1. A.

CORRECT: Initiate a referral for a social worker to provide information and assistance in
coordinating hospice care for a client.
B. CORRECT: Initiate a referral for a social worker to provide information and assistance in
coordinating care for community resources available for clients.
C. Initiate a referral for spiritual support sta if a client requests speci c religious sacraments
or prayers.
D. CORRECT: Initiate a referral for a social worker to assist the client in obtaining medical
equipment for use after discharge.
E. Provide client teaching for concerns regarding the use of a nebulizer. If additional
information is needed, initiate a referral for a respiratory therapist
2. A. CORRECT: The provider must be knowledgeable about any medication prescribed for the
client, including its actions, e ects, and interactions.
B. It is not within the scope of a certi ed nursing assistant’s duties to counsel a client about
medications.
C. CORRECT: A pharmacist must be knowledgeable about any medication dispensed for the
client, including its actions, e ects, and interactions.
D. CORRECT: A registered nurse must be knowledgeable about any medication
administered, including its actions, e ects, and interactions.
E. Although some analgesics can cause respiratory depression, requiring assistance from a
respiratory therapist, it is not within this therapist’s scope of practice to counsel the client
about medications prescribed by the provider.
3. A. The right route is one of the rights of medication administration, not delegation.
B. CORRECT: The right supervision and evaluation is one of the ve rights of delegation. They
also include the right task and the right person.
C. CORRECT: Right direction and communication is one of the ve rights of delegation. They
also include the right task and the right person.
D. The right documentation is one of the rights of medication administration, not delegation.
E. CORRECT: The right circumstances is one of the ve rights of delegation. They also
include the right task and the right person.
4. A. CORRECT: Collect further data from the client to determine why they have not achieved
satisfactory pain relief, because various factors might be interfering with their comfort. The
nursing process repeats in an ongoing manner across the span of client care.
B. Do not wait longer to see how the client would respond, but take action to determine why
the client is not achieving satisfactory pain relief.
C. Do not make random changes to the plan of care without gathering evidence to guide the
nurse in knowing what new interventions might help.
D. The action does not acknowledge the client’s condition or that the current plan is
ine ective.
5. A. CORRECT: The newly licensed nurse should have used the assessment step of the nursing
process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also
should have asked about the characteristics of the pain and assessed for any changes that
might have contributed to the worsening of the pain.
B. The newly licensed nurse used the planning step of the nursing process when deciding that
it was the right time to administer the medication.
C. The newly licensed nurse used the implementation step of the nursing process when
administering the medication.
D. The newly licensed nurse used the evaluation step of the nursing process when checking
the e ectiveness of the pain medication in relieving the client’s pain.
6. A. CORRECT: Objective data includes information the nurse measures (vital signs).
B. Subjective data includes a client’s reported manifestations, even if a secondary source
gave the nurse the information.
C. Subjective data includes a client’s reported manifestations.
D. CORRECT: Objective data includes information the nurse observes (skin appearance).
E. CORRECT: Objective data includes information from the observations of others (family and
sta ).
7. A. CORRECT: The rst action to take using the nursing process is to assess or collect data
from the client. Therefore, the priority action is to determine the client’s fall risk. This will work
as a guide in implementing appropriate safety measures.

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 B. Educate the client and family about fall risk factors so they can help promote client safety,
but this is not the priority action.
C. Eliminate safety hazards from the client’s environment to help reduce the risk for falls, but
this is not the priority action.
D. Aids (eyeglasses, hearing aids, canes, and walkers) should be accessible to reduce the
client’s risk for falls, but this is not the priority action.
8. A. It would be di cult for to maintain a sterile eld away from the bedside. But more
important, this might not have any e ect on the transmission of some micro-organisms.
B. The client might be unable to refrain from coughing and sneezing during the dressing
change.
C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound
during the dressing change.
D. Keeping tissues close by for the client to use still allows contamination of the surgical
wound.
9. A. The APs should apply alcohol rubs to dry hands and wet the hands rst before applying
soap for handwashing.
B. CORRECT: This is the amount of time it takes to remove transient ora from the hands. For
soiled hands, the recommendation is 2 minutes.
C. The APs should use warm water to minimize the removal of protective skin oils.
D. CORRECT: If the sink does not have foot or knee pedals, the APs should turn o the water
with a clean paper towel and not with their hands.
E. The APs should dry their hands with a clean paper towel. This helps prevent chapped skin.
10. A. As long as the provider has not reached over the sterile eld (by placing the instrument on
a near portion of the eld), the eld remains sterile.
B. CORRECT: Fluid permeation of the sterile drape or barrier contaminates the eld.
C. CORRECT: Prolonged exposure to air contaminates a sterile eld.
D. CORRECT: Turning away from a sterile eld contaminates the eld because the nurse
cannot see if a piece of clothing or hair made contact with the eld.
E. The 1-inch border at the outer edge of the sterile eld is not sterile. Unless the client
reached farther into the eld, the eld remains sterile.
11. A. CORRECT: Having the client sit upright facilitates full ventilation and gives the assistive
personnel a clear view of chest and abdominal movements.
B. CORRECT: With the client’s arm across the abdomen or lower chest, it is easier for the AP
to see respiratory movements.
C. CORRECT: Observing for one full respiratory cycle before starting to count assists the AP
in obtaining an accurate count.
D. The AP should count the rate for 1 min if it is irregular.
E. An occasional sigh is an expected nding in adults and can assist to expand airways. AP
do not need to count sighs.
12. A. Report pallor, which can indicate anemia or circulation di culties. However, another
assessment nding is the priority.
B. CORRECT: The priority nding when using the airway, breathing, circulation (ABC)
approach to care is cyanosis, which an indication of hypoxia (inadequate oxygenation).
Therefore, immediately report this nding to the provider.
C. Report jaundice, which can indicate liver dysfunction or red blood cell destruction.
However, another assessment nding is the priority.
D. Report erythema, which can indicate in ammation. However, another assessment nding is
the priority.
13. A. CORRECT: The thyroid gland lies in the anterior portion of the lower half of the neck, just
in front of the trachea.
B. An average-size thyroid gland is not visible on inspection. Visualization of the thyroid under
the skin could indicate a thyroid disorder.
C. A bruit indicates increased blood ow, possibly due to hyperthyroidism.
D. CORRECT: When the client swallows a sip of water, the nurse should feel the thyroid move
upward with the trachea.
E. CORRECT: The thyroid gland lies in front of the trachea and extends symmetrically to both
sides of the midline.
14. A. CORRECT: The greatest risk to a client during bathing is the transmission of pathogens
from one area of the body to another. Begin with the cleanest area of the body and proceed to
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 the least clean area. The face is generally the cleanest area, and washing it rst follows a
systematic head-to-toe approach to client care.
B. The client is at risk for infection from pathogens on the client’s feet. Therefore, wash
another area rst.
C. The client is at risk for infection from pathogens on the client’s chest. Therefore, wash
another area rst.
D. The client is at risk for infection from pathogens on the client’s arms. Therefore, wash
another area rst.
15. A. To auscultate a ventricular gallop (an S3 sound), place the bell of the stethoscope at each
of the auscultatory sites.
B. CORRECT: To auscultate the closure of the mitral valve, place the diaphragm of the
stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the
fth intercostal space.
C. To auscultate the closure of the pulmonic valve, place the diaphragm of the stethoscope
over the aortic area, which is just to the right of the sternum at the second intercostal space.
D. CORRECT: To auscultate the apical heart rate, place the diaphragm of the stethoscope
over the apex of the heart, which is on the left midclavicular line at the fth intercostal space.
E. To auscultate a murmur, place the bell of the stethoscope at various auscultatory sites.
16. A. Telling the preschooler the injection will not hurt will cause the child to distrust the nurse.
B. Oral medications should be mixed in a small amount of uid to increase the chance of the
child taking the entire dosage.
C. O er the child choices when possible gives the child some control and helps reduce the
child’s fears.
D. CORRECT: Having familiar and cherished objects nearby is therapeutic for children during
their hospitalization and is useful as a distraction during uncomfortable procedures.
E. CORRECT: Pretend play helps children determine the di erence between reality and
fantasy (imagined fears), especially with the assistance of the nurse during hospitalization.
17. A. CORRECT: Older adults should increase protein intake to increase muscle mass and
improve would healing.
B. Older adults should increase uid intake to prevent dehydration and constipation.
C. CORRECT: Older adults should increase calcium intake to reduce the risk for osteoporosis.
D. CORRECT: Older adults should limit sodium intake to reduce the risk for edema and
hypertension.
E. CORRECT: Older adults should increase ber intake to prevent constipation.
18. A. The communication should not be reciprocal but client-focused.
B. CORRECT: Therapeutic communication facilitates a helping relationship that maximizes
the client’s ability to express their thoughts and feelings openly.
C. Limit therapeutic communication to the boundaries of the therapeutic relationship,
including time.
D. Plan therapeutic communication.
19. A. According to the concept of body image, an appendectomy would not place a client at high
risk for a body image disturbance.
B. CORRECT: Having a mastectomy involves a change in physical appearance and can lead
to body-image disturbances related to sexuality.
C. CORRECT: Having an above-the-knee amputation involves a change in physical
appearance and can lead to body-image disturbances related to function, health, and
strength.
D. Depending on the prognosis post-catheterization, the client can have some limitations.
However, in general, a cardiac catheterization would not place a client at high risk for a body-
image disturbance.
E. CORRECT: Having right-sided hemiplegia involves a change in physical appearance and
can lead to body-image disturbances related to function, health, and strength.
20. A. Jewish culture, not Islam, requires food to be kosher.
B. CORRECT: Islamic practices include praying ve times per day. Work with the client to
establish a schedule for the day, noting which times the client prefers to pray, and scheduling
treatments around those times when possible.
C. American culture appreciates direct eye contact. In Middle Eastern cultures, direct eye
contact can be perceived as rude, hostile, or sexually aggressive.
D. Daily communion is a ritual to consider for a Catholic client, not for a Muslim client.
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 21. A. Labored breathing and irregular patterns indicate imminent death.
B. Cool extremities indicate imminent death.
C. Decreased urine output indicates of imminent death.
D. CORRECT: Muscle relaxation is an expected nding when a client is approaching death.
22. A. CORRECT: Planning for rest periods during morning care will help prevent fatigue and
continue to foster independence.
B. Fatigue and dyspnea do not eliminate the need for morning care.
C. Performing all of the client’s care quickly might a ect the client’s self-esteem and reduce
their independence.
D. Having a family member bathe the client reduces their self-esteem and independence, and
does not reduce the client’s fatigue.
23. A. Although the body gets more than half of its energy supply from fat, it is an ine cient
means of obtaining energy. It produces end products the body has to excrete, and it requires
energy from another source to burn the fat.
B. Protein can supply energy, but it has other very essential and speci c functions that only it
can perform. So it is not the body’s priority energy source.
C. Glycogen, which the body stores in the liver, is a backup source of energy, not a primary or
priority source.
D. CORRECT: Carbohydrates are the body’s greatest energy source; providing energy for
cells is their primary function. They provide glucose, which burns completely and e ciently
without end products to excrete. They are also a ready source of energy, and they spare
proteins from depletion.
24. A. Pain from a recent, non-healed bone fracture is acute pain.
B. Postoperative pain is acute pain.
C. Pain associated with a current illness (food poisoning, is acute pain).
D. CORRECT: A client who reports pain that lasts more than 6 months and continues beyond
the time of tissue healing is experiencing chronic pain. Assist with planning interventions to
relieve manifestations associated with the pain.
25. Nursing Foundation Q 149
26. Nursing Foundation Q 147
27. Nursing Foundation Q 146
28. Nursing Foundation Q 139
29. Nursing Foundation Q 128
30. Nursing Foundation Q 119
31. Nursing Foundation Q 112
32. Nursing Foundation Q 083
33. Nursing Foundation Q 073
34. Correct answer D: "Speed shock" is caused by too rapid injection of an IV medication,
resulting in a systemic response. Speed shock can result in cardiac arrest. The rapid injection
leads to the toxicity of the medication in the bloodstream. Signs and symptoms of speed
shock include:
1. ushed face
2. irregular pulse
3. dizziness
4. headache
5. chest tightness
Options A, B, and C: The client is exhibiting signs and symptoms of speed shock due to an
excessively rapid, not slow, injection of the IV medication. Not scrubbing the hub with alcohol
wipes can result in infection, not speed shock. Not priming the IV tubing can result in air
entering the bloodstream with the potential of developing an embolism, not speed shock.
35. Correct answer B: The FLACC scale is most appropriate for nonverbal children as it
evaluates behavioral indicators including Face, Legs, Activity, Cry, and Consolability. Each
category is scored 0-2, providing an objective measurement for preverbal, nonverbal, or
cognitively impaired young children.
Option A: The PAINAD scale is speci cally designed for older adults with advanced dementia.
While it also uses behavioral indicators, its categories are tailored to geriatric populations, not
pediatric clients.
Option C: While the Wong-Baker FACES scale is appropriate for pediatric clients, it requires
the child to be able to identify and point to faces showing di erent levels of distress. A
nonverbal child may have di culty communicating using this tool.
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 Option D: A numeric rating scale requires the client to verbally rate pain from 0-10 and
requires cognitive understanding of numbers. A 3-year-old nonverbal client would not be able
to e ectively use this scale.
36. Correct Answer B: A gait belt is a safety device used to help someone move, such as from a
bed to a chair. The belt is also used to help hold someone up while he walks, if the client is too
weak to alone. The gait belt helps provide support and helps prevent a fall. It also decreases
the risk of a back injury while helping the person move or walk. This is the priority safety
action.
Options A: This is a psychosocial interaction and would not be a safety action.
Option C: Information from the client will help determine the length of the walk but it is not the
only information utilized.
Option D: Discussing the importance of ambulation and safety with a walker is an appropriate
action but not a priority above safety.
37. Correct answer B: Leaving the sterile eld unattended is considered a violation of the sterile
eld. The nurse must always ensure that the sterile eld is not violated by keeping a watchful
eye on the sterile eld, or ask another nurse to assist as necessary.
Correct answer E: The nurse should never place a non-sterile item onto the sterile eld. Only
sterile items can be transferred onto the sterile eld. Placing a pair of non-sterile latex gloves
onto the sterile eld is a violation of the sterile eld that can place the client at risk for
infection. The non-sterile gloves can contaminate the sterile contents of the sterile dialysis kit.
Option A: The nurse is following evidence-based practice guidelines by inspecting the
package for the integrity or damage, such as tears, openings, loosened tape, wetness, or
soiling which could contaminate the contents of the sterile kit.
Option C: The nurse is not violating the sterile eld by touching the outer 1-inch border of the
unfolded paper wrapper. The outer 1 inch is considered non-sterile and can be touched by
ungloved hands, whereas the rest of the contents are considered sterile and cannot be
touched by ungloved hands.
Option D: Transferring a sterile item onto the sterile eld is not considered a violation of the
sterile eld. The nurse appropriately transfers the sterile 4 x 4 gauze by opening the package
at the top edges, pulling the wrapper apart, and transferring the sterile gauze by dropping it
onto the sterile eld.
38. Correct Answers B and D: The correct steps when auscultating a client's bowel sounds
include explaining to the client what is about to take place; cleaning the stethoscope and
ensuring that the end piece that is being used is open (live); placing the diaphragm on the
client's bare skin and listening to each quadrant.
Option A: Waiting for the client to exhale is not realistic, as the client cannot hold the breath
while the nurse auscultates, which may require listening for several minutes.
Option C: Palpation is not done rst, as it is performed after inspection and auscultation, so
not to disturb the abdomen before listening.
Option E: It is best to auscultate over bare skin as the sound of moving clothing could provide
false sounds or modify the sounds being heard. The diaphragm can be warmed by placing or
rubbing over the hand.
39. Correct answer C: Droplet precautions are recommended for care of clients diagnosed with a
SARS-CoV-2 infection. These precautions include covering the nose and mouth with a
surgical mask or a NIOSH-approved N95 equivalent or higher respirator (preferred with SARS-
CoV-2). Eye protection such as goggles should be applied before entering the room.
Option A: The nurse does not understand that although N95 masks can be reused if there is a
shortage, when the N95 mask becomes soiled it cannot be cleaned and reused.
Option B: Once the gown and gloves are worn, they are considered contaminated and should
be removed before exiting the room to prevent transmission of the virus to others.
Option D: The mask should be removed after exiting the room for a client under airborne
precautions, not before exiting the room. A surgical mask is not recommended for droplet
precautions.
40. Content tip: SBAR - Situation, Background, Assessment, Recommendation.
Correct answer D: The “B” part of the SBAR report is the “background” section, in which the
nurse conveys information related to the client’s history of present illness and other relevant
information about the client’s health and treatment history. The client with chronic bronchitis
would have a chronic productive cough for at least 3 months. Chronic bronchitis is a form of
chronic obstructive pulmonary disease.
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 Option A: This statement would be included in the “B,” or “background,” part of the SBAR
report for a client with acute bronchitis; however, the time course for chronic bronchitis is at
least 3 months, not 2 weeks. Bronchitis does not typically include a fever, which is a
complicating factor that may indicate a new disease process, such as pneumonia.
Option B: This statement would be included in the “S,” or “situation,” part of the SBAR report.
This section of the report includes the basic identifying information about the client. This
information includes name, date of birth, gender, code status, and allergies.
Option C: This statement is an example of the “A,” or “assessment,” part of an SBAR report.
This section contains a synthesis of the situation and background with the nurse’s conclusions
about the client’s status and potential requirements. In this example, the nurse concluded that
the client has pneumonia and is at risk for further decompensation.
41. Correct answer C: Wrapping the arm’s circumference in tape to secure the intravenous (IV)
catheter is an incorrect technique. This action can impede circulation to the extremity.
Options A, B, and D: Placing the tourniquet several inches above the insertion site, avoiding
varicose veins for intravenous catheter placement, and activating the safety device after
removing the needle are all safe and appropriate actions during IV catheter placement.
42. Correct answer C: During intravenous (IV) administration of uids or medication at a
peripheral IV site the client is at risk for in ltration. Upon noticing that the infusion is running
behind schedule, the nurse knows to assess the peripheral IV site for any signs of malfunction
such as in ltration.
Option A: The nurse will not increase the ow rate of a prescribed IV infusion without rst
discussing with the primary healthcare provider (HCP).
Option B: The infusion does not need to be immediately stopped because it is running behind
schedule. The nurse's rst response is to assess the peripheral IV site rst. If the nurse
notices signs of malfunction such as in ltration, then the infusion will be stopped and a new IV
site will be obtained.
Option D: The nurse may want to contact the HCP to discuss prescribing an increased ow
rate for this client; however, the rst action is to assess the IV site for signs of malfunction,
which is a potential safety issue. This client is diagnosed with acute kidney injury and may
have di culty tolerating an increased ow rate. If an increased ow rate is prescribed, the
nurse will assess the client for increased heart rate, increased respirations, and increased lung
congestion, which could indicate uid overload.
43. Correct answer A: The rst step in administering topical medication is to verify the
medication using the seven rights of administration, which ensures the correct medication is
administered to the correct client and prevents a medication error that could lead to adverse
e ects.
Correct answer B: Hand hygiene and gloves are required before starting topical medication
administration. Gloves should be changed immediately after administration, and hand hygiene
should be repeated to prevent the spread of healthcare-associated infections and prevent
inadvertent administration of a topical medication to the nurse.
Correct answer C: After opening the topical medication, the medication is applied to the
gloved hand or directly to the client’s application site. Using gentle, smooth strokes, the nurse
applies the medication to the a ected area or selected site. Excessive pressure could cause
discomfort, tear, or shear damage to the skin.
Correct answer E: It is essential to routinely assess the topical medication application site to
evaluate if the a ected skin is showing improvement from the treatment or if the healthy skin
site is reacting poorly to the topical medication. If the a ected area or site is worsening,
reevaluation of the treatment should be addressed. If an allergic reaction develops, the nurse
should remove the medication and contact the health care provider.
Option D: The medication should be applied directly to the gloved hand or the client's skin,
not on gauze.
44. Correct answer D: A client who is postoperative and given a dose of IV morphine for pain is
at immediate safety risk for falling. Anesthetics and narcotics have sedative e ects that will
impair mobility and lead to a potential fall if the client attempts to ambulate.
Option A: A client who is postoperative and was given a dose of IV morphine is not at
immediate risk for skin breakdown. There would be a potential risk for skin breakdown over
time if the client has loss of sensory perception, there is moisture on the skin, or the client
lacks mobility, has malnutrition and/or friction or shearing of the skin, or all of these.

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 Option B: A risk for suicide would be more commonly seen in the client who is an adolescent
or in a client with a history of a suicide attempt, depression, or both. After surgery, the
immediate safety risk for the postoperative client is the combined sedentary e ects of the
anesthetic and morphine causing the risk for falling.
Option C: The immediate safety risk of a postoperative client who was administered an
anesthetic and a narcotic is the risk for falling, not sepsis. Sepsis may develop later if there
were surgical complications and contamination.
45. Correct answer B: Wearing clean and aseptic gloves when changing a wound dressing, even
for a minor cut, is essential to prevent contamination and infection. Clients should be
educated on the importance of using gloves to maintain proper wound care and reduce the
risk of infection.
Correct answer C: Using safety goggles when mowing the lawn helps prevent eye injuries
from ying debris. Clients should be advised to wear appropriate eye protection during
activities with potential hazards to safeguard vision.
Correct answer D: Wearing thick toed shoes is added protection in the event of a fallen
object on the foot. Thick soles protect the foot from sharp objects that could go through the
bottom. Shoes being water proof is an extra bonus protection.
Option A: Discarding used needles and syringes in a tall trash bin poses a risk of needlestick
injuries to others. Clients should be encouraged to dispose of sharps in puncture-resistant
containers to prevent injuries and exposure to bloodborne pathogens.
Option E: Abstaining or failing to wear a mask while cleaning up spilled chemicals increases
the risk of inhalation exposure to harmful fumes. Clients should be instructed to wear
appropriate respiratory protection when handling hazardous substances to protect respiratory
health.
46. Correct answer C: The nurse will assess the intravenous (IV) catheter site and surrounding
skin every four hours for redness, swelling, warmth, and pain. These could be signs of
infection, in ltration, extravasation, or phlebitis.
Option A: The IV catheter, the area around the insertion site and infusing uids will be
assessed every four hours (not once a day) for signs of in ltration, extravasation, dislodgment,
or phlebitis.
Option B: If the dressing is soiled, wet, or peeling away, it will be replaced with a new
transparent dressing. Allowing uid to accumulate and remain under the dressing increases
the risk of bacterial growth and infection. The catheter will also be further assessed by ushing
to assess patency and the connection between the catheter and tubing will be assessed to
ensure it is tight. If uid leaks around the catheter when it is ushed or the area around the
catheter becomes swollen, the catheter is dislodged and will be replaced.
Option D: Depending on the facility policy, the date/time may or may not be written on the
dressing, but it will be documented in the health care record. The site will be changed her the
facility protocol or if needs replaced to to malfunction.
47. Correct answer A: The trunk region is the middle portion of the body and includes the thorax
and abdomen.
Option B: The cephalic region is the head. Shown in bracketed area A in the image above.
Option C: The lumbar region is the lower back.
Option D: The cervical region is the neck. Shown in bracketed area B in the image above.
48. Content tip: After the insertion, the catheter is secured to the client's thigh by a strap or
another type of securement device, allowing for some slack in the tube with movement. The
bag is then placed is a position that is below the client's bladder, but is on on the oor, bed or
rail.
Correct answer C: The urine collection bag is placed lower than the client’s bladder and
a xed to a non-moving part of the bed. The bed frame is a common area where urine
collection bags are hung because it is non-movable. The hanger that comes with the
collection bag can t on the bed frame securely and it is below the client’s bladder. The nurse
also makes sure that the collection bag is situated in order to avoid unnecessary tugging on
the catheter.
Option A: Placing the collection bag on the oor is unsanitary and is not the correct nursing
action. The urine may not drain properly because the bag does not hang freely. Placing it on
the oor can also cause tugging because it is not secured to the bed.
Option B: The collection bag is not attached to a moving part of the bed, such as the bed
rails. When the bed rail is moved while the collection bag is hanging there, it can cause
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 tugging on the catheter, which can be painful to the client and can also accidentally detach
the catheter tubing.
Option D: Placing the collection bag on the bed would not allow proper drainage of urine.
Urine may pool in the catheter and tubing, potentially causing the urine to move back into the
client’s bladder and result in an infection. The collection bag is hung without any kinks or
loops in the tubing to allow unobstructed drainage into the bag by gravity.
49. Correct answers: B, C, E, F, G, H
Incisional tenderness is present due to the tissue and muscle injury during the surgery. After
the rst few days, the pain should not be feeling worse.
Dehiscence is when the two edges of a wound have a new opening after the initial closure.
This can cause infection and needs to be addressed.
Incisional erythema is not expected after 9 days from surgery. This is a sign of possible
infection.
Thick yellow exudate is a sign of infection, and can be white, brown or yellow, caused by
white blood cells ghting an infection.
Poorly controlled DM type 2 puts the client at increased risk for delayed wound healing and
infection and contributes to this current problem. The blood ow is slower and delays
nutrients to the wound.
The temperature is elevated and another indication of a present infection.
Incorrect answers
Though 98% occlusion is signi cant, the client was treated for this as CABG provides
circulation to the heart to improve heart function. The respiratory rate is within normal limits,
as a normal rate for an adult is between 12 to 20 breaths per minute.
50. Sepsis
Tachypnea, temperature,
thick exudate or drainage, are
all signs of a systemic Wound Delayed Wound
Assessment Finding Sepsis
infection or sepsis, which is a Infection Healing
complication of surgery.
Incisional tenderness, lack Incisional tenderness ✔ ✔
of approximation, and
erythema could indicate a
Incisional edges not
wound infection that can lead ✔ ✔
approximated
to sepsis but are not signs of
sepsis, rather, they are signs
of a more localized process. Tachypnea ✔ ✔
Wound infection
All the ndings listed are signs
of wound infection. Incisional Temperature ✔ ✔
tenderness should be
reported as less pain, not Thick exudate ✔ ✔
worse this long after surgery.
The wound edges not
approximated (dehiscence) Incisional erythema ✔ ✔
allow microorganisms to enter.
An elevated temperature
increases the metabolic Note: Each row must have at least 1 response option selected.
demand, causing increased
heart rate (tachycardia) and respiratory rate. Thick yellow exudate is purulent drainage,
which is indicative of wound infection. Incisional erythema is redness from either irritation or
injury.
Delayed wound healing
Delayed wound healing (tertiary intention) often results from wound infection and leaves a
larger and deeper scar. The incisional tenderness and erythema are signs of a present
infection. The dehiscence also is due to the delayed wound healing and a contributing cause
is the uncontrolled DM.
Tachypnea, temperature, thick exudate (drainage) are not associated with delayed wound
healing. They are all signs of a systemic infection or sepsis, which is a complication of surgery.

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51. Correct answers
The client is most likely experiencing a wound infection, as evidenced by elevated
temperature and purulent drainage. Wound infection is a complication of surgery as any
break in the skin (in this case from the surgical incision) weakens this protective layer allowing
foreign particles including bacteria and viruses to enter the body. The elevated temperature
and drainage indicate the body is trying to ght the infection.
Incorrect answers
There is not enough evidence to support a sepsis diagnosis, although this is a de nite risk to
consider; a diagnosis of sepsis must meet speci c criteria. The delayed wound healing is
evident by dehiscence and wound infection; however, this is not the primary concern that the
nurse must address. Addressing the infection is essential to avoid further delayed wound
healing. Higher blood glucose levels are not evidence of an infection, just a risk factor.
Tenderness is a result of the current infection. Tachypnea is also a criterion for sepsis when
accompanied by a known infection, which is at the high end of normal, but not above 100
beats/min. The nurse’s wound assessment does not include a lack of granulation-tissue
formation.
52. Correct answers: A, C, E, F, H, I
The nurse anticipates vancomycin, a broad-spectrum antibiotic, to treat the infection. A
wound team consult and acetaminophen are treatments to heal the wound and the
symptom of pain. A culture of the wound will identify the speci c infective organisms. Blood
cultures will determine if the organism is in the blood, causing sepsis. The complete blood
counts (CBC) will reveal the extent of the infection by examining the white blood cell count.
Incorrect answers
The complications of bed rest outweigh the bene ts. The client should remain mobile unless
weakness and altered mental status occur, which could be symptoms of the infective
organism going into the bloodstream, causing sepsis. An oral antibiotic such as uconazole
is not potent enough to treat a serious and potentially life-threatening infection, so a broad-
spectrum IV antibiotic is best in this setting. There is no need for the client to remain NPO as
the surgery was 9 days ago and normal digestive functions have been restored, and another
surgery is not warranted at this time.
53. Correct answers: B, D, E
Cultures should be drawn before antibiotics administration to avoid skewing the results.
Treating the pain and infection are the most important actions, as the infection can become
life-threatening, and the client must be made comfortable. Unaddressed pain delays healing.
Vancomycin should be given as soon as possible to ght the infection. Hydrocodone/
acetaminophen must be given to relieve moderate and severe pain, which the client rates as
a 7/10.
Content tip: The intensity of pain is typically assessed by the health care team with a
numerical scale of 0 to 10: 1 – 3 is mild; 4 – 6 is moderate; 7 – 10 is severe.
Incorrect answers
After the client’s pain is treated and the rst antibiotic is given, the nurse can call the wound
team and draw the CBC and BMP. Examining the wound will likely cause some pain, so it is
appropriate that the client be medicated for pain beforehand. Acetaminophen treats mild
pain, but the client complains of moderate to severe pain as evidenced by a pain level of 7/10,
so hydrocodone/acetaminophen must be given instead.
Does Not
54. Correct answers Indicates
Indicate
The client’s WBC and temperature are normal, indicating the infection
is under control. The wound vacuum system is an e ective way to heal ✔
open and infected wounds. A small amount of exudate is acceptable for
discharge. The infection was not in the bloodstream because the blood ✔
culture is negative, indicating the infection remains within the wound.
Incorrect answers ✔
A wound vacuum system and home IV antibiotics require home health
care and the Home Health nurse must discuss the process with the ✔
client before discharge, so the instructions can be documented as
complete. The client must be aware of home health procedures, and ✔
home health must have permission to come to the client’s home. More
✔
education may be necessary, and the nurse should explore other ways to
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 alleviate the client's fear of going home with the wound system before discharging the client.
55. Correct answers

Draw blood for CBC Enema results

and BMP
Fecal impaction

Manual disimpaction Stool output

Parkinson disease is a progressive neurodegenerative disease that a ects many systems in

the body, including the gastrointestinal system causing neurogenic constipation. The client
reports taking a daily stool softener and laxative but misses doses. In addition, the client
began taking an iron supplement, which causes constipation. The signs and symptoms,
including not passing stool for several days, the CT ndings, and the presence of stool mass
in the rectum upon exam, all indicate a fecal impaction secondary to chronic constipation.
This must be treated to prevent further complications such as perforation and peritonitis.
The nurse draws blood for a CBC and BMP for signs of dehydration that can be associated
with this condition. Manual disimpaction is indicated to evacuate the hard stool in the
rectum. An enema can be administered to help evaluate any remaining stool.
Incorrect answers
The client is not exhibiting signs or symptoms indicating a complete bowel obstruction such
as nausea, vomiting, or dilation of the small bowel or colon and free air in the CT scan.
Encopresis is fecal incontinence or soiling, which is not consistent with the client’s
symptoms. Although the client reports abdominal pain, the client is not exhibiting symptoms
indicating bacterial gastroenteritis, such as fever and diarrhea.
Insertion of an NG to suction is indicated for the treatment of bowel obstruction, not
constipation or fecal impaction. It is advisable to instruct the client in methods to prevent
future episodes of constipation, which would be to increase ber and uid intake. However,
due to the immediate problem and the client’s state of anxiety of the current situation, this is
not the best teaching time. Once the problem has been corrected, then teaching can begin. A
rectal tube is inserted to decrease soiling from diarrhea or to deliver medications, not for the
treatment of constipation or fecal impaction.
Since the client is not experiencing an infectious process such as gastroenteritis, a stool
culture is not needed. Pancreatic enzyme and liver function testing are unrelated to
constipation and fecal impaction.

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