Nurse Assignments and Client Care Procedures, Exams of Nursing

Download Nurse Assignments and Client Care Procedures and more Exams Nursing in PDF only on Docsity! ATI RN Fundamentals Proctored Exam With NGN Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? - CORRECT ANSWER -Yes. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer - CORRECT ANSWER -C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning - CORRECT ANSWER -B, C, D An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24hr postop to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump - CORRECT ANSWER -D. Replacing the cartridge and tubing on a PCA pump Rationale: The RN is responsible for the PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances - CORRECT ANSWER -B, C, E A and D are rights of medication administration A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that her coworker's fatigue is not her problem to solve - CORRECT ANSWER -C. Any nurse who notices behavior that could possibly jeopardize client care or indicate a substance abuse problem has a duty to report the situation immediately to the nurse manager A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record - CORRECT ANSWER -C. A bone scan that is scheduled for today This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A. The client fell in the shower. B. The client states he fell in the shower & was able to get himself back into his chair C. The nurse should not document this info because she did not witness the fall D. The client fell in the shower & is now resting comfortably - CORRECT ANSWER -B. By writing what the client states, the info is subjective data A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all. A. Cover errors w/correction fluid, & write in the correct info B. Put the date & time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document - CORRECT ANSWER -B, C The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today B. The skin barrier's seal stays on in bed but loosens when the - CORRECT ANSWER -A, B, D A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all. A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone - CORRECT ANSWER -A, B, C A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist C. Physical therapist D. Social worker - CORRECT ANSWER -D. social worker A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - CORRECT ANSWER -D. A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink - CORRECT ANSWER -C. Fastening a bra from behind requires internal rotation of the shoulder, so this activity will illicit pain A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test - CORRECT ANSWER -A, B C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to shrug shoulders without complication. A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation - CORRECT ANSWER -B, C, D A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No smoking" sign should be placed on the front door D. Cotton bedding & clothing should be replaced w/items made from wool E. A fire extinguisher should be readily available in the home - CORRECT ANSWER -B, C, E Family members that smoke should do so outside, and wool creates static electricity so it should be avoided. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temp of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed." - CORRECT ANSWER - B Although the baby can hold his head above the water by sitting up, this does not make the baby safe in the tub. Parents should never leave a child unattended in a tub. A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds w/hemoglobin in the body - CORRECT ANSWER -D. Carbon monoxide is a very dangerous gas because it binds w/hemoglobin & ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless, has no scent, and cannot be seen. The water heaters, gas-burning furnances, and appliances should be inspected annually The lungs are not damaged in the process of inhalation A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - CORRECT ANSWER -A. Hypotension Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A. Most food poisoning is caused by a virus A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate - CORRECT ANSWER -A, B, E Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I should expect." - CORRECT ANSWER -B. routine health screenings are important at any age A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between & being responsible for 2 generations - CORRECT ANSWER - C. Exploring and establishing career options & establishing oneself is important developmental task in a young adult A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father." - CORRECT ANSWER -C. Applying Erikson stages of development, knowing oneself is done in adolescence, and this requires the most urgent help A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. A. Install bath rails & grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home - CORRECT ANSWER -B, C, D A is recommended for older adults and E as well for risk of falls A nurse is reviewing the CDC's immunization recommendations w/a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all. A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio - CORRECT ANSWER -A, B, C D is not for after 18 months of age and polio is also given as a child and not usually beyond 18 yrs old A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to limit activity & rest D. Allow the client to shiver to dispel excess heat E. Assist the client w/oral hygiene frequently - CORRECT ANSWER -A, C, E The nurse should prevent shivering & encourage the client to increase fluids. Why E-Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips. D. Roast chicken & white rice - CORRECT ANSWER -B. A high-fiber diet promotes normal bowel elimination A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all. A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor E. Peripheral edema - CORRECT ANSWER -B, C, D fever=caused by dehydration tachycardia not brady hypotension because of decreased BP from dehydration fluid overload=peripheral edema 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 w/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 -D is the appropriate length of insertion for a child, 3-4 for an adult. -24 inches is too high & will cause it to run to fast & possible painful distention of the colon, 18 inches is the recommended height While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have the client hold his breath briefly B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container - CORRECT ANSWER -D. This will slow the rate of instillation & relieve some discomfort A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following problems is the client at risk for developing? A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction - CORRECT ANSWER -Answer: C Unrelieved pressure over a bony prominence for too long increases the risk of a pressure ulcer A-sitting will help prevent stasis of secretions B and D-these are from prolonged bed rest A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? A. Encourage isometric exercises B. Suction Q8 hr C. Give low-dose heparin D. Promote incentive spirometer use - CORRECT ANSWER -Answer: D. it helps keep airways open and prevent atelectasis A-this strengthens skeletal muscles B-this is not indicated C-helps prevent thrombus formation A nurse is caring for a client who is postop. Which of the following nursing interventions reduce the risk of thrombus development? Select all. A. Instruct the client not to use the Valsalva maneuver B. Apply elastic stockings C. Review lab values for total protein level D. Place pillows under the client's knees & lower extremities E. Assist the client to change position often - CORRECT ANSWER -B, E A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the med. Which of the following effects should the nurse anticipate? Select all. A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea - CORRECT ANSWER -C, D, E Urinary retention, not incontinence is an adv effect of these meds as well as constipation, not diarrhea. A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all. A. Orthostatic hypotension B. Fine motor tremors C. Acute dystonias D. Decreased level of consciousness E. Uncontrollable restlessness - CORRECT ANSWER -B, C, E A and D are adverse effects, but not EPS A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all. A. Take frequent sips of water B. Wear sunglasses when exposed to sunlight C. Use a soft toothbrush when brushing teeth D. Take the medication w/an antacid E. Urinate prior to taking the med - CORRECT ANSWER -A, B, E side effects of this med include: dry mouth, photophobia, and urinary retention A nurse is reviewing the reported meds of a client who was recently admitted. The meds include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine hydrochloride toxicity C. Decreased risk of adv effects of cimetidine D. Increased therapeutic effects of imipramine hydrochloride - CORRECT ANSWER -B. A med that decreases the metabolism of a 2nd med increases the serum level of the 2nd med, increasing risk for toxicity A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk med for the control of seizures. Which of the following statements by the nurse is appropriate? A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus." B. "This med has evidence indicating that it is safe to take during pregnancy & will not harm the fetus." C. "This med cannot be taken during pregnancy because the risk outweighs the potential benefits." D. "This med hasn't been studied in pregnant women but is believed to be safe for the fetus." - CORRECT ANSWER -A. Category D meds are known to cause harm to fetuses, however the use during pregnancy may be warranted based on potential benefits. A nurse in an outpatient surgical center is admitting a client for a laproscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the med, which of the following actions is the highest priority? A. Teaching the client about the purpose of the med B. Administering the med to the client at the prescribed time C. Identifying the client's med allergies D. Documenting the client's anxiety level - CORRECT ANSWER -C. The greatest risk to the client is an allergic reaction to the med A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer? (round to nearest tenth) - CORRECT ANSWER -0.3 mL A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number) - CORRECT ANSWER -400 mL/hr A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (round to nearest whole number) - CORRECT ANSWER -83 gtt/min A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention? A. "I can open the capsule w/the beads in it & sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding." C. "The pills w/the coating on them can be crushed." D. "I will eat 2 crackers w/the pain pills." - CORRECT ANSWER -D. this will prevent N&V from the narcotic A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? A. "Flush the tube before & after each med." B. "Administer your meds w/your enteral feeding." C. "Administer tablets through the tube slowly." D. "Mix all the crushed meds prior to dissolving in water." - CORRECT ANSWER -A The client should flush the tube w/15-30 mL of water to prevent clogging of the tube 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 effecct? 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. first pass deals with the liver A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique? A. "I will straighten my ear canal by pulling my ear down & back." B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." - CORRECT ANSWER -B. The client should apply gentle pressure w/the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal. A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take? A. Offer to assist the client needing the bedpan. B. Administer the injection prepared by the other nurse C. Prepare another syringe & administer the injection D. Tell the client needing the bedpan she will have to wait for her nurse - CORRECT ANSWER -A. A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all. A. 0905 B. 0825 C. 1000 D. 0840 E. 0935 - CORRECT ANSWER -A, D 30min time frame for meds A nurse is working w/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 w/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 this could indicate a possible error so it should be checked w/the provider A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all. A. "I will observe for med side effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a med if I believe it is unsafe." - CORRECT ANSWER -A, B, E A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that med. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation? A. "Your physician prescribed it for you, so you really should take it." B. Remove the nasal cannula during mealtimes C. Check the position of the cannula often D. Report any nasal stuffiness, nausea, or fatigue E. Post "no smoking" signs in a prominent location - CORRECT ANSWER -C, D, E A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." - CORRECT ANSWER -A this action clears the excess formula preventing any clumps/clogging A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been opened B. Verify the placement of the NG tube C. Confirm that the client doesn't have diarrhea D. Make sure the client is alert & oriented - CORRECT ANSWER -B the greatest risk is aspiration so verifying the placement of the tube is most important A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest xray D. Initiate oxygen therapy - CORRECT ANSWER -B. Stop the feeding A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all. A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temp. E. Discard any residual gastric contents. - CORRECT ANSWER -A, B, C D-the formula should be room temp not body E-unless the volume of the contents is more than 250 mL, the nurse should return the residual content to the client's stomach A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available - CORRECT ANSWER -A, B An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, w/scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all. A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care - CORRECT ANSWER -B, C A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A. Increase in incisional pain B. Fever & chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - CORRECT ANSWER -A, B, C A nursing instructor is reviewing the wound healing process w/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