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Patient Data

Exhibits

Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

1400

1200

1800

1600

0800

2000

1500

Answer and Explanation

Correct Answer : B,D,E,F,G

The order is vital signs to be taken every 4 hours

Additional vital signs should be document when the client’s status changes like the diaphoresis seen at 1500 as this could signify a complication.

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Correct Answer is A

Explanation

A. A well-approximated incision site refers to the edges of the surgical incision being closely aligned and in good alignment with minimal separation.
This finding is indicative of proper wound closure and initial stages of healing. It suggests that the wound edges are healing together, which is essential for preventing complications such as infection and promoting optimal wound healing.
B. Beefy red granulation tissue is a sign of the proliferative phase of wound healing. It appears as healthy, pinkish-red tissue that fills in the wound bed.
Granulation tissue consists of new blood vessels, fibroblasts, and connective tissue, and it serves to support wound healing by providing a scaffolding for tissue repair and promoting angiogenesis (formation of new blood vessels).
While the presence of granulation tissue is a positive sign indicating that the wound is progressing through the healing process, it typically occurs later in the healing timeline, beyond the initial one- week post-surgery period.
C. Eschar and slough are non-viable tissue components that can be present in a wound. Eschar is typically dry, black, or brown necrotic tissue, while slough is moist, yellow, or white necrotic tissue.
The presence of eschar and slough in a wound indicates that there is still non-viable tissue present that needs to be removed to facilitate healing.
D. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are common findings in the early inflammatory phase of wound healing.
While some degree of erythema and serosanguineous exudate may be expected in the immediate postoperative period, especially within the first few days, persistent or increasing erythema and exudate beyond one week post-surgery may indicate inflammation or infection.

Correct Answer is ["0.5"]

Explanation

Amount to administer=Prescribed dose/ Concentration of the medication

Prescribed dose = 200 mg

Concentration of the medication = 1 gram/2.5 mL = 1000 mg/2.5 mL Plugging the values into the formula:

Amount to administer -200/1000 * 2.5ml Amount to administer

= 200* 2.5 /1000 1000

Amount to administer=0.5 mL

So, the nurse should administer 0.5 milliliters of streptomycin.

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Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is A

Explanation

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.5"]

Explanation

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The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

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Patient Data

Exhibits

Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.