove tape
    pull it toward the wound
  19. an abdominal binder is used to
    provide support and hold dressings in place
  20. Heat applications have these effects except
    decreased blood flow
  21. the greatest threat from heat application is
    burns
  22. Which statement about moist heat applications is false
    the effects of moist heat are less than from dry heat application
  23. a hot application is usually
    98-106 F
  24. Which statement about sitz baths are false
    sitz baths last 25-30 minutes
  25. a person uses an aquathermia pad. which statement is false
    pins secure the pad in place
  26. cold applications reduce
    reduce pain, prevent swelling and decrease circulation
  27. Which isn't a complication of cold applications
    infection
  28. before applying an ice bag
    place the bag in a cover
  29. a pressure ulcer is
    a localized injury to the skin and or underlying tissue
  30. pressure ulcers are the result of
    unrelieved pressure
  31. which of the following contribute to the development of pressure ulcers
    shear and friction
  32. a pressure ulcer can develop within
    2-6hrs
  33. the following are risk factors for pressure ulcers except
    balanced diet
  34. which is the most common site for pressure ulcer
    sacrum
  35. in a light-skinned person the 1st sign of a pressure ulcer is
    a reddened area
  36. a persons care plan includes the following, which should you u question
    scrub & rub the skin during bathing
  37. when positioning a person you should position the person
    using assist devices
  38. what is the preferred position for preventing pressure ulcers
    30 degree lateral position
  39. besides heel and foot elevators, which are used to keep the heels and ankles off the bed
    pillows
  40. persons sitting in a chair should shift every
    15 minutes
  41. a person sitting in a chair their feet don't touch the floor. What should you do
    position the feet on a foot rest
  42. Which arent used to treat pressure ulcers
    plastic drawsheets & waterproof pads
  43. the following are sources of moisture except
    barrier ointment
  44. u see a reddened area on a person skin what should you do
    tell the nurse
  45. the nurse tells you that the persons pressure ulcer is colonized. this means
    bacteria are present
  46. t/f: all pressure ulcers are avoidable
    false
  47. skin breakdown can lead to pressure ulcers T/F
    TRUE
  48. T/F: unrelieved pressure squeezes tiny blood vessels. tissue doesnt receive needed oxygen and nutrients
    true
  49. t/f: persons who r bedfast or chairfast are at risk for pressure ulcers
    true
  50. t/f: pressure ulcers can develop on the ears
    true
  51. t/f: pressure ulcers can develop where medical devices are attached to the skin
    true
  52. t/f: you are responsible for identifying persons at risk for pressure ulcers
    false
  53. t/f: person has a don't resuscitate order. this means that the person is refusing treatment for a pressure ulcer
    false
  54. t/f: u use the resident assessment instrument to assess a persons risk factorand skin condition
    fasle
  55. t/f: pressure ulcers can involve muscles, tendons, and bones
    true
  56. t/f: to prevent pressure ulcers the head of the bed is raised higher than 30 degrees
    false
  57. t/f: u should inspect the persons skin every time you provide care
    true
  58. t/f: person is at risk for presure ulcers. a bath is needed every day
    false
  59. t/f: u are giving a back massage u should massage bony areas
    false
  60. t/f: u can use pillows and blankets to prevent skin from being in contact with skin
    true

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